Predictors of low bone mineral density in the elderly: the role of dietary intake, nutritional status and sarcopenia

OBJECTIVES

The aims of this study were to investigate the relationship between sarcopenia, dietary intake, nutritional indices and hip bone mineral density (BMD) in the elderly, and to estimate the risk of low BMD due to specific independent predictor thresholds.

SUBJECTS AND METHODS

Body mass index (BMI), serum albumin, energy and protein intake were studied in 352 elderly outpatients (216 women aged 73.5+/-5.3 years and 136 men aged 73.9+/-5.6 years). BMD at different hip sites and appendicular skeletal muscle mass (ASMM) were assessed by dual-energy X-ray absorptiometry.

RESULTS

The prevalence of osteoporosis was 13% in men and 45% in women, while the prevalence of sarcopenia (50%) and hypoalbuminemia (5%) were similar in both genders. BMI, albumin and ASMM were significantly associated with BMD in both genders: so was protein intake, but only in men. By multiple regression analysis, the variables that retained their independent explanatory role on total hip BMD, were BMI and protein intake in men, and BMI and albumin in women. By logistic regression analysis, men risked having a low BMD with a BMI <22 (OR=12) and a protein intake <65.7 g/day (OR=3.7). Women carried some risk already in the BMI 25-30 class (OR=5), and a much greater risk in the BMI <22 class (OR=26). Albumin <40 g/l also emerged as an independent risk factor (OR=2.6).

CONCLUSIONS

BMI in both genders, albumin in women and protein intake in men have an independent effect on BMD. BMI values <22 are normal for younger adults but carry a higher risk of osteoporosis in the elderly, particularly in women. Age-related sarcopenia does not seem to be involved in bone mass loss.

Laparoscopic adjustable gastric banding in 1,791 consecutive obese patients: 12-year results

BACKGROUND

This study examines 1,791 consecutive laparoscopic adjustable gastric banding (LAGB) procedures with up to 12 years follow-up. Long-term results of LAGB with a high follow-up rate are not common.

METHODS

Between September 1993 and December 2005, 1,791 consecutive patients (75.1% women, mean age 38.7 years, mean weight 127.7 +/- 24 kg, mean BMI 46.2 +/- 7.7) underwent LAGB by the same surgical team. Perigastric dissection was used in 77.8% of the patients, while subsequently pars flaccida was used in 21.5% and a mixed approach in 0.8%. Data were analyzed according to co-morbidities, conversion, short- and long-term complications and weight loss. Fluoroscopy-guided band adjustments were performed and patients received intensive follow-up. The effects of LAGB on life expectancy were measured in a case/control study involving 821 surgically-treated patients versus 821 treated by medical therapy.

RESULTS

Most common baseline co-morbidities (%) were hypertension (35.6), osteoarthritis (57.8), diabetes (22), dyslipidemia (27.1), sleep apnea syndrome (31.4), depression (21.2), sweet eating (22.5) and binge eating (18.5). Conversion to open was 1.7%: due to technical difficulties (1.2) and due to intraoperative complications (0.5). Together with the re-positioning of the band, additional surgery was performed in 11.9% of the patients: hiatal hernia repair (2.4), cholecystectomy (7.8) and other procedures (1.7). There was no mortality. Reoperation was required in 106 patients (5.9%): band removal 55 (3.7%), band repositioning 50 (2.7 %), and other 1 (0.05 %). Port-related complications occurred in 200 patients (11.2%). 41 patients (2.3%) underwent further surgery due to unsatisfactory results: removal of the band in 12 (0.7%), biliopancreatic diversion in 5 (0.27%) and a biliopancreatic diversion with gastric preservation ("bandinaro") in 24 (1.3%). Weight in kg was 103.7 +/- 21.6, 102.5 +/- 22.5, 105.0 +/- 23.6, 106.8 +/- 24.3, 103.3 +/- 26.2 and 101.4 +/- 27.1 at 1, 3, 5, 7, 9, 11 years after LAGB. BMI at the same intervals was 37.7 +/- 7.1, 37.2 +/- 7.2, 38.1 +/- 7.6, 38.5 +/- 7.9, 37.5 +/- 8.5 and 37.7 +/- 9.1. The case/control study found a statistically significant difference in survival in favor of the surgically-treated group.

CONCLUSIONS

LAGB can achieve effective, safe and stable long-term weight loss. In experienced hands, the complication rate is low. Follow-up is paramount.

New approach to gerontology: building up "successful aging" conditions

BACKGROUND AND AIMS

Great efforts have been made in developed societies to extend human life expectancy as much as possible. Continuing investments into extending the life-span into the "fourth age" actually reduce the opportunities of people to age successfully and die in dignity. Consequently, in recent years, the concept of "Successful Aging" (SA) has gained increased attention: investigators recognize the importance of separating pathologic changes from those which may be attributed to aging in itself, in order to interpret correctly the differences between Pathologic Aging, Normal Aging, and Successful Aging. Hence, according to recent literature on aging, our aim was to question here the validity of recommendations made in the literature for policy making in the treatment of aging and suggest new alternatives.

METHODS

We have tried to understand and develop a method of analysis to the following question: what do we actually mean by SA? Successful Aging may be seen as an arbitrary, subjective term, so we studied which indicators characterize elderly persons as successful aged.

RESULTS

The results of this study show that older people's views of SA appear to be multidimensional and more complex than the apparent viewpoint of many of early studies, which tended to focus on a single dimension of health - psychological or mental.

CONCLUSIONS

We argue the proper use of various health indicators and health enhancers, as proposed in the current international literature, in the definition of SA.

Resting Energy Expenditure and Body Composition in Bedridden Institutionalized Elderly Women With Advanced-Stage Pressure Sores

BACKGROUND

Our study investigated nutritional status, body composition, and resting energy expenditure (REE) in elderly patients with advanced-stage pressure sores (PS), in addition to researching any hypermetabolic condition and its relationship with PS size.

METHODS

The study involved 52 institutionalized bedridden elderly women (aged 83.7 +/- 6.3 years), divided into two groups: 23 with advanced-stage (stage 3 and 4) PS and 29 without PS. Albumin, prealbumin, and retinol-binding protein were measured in all patients, and fat-free mass (FFM) and fat mass (FM) were obtained by dual-energy x-ray absorptiometry (DEXA). REE was measured by indirect calorimetry and predicted with the Harris-Benedict formula. PS area and volume were also measured.

RESULTS

The elderly women with and without PS were comparable in age, FFM, and FM. Mean albumin, prealbumin, and retinol-binding protein values were lower in cases with PS. Unadjusted mean REE was significantly higher in patients with PS (1212.3 +/- 236.7 vs 1085.5 +/- 161.3 kcal/d; p <.05), even after adjusting for FFM or expressed per kilogram of body weight (25.8 +/- 6.7 vs 21.1 +/- 4.0 kcal/d/kg; p <.01). Hypermetabolism, i.e., a measured REE > 110% of the predicted REE, was seen in 74% of patients with PS and 38% of controls. The difference between measured and predicted REE (DeltaREE) correlated with PS volume (r = 0.58; p <.01), but not with area.

CONCLUSION

Advanced-stage PS in elderly women are associated with a hypermetabolic state that is influenced by the volume of the PS.

High ghrelin concentration is not a predictor of less weight loss in morbidly obese women treated with laparoscopic adjustable gastric banding

BACKGROUND

We analyzed the role of high plasma ghrelin concentrations at surgery as a negative predictor of weight loss in morbidly obese patients treated with laparoscopic gastric banding (LAGB).

METHODS

Fasting plasma ghrelin concentrations were measured in 113 women before LAGB, and 16 of them were identified as having ghrelin concentrations clearly higher than expected according to the BMI levels. The 2-year postoperative outcome of these 16 patients was compared to the outcome of the remaining subjects.

RESULTS

Mean fasting plasma ghrelin concentration in the group with hyperghrelinemia was 82.3+/-23.1 pg/ml and in women with normal ghrelin was 27.1+/-11.3 pg/ml (P<0.001). No differences in age, age at onset of obesity or degree of obesity were observed between the two groups. Women with hyperghrelinemia had a weight gain during the waiting time similar to women with normal ghrelin. The prevalence of comorbidities and eating behavior disturbances was similar in the two groups, but depression was 2.5 fold more prevalent in the hyperghrelinemic women than in the women with normal ghrelin. The %EWL after LAGB surgery was similar in women with high and normal ghrelin concentrations, with no differences in levels of postoperative band filling. No differences in band-related complications or revisional surgery rate were observed between the two groups.

CONCLUSION

A high fasting ghrelin concentration at baseline did not significantly affect the outcome after LAGB in morbidly obese women, in terms of weight loss and complications rate.

Body composition and resting energy expenditure in elderly male patients with chronic obstructive pulmonary disease

STUDY OBJECTIVE

Our study investigates nutritional status, resting energy expenditure (REE) and physical performance in elderly patients with stable COPD to identify any early conditions of hypermetabolism, malnutrition and sarcopenia.

METHODS

Eighty-six males (40 stable COPD and 46 healthy subjects) over 65 years old were studied. All subjects underwent spirometry, blood gas analysis and a 6-min walking test (6MWT). Fat-free mass (FFM) and appendicular skeletal muscle mass (ASMM) were measured by dual energy X-ray absorptiometry (DEXA). REE was measured by indirect calorimetry.

RESULTS

COPD patients had a lower FFM both expressed in kilograms and after correction for height squared. The prevalence of sarcopenia was higher for COPD subjects (38% vs 31%). REE, both in absolute values and adjusted for FFM was significantly higher in COPD patients. Hypermetabolism was found in 60% of COPD cases and 13.7% (P<0.01) of healthy subjects. No relationship was found in COPD patients between the measured/predicted REE ratio (REE(m)/REE(p)) and FEV1. In the hypermetabolic COPD subgroup, the REE(m)/REE(p) ratio correlated with 6MWT.

CONCLUSIONS

Elderly patients with stable COPD develop an increased REE. This hypermetabolism seems to be independent of the severity of the pulmonary obstruction and to influence the patient's physical performance.

Role of visceral proteins in detecting malnutrition in the elderly

OBJECTIVE

In the clinical practice, visceral proteins are used as indirect markers of protein energy malnutrition (PEM), but their reliability could be reduced with advancing age. The aim of this work is to investigate the reliability of albumin, prealbumin, retinol-binding protein (RBP) and transferrin in evaluating nutritional status in old patients and their relationship with fat-free mass (FFM).

DESIGN

Cross-sectional study.

SETTING

Padua, Italy.

SUBJECTS

In 44 underweight (body mass index < 20 kg/m(2)) (66-97 years) and 69 normal weight or overweight elderly subjects (62-98 years), albumin, prealbumin, transferrin and RBP were determined in the plasma. Body composition and particularly FFM was obtained by dual X-ray absorptiometry. FFM was also expressed as FFM index (FFMI) calculated as FFM divided by height squared. Subjects affected by acute illnesses and inflammatory states were excluded.

RESULTS

Albumin, prealbumin and RBP mean values were significantly lower in underweight subjects. No differences between two groups were found for transferrin. Albumin prealbumin and RBP resulted under the normal range in 55, 25 and 54% of underweight subjects, respectively. Transferrin's values were low in about 40% of underweight and normal weight subjects, respectively. In all subjects, FFMI shows a significant correlation with albumin (r: 0.52), prealbumin (r: 0.64) and RBP (r: 0.57). No correlation between FFMI and transferrin was found.

CONCLUSIONS

Visceral proteins, except for transferrin, seem to be useful indexes in detecting malnutrition in the elderly; low values still in the normal range should also be carefully evaluated because they could suggest a poor nutritional status.

Reliability of bioelectrical impedance methods in detecting body fluids in elderly patients with congestive heart failure

OBJECTIVE

To investigate the reliability of bioelectrical impedance analysis (BIA) in estimating total body water (TBW) and extracellular water (ECW) in elderly patients suffering from congestive heart failure (CHF).

MATERIAL AND METHODS

In 72 elderly subjects, 34 with CHF (aged 83.9+/-6.9 years) and 38 healthy controls (78.7+/-7.5 years), TBW and ECW values were assessed using dilution methods, and bioelectrical variables were measured using single frequency BIA (SF-BIA) at 1 and 50 kHz, and bioelectrical spectroscopy (BIS).

RESULTS

In CHF patients, Ht(2)/R(1) correlated weakly with TBW (r = 0.56) and ECW (0.47). In both healthy controls and CHF patients, TBW correlated strongly with Ht(2)/R(50), Ht(2)/R(0), Ht(2)/R(8) and Ht(2)/Zc. Using multiple regression analysis and the Bland-Altmann approach, SF-BIA at 50 kHz and BIS proved similar in predicting TBW for both the explained variance (R(2)~0.89) and the limits of agreement. In all subjects, ECW was estimated best by including height, weight and Ht(2)/R(0 )(R(2) 0.75) or Ht(2)/Zc (R(2) 0.77) in multivariate models, while SF-BIA at 50 kHz did not explain more than 71 % of ECW variability. The SEE % was nonetheless about twice the SEE % for estimating TBW.

CONCLUSIONS

SF-BIA at 1 kHz is unreliable in predicting body fluids in elderly people with CHF. SF-BIA at 50 kHz and BIS are useful for estimating TBW in healthy elderly people and in cases of water imbalance, but both methods are less reliable in estimating ECW, particularly in conditions of fluid overload.

Clinical and prognostic aspects of gastric carcinoma in the elderly

The aim of the present study was to analyze the influence of various factors on the prognosis for elderly patients with gastric carcinoma. Forty-eight patients aged > or =65 years admitted to Padova General Hospital were divided into two groups by age (<75 or >75 years). They all had a histologically confirmed diagnosis of gastric adenocarcinoma. Information on their clinicopathological characteristics was collected from the Padova Hospital medical records. On univariate analysis, significant prognostic factors in the two age groups were gender, stage, histotype (Lauren's intestinal type), Charlson index, and type of surgery (curative resection, palliative resection, and no surgery). On multivariate analysis, independent prognostic factors were the Charlson index, tumor stage, and age group. The 52-month survival rate was 72.7% for females and 12.5% for males for patients > or =75 years (P = 0.01), while for the whole series of patients it was 67.5% for females and 29.9% for males (P = 0.003). The 17-month survival rate was 55.6% for surgically treated patients and 0% for the untreated cases in stage 4 (P = 0.03). Gastric cancer should be treated with conventional surgery even in the very elderly, since the survival rate for this age group does not differ significantly from the figures for younger patients.

An adequate threshold for body mass index to detect underweight condition in elderly persons: the Italian Longitudinal Study on Aging (ILSA)

BACKGROUND

The present study aims at defining a body mass index (BMI) threshold for risk of being underweight in elderly persons on the basis of the BMI distribution in a large Italian population-based sample and on its ability to predict short-term mortality.

METHODS

At baseline (1992), BMI was obtained for 3110 (1663 males and 1447 females) persons aged 65-84 participating in the Italian Longitudinal Study on Aging (ILSA). BMI and risk factors (age, sex, education, smoking status, disability, and disease status) have been considered for their potential association with 4-year all-cause mortality. Information on vital status at 1995 was obtained for 2551 participants.

RESULTS

The fifth centile of BMI was well approximated by a value of 20 for both sexes. Also in both sexes, at a BMI value of 24 the a posteriori probability of death started to increase, doubling at a value of 22 for men and 20 for women. Crude mortality was 14.6% for men and 9.8% for women. The hazard ratios and confidence intervals (CIs) comparing mortality for each BMI two-unit class to the 26-28 class, after adjusting for confounding variables, showed significantly higher rates only for BMI values below 20 (2.9; 95% CI, 1.2-7.0), although a consistent increase in hazard ratio (1.6; 95% CI, 0.9-3.0) already appeared for the 20-22 BMI group.

CONCLUSIONS

Our study confirms that low BMI is an independent predictive factor of short-term mortality in elderly persons. A BMI value of 20 kg/m2 seems to be a reliable threshold for defining underweight elderly persons at high risk. Nevertheless, more careful clinical and nutritional management should also be applied to elderly persons with higher BMI values.

Obstructive sleep apnea syndrome in morbid obesity: effects of intragastric balloon

STUDY OBJECTIVES

In obese patients, obstructive sleep apnea syndrome (OSAS) is attributed to a reduction in pharyngeal cross-sectional area due to peripharyngeal fat deposition. The effect of weight loss on the size of the upper airways of obese subjects is still unknown. We analyzed the pharyngeal cross-sectional area before and after weight loss in morbidly obese patients with OSAS.

DESIGN, SETTING, AND SUBJECTS

A group of 17 middle-aged, morbidly obese men was evaluated by anthropometry and cardiorespiratory sleep studies before and after weight loss obtained by insertion of an intragastric balloon. The pharyngeal cross-sectional area was measured by acoustic pharyngometry.

RESULTS

The mean (+/- SD) body mass index was 55.8 +/- 9.9 kg/m2 at baseline and 48.6 +/- 11.2 kg/m2 at the time of balloon removal (6 months after insertion) [p < 0.001]. At baseline, patients had visceral obesity, large necks, and severe OSAS. Weight loss was associated with a significant mean reduction of waist circumference (156.4 +/- 17.6 vs 136.7 +/- 18.4 cm, respectively; p < 0.001), sagittal abdominal diameter (37.8 +/- 3.0 vs 32.3 +/- 4.0 cm, respectively; p < 0.001), and neck circumference (51.1 +/- 3.7 vs 47.9 +/- 4.3 cm, respectively; p < 0.001). Moreover, weight loss induced a nearly complete resolution of OSAS (apnea-hypopnea index, 52.1 +/- 14.9 vs 14.0 +/- 12.4 events/h, respectively; p < 0.001). At baseline, obese patients had significantly lower pharyngeal cross-sectional areas compared to a group of 20 nonobese male control subjects, both in the upright and supine position, at different levels of the pharynx. In obese patients, the weight loss induced by the positioning of the intragastric balloon was associated with an increase in the size of the upper airway passage. After weight loss, both the mean pharyngeal cross-sectional area and the area at glottis level were still lower in obese subjects than in nonobese subjects; however, the pharyngeal cross-sectional area at the oropharyngeal junction was similar in the two groups.

CONCLUSIONS

Morbidly obese men with OSAS have a reduced pharyngeal cross-sectional area. A weight reduction of about 15% of baseline body weight may substantially increase the pharyngeal cross-sectional area and substantially improve the severity of OSAS in morbidly obese subjects with sleep apnea.

HIV/AIDS in older adults: a case report and literature review

CASE REPORT

A 75-year-old man presented in May 2003 with suspected drop attack (atonic seizure). He reported falling over and losing consciousness. He was a retired, single ex-smoker, who lived alone in an apartment that was in a poor state of repair with precarious hygienic conditions. Over the course of 2 years he had unintentionally lost more than 10 kg (22 lbs) in weight. He had been diagnosed with diabetes approximately 10 years prior, and was receiving treatment with oral hypoglycemic therapy (fenformin/ glibenclamide, 25/2.5 mg, bid). He had been hospitalized for pneumonia in 2000. In recent months, he had gone to the emergency department several times (about once every 2 weeks) due to his weight loss and asthenia, without obtaining a definite diagnosis. On physical examination, his cognitive status was normal, but his nutritional status was deteriorated. Other clinical findings were negative. Blood chemistry tests revealed hypoalbuminemia (26.00 g/L). His personal hygiene was precarious and the apartment was completely neglected despite assistance by social support networks. In conversation with the social support worker, it was revealed that the patient was homosexual; with the patient's informed consent, he was tested and found positive for HIV. He was consequently transferred to the Infectious Diseases Department where further biochemical tests revealed: HIV-RNA Quantitative > 100.000 copies/ML COBAS Amplicor, antibodies anti-HIV 1-2 reactive sample (Enzygnost HIV Integral and Axsym HIV 1/2 GO [Abbott] EIA method, antibodies anti-HIV 1 positive (Western Blot). The patient's serum also tested positive for syphilis (TPHA positive 1:320). The patient refused any specific treatment, left the hospital, and was lost to follow-up.

Evaluation of Helicobacter pylori with a stool antigen assay in frail, elderly patients

OBJECTIVE

Helicobacter pylori infection has not been studied thoroughly in elderly patients. The aim of this study was to evaluate the reliability of stool antigen assay (HpSA) in the assessment of H. pylori infection in hospitalized, frail, elderly patients.

MATERIALS AND METHODS

The study population consisted of 85 consecutively recruited elderly patients (> or =65 years old) hospitalized between May 1999 and December 2001 with diagnostic indications for upper gastrointestinal endoscopy. Twenty-nine subjects had been receiving treatment with proton-pump inhibitors (PPIs), such as omeprazole (10-20 mg/day) for 2-15 days, and 56 were not receiving treatment. HpSA was evaluated versus UBT (urea breath test), serology and histology: patients with at least two positive results out of the latter three tests were considered positive for H. pylori infection, while patients with at least two negative tests out of three were considered negative.

RESULTS

The sensitivity and specificity of HpSA in the 56 untreated patients were, respectively, 76% (true positives TP = 22; false negatives FN = 7) and 93% (true negatives TN = 25; false positives FP = 2). The sensitivity and specificity of HpSA in the 29 patients on PPI treatment were, respectively, 82% (TP = 9; FN = 2) and 83% (TN = 15; FP = 3).

CONCLUSIONS

HpSA is an accurate, non-invasive and easy method for diagnosing H. pylori infection in elderly patients.

Total and regional body composition and energy expenditure in multiple symmetric lipomatosis

AIMS

The aim of the present study was to investigate possible alterations in body composition and resting energy expenditure (REE) in type 1 multiple symmetric lipomatosis (MSL).

SUBJECTS AND METHODS

Thirteen men aged from 40 to 78 years affected by type I MSL were compared with 13 healthy control subjects. Fat mass (FM) and fat-free mass (FFM) were determined by DEXA using both standard analysis and specifically for the lipomatous region. REE was measured by indirect calorimetry.

RESULTS

FM was higher in MSL subjects at proximal arm level, but significantly lower at distal leg level than in controls (left 1.63+/-0.55 vs. 2.26+/-0.49 kg, P<0.05; right 1.63+/-0.53 vs. 2.40+/-0.54 kg, P<0.01). Arm FFM was similar in the two groups, while distal leg FFM was significantly lower in MSL cases (left: 7.8+/-1.3 vs. 8.7+/-0.8 kg, P<0.05; right: 8.0+/-1.5 vs. 9.2+/-0.9 kg, P<0.05). FFM strongly correlated with REE (r:0.86;P<0.001). REE, expressed as an absolute value and adjusted for FFM (1830+/-215 vs. 1675+/-120 kcal, P<0.05) was higher in MSL patients.

CONCLUSION

In conclusion, MSL patients had a marked FFM and FM atrophy in the lower segments of the legs and an altered energy expenditure (hypermetabolism).

Weight loss and postoperative complications in morbidly obese patients with binge eating disorder treated by laparoscopic adjustable gastric banding

BACKGROUND

The authors investigated the outcome of morbidly obese patients with binge eating disorder (BED) treated surgically with laparoscopic adjustable gastric banding.

METHODS

The 5-year outcomes of 130 patients with BED and 249 patients without BED are described. The diagnosis of BED was made preoperatively and all patients with BED were supported with psychological therapy.

RESULTS

Patients with and without BED had similar BMI levels before surgery. More patients with than without BED had depressive symptoms and associated minor disturbances of eating behavior (night eating and grazing). Percent excess weight loss (%EWL) in the first 5 years after surgery was similar in patients with and without BED. The percentage of BED patients showing %EWL >50% at the 5-year evaluation was 23.1, and 25.7% in non-BED patients. The percentage of patients showing weight regain in the last 4 years of follow-up was similar in binge eaters (20.8%) and in non-binge eaters (22.5%). The 5-year frequency of gastric pouch and esophageal dilatation was significantly higher in binge eaters than in non-binge eaters (25.4 vs 17.7 %, P<0.05 and 10.0 vs 4.8%, P<0.05, respectively). Binge eaters underwent a higher number of postoperative band adjustments than non-binge eaters (3.0+/-2.1 vs 2.6+/-1.9, P<0.05) and the maximum band fill after surgery was higher in the BED patients than in non-BED patients (3.2+/-1.2 vs 2.8+/-1.3 ml, P<0.01).

CONCLUSION

Morbidly obese patients with BED supported by adequate psychological treatment can have good outcomes after gastric banding.

Predictors of drop-out in overweight and obese outpatients

OBJECTIVE

To investigate the impact on drop-out rates of several baseline clinical characteristics of a sample of overweight and obese outpatients.

DESIGN

Retrospective clinical trial.

SUBJECTS

The charts of 383 patients aged 15-82 y attending an outpatient clinic for the treatment of obesity were examined from the first clinical evaluation until 1 y of diet ambulatory treatment.

MEASUREMENTS

We characterised the participants at baseline on the basis of their somatic characteristics, socioeconomic status, obesity-related diseases and dietary habits. The most significant factors resulting in univariate statistical analysis (waist, body mass index (BMI), full-time job, depressive syndrome, number of obesity-related diseases, daily frequency of fruit consumption) were then examined as independent variables in direct multiple logistic regression with the dependent variable drop-out.

RESULTS

The 1-y drop-out rate was 77.3%. A total of 87 patients completed the follow-up study. The noncompleter patients had slightly lower BMI and waist circumference mean values, and they were further regularly employed in full-time jobs, while the completer patients were principally pensioners and housewives. Drop-outs had a lower number of obesity-related diseases and as a result were less depressed. By the logistic regression, full-time job is the best predictor of premature withdrawal (odds ratio=2.40). Age, gender, anthropometric measurements, lifestyle and dietary habits did not result as significant predictors of drop-out.

CONCLUSION

The overweight and obese outpatients at higher risk of ambulatory treatment drop-out are more likely to work full hours, have less obesity-related complications and be less depressed. In our study, the full-time job condition seems to be the strongest predictor of premature withdrawal.

Body composition in underweight elderly subjects: reliability of bioelectrical impedance analysis

BACKGROUND AND AIMS

In underweight elderly subjects it is important to estimate body composition and particularly fat-free mass (FFM). Bioelectrical impedance analysis (BIA) is a non-invasive method in determining FFM, but its usefulness in these frail subjects should be verified. The aim of this study is to verify in underweight elderly people the reliability of previously published BIA formulas in detecting FFM.

METHODS

Fifty-seven hospitalized elderly subjects (27 males and 30 females) with body mass index <20 kg/m(2) were selected. In all subjects, FFM was detected by dual energy X-ray absorptiometry. Moreover, BIA measurements were performed at standard frequency (50 kHz and 800 microA) and FFM was derived using the main previous published BIA equations.

RESULTS

In men, Kyle and Rising equations gave acceptable estimates of FFM with a mean error, respectively, of 1+/-1.9 and 1.4+/-1.7 kg. Also RJL formula could be used after adjusting for a correction factor. In women, no equation seemed sufficiently reliable to estimate FFM.

CONCLUSIONS

BIA method seems useful to evaluate body composition in underweight elderly men but it seems to have intrinsic limits in women. Nevertheless, the variability in behavior of the different equations suggests to be careful in adopting BIA equations.

Atherosclerotic risk factors and renal function in the elderly: the role of hyperfibrinogenaemia and smoking. Results from the Italian Longitudinal Study on Ageing (ILSA)

BACKGROUND

We examined associations between cardiovascular diseases and risk factors with pathological levels of and significant changes in serum creatinine (SCr) in a large prevalence phase and longitudinal phase community-based sample of an elderly Italian population (ILSA Study) showing no clinical evidence of renal impairment.

METHODS

The prevalence phase was performed on 2981 subjects, aged 65-84 years, who were negative for renal diseases, had available SCr values and had complete clinical information on their cardiovascular risk factors. Of these, 371 were considered 'healthy' since they were not affected by cardiovascular diseases or diabetes, whereas 2610 tested positive for cardiovascular diseases and were considered 'diseased'. The sex-specific 95th percentiles for SCr (cut-off points) were calculated in the healthy reference sample to define the upper limit for normal SCr values. The distribution and prevalence of diseased subjects having values over the cut-off point values were then estimated. Associations between values over the cut-off point levels and pathological or clinical conditions were analysed from the diseased sample. The longitudinal phase was carried out on 1906 subjects who had SCr values and sufficient clinical information for our investigation. The incidence of an increase of >26.5 micromol/l of SCr was evaluated in the longitudinal cohort.

RESULTS

In healthy subjects, the 95th SCr percentiles (cut-off points) were 123.8 micromol/l in men and 97.2 micromol/l in women. In diseased subjects, the prevalence of SCr values over the cut-off point was 4.6% in men and 9.3% in women. In logistic regression analysis, independent variables that correlated with over the cut-off point SCr values were: age >75 years [odds ratio (OR) = 2.2; 95% confidence interval (CI) = 1.5-3.4], atherosclerosis of the lower limbs (OR = 2.0; 95% CI = 1.2-3.3), cerebrovascular disease (OR = 1.9; 95% CI = 1.2-3.3), angiotensin-converting enzyme (ACE) inhibitor medication (OR = 1.8; 95% CI = 1.2-2.8), fibrinogen values >3.5 g/l (OR = 1.2; 95% CI = 1.2-2.7) and diuretic treatment (OR = 1.6; 95% CI = 1.1-2.4). After a mean 3.6 years follow-up, multiple logistic regression analysis showed that risk factors for pathological loss of renal function (rise of SCr >26.5 micromol/l) were: current smokers >20 cigarettes/day (OR = 2.3; 95% CI = 1.0-5.3), fibrinogen values >3.5 g/l (OR = 2.2; 95% CI = 1.6-3.3), diabetes (OR = 1.8; 95% CI = 1.1-2.8), age >75 years (OR = 1.7; 95% CI = 1.2-2.4) and isolated systolic hypertension (OR = 1.6; 95% CI = 1.0-2.6). The loss of renal function examined during the longitudinal phase appeared to be independent of baseline SCr levels.

CONCLUSION

The present prevalence and longitudinal studies show that age-associated decline in renal function in elderly subjects is associated with co-existing cardiovascular diseases and risk factors. These observations should be incorporated into clinical practice since some of the factors detrimental to kidney function, such as smoking, altered fibrinogen levels and elevated systolic blood pressure, can be prevented and/or modified when appropriate measures are taken.

Short-term effects of weight loss on the cardiovascular risk factors in morbidly obese patients

OBJECTIVE

To analyze the short-term effects of weight loss on the cardiovascular risk factors in morbidly obese patients.

RESEARCH METHODS AND PROCEDURES

Five metabolic cardiovascular risk factors (blood glucose, blood pressure, total cholesterol, high-density lipoprotein (HDL)-cholesterol, and triglycerides) were determined before and 15.3 +/- 2.1 months after laparoscopic gastric banding in 650 morbidly obese patients. Global cardiovascular risk was calculated according to the Prospective Cardiovascular Münster (PROCAM) scoring system.

RESULTS

Mean weight loss was 22.7 +/- 20.4 kg. Normalization of the metabolic alteration was observed in 67.3% of patients with diabetes, 38.3% of patients with hypercholesterolemia, 72.5% of patients with low HDL-cholesterol, 72.3% of patients with hypertriglyceridemia, and 46.7% of patients with hypertension. PROCAM score fell from 31.4 +/- 11.6 to 28.0 +/- 12.0 points (p < 0.001). The modifications of total cholesterol and blood pressure were unrelated to percentage weight loss. Percentage weight loss was significantly related to the reductions of fasting blood glucose, triglyceride level, and the PROCAM score and to the increase of HDL-cholesterol concentrations observed after surgery. However, the strength of these four relationships was generally low. The variations of HDL-cholesterol concentrations and blood pressure levels were more influenced by actual energy balance than by the extent of weight loss.

DISCUSSION

Weight loss observed in the first 12 to 18 months after gastric banding was associated with a significant improvement of single cardiovascular risk factors and global risk. On the other hand, the extent of weight loss was poorly related to the magnitude of improvement in cardiovascular risk.

Helicobacter pylori infection diagnosis in hospitalised elderly patients: the stool antigen test (HpSA) in comparison with other methods

BACKGROUND AND AIMS

Helicobacter pylori (Hp) infection prevalence increases with age. In elderly patients, who often do not collaborate and who are affected by multiple pathologies, worldwide-recognised invasive and non-invasive methods (histology and Urea Breath Test) are not easy to apply. A new test based on the detection of Hp antigens in the stool (HpSA test) is now available. The aim of our study was to evaluate the sensitivity and specificity of the HpSA test, and the interference of drugs (acid suppression, antibiotics) on test performance.

METHODS

Hp infection was detected by UBT, HpSA and histology in 122 hospitalised elderly subjects, divided into two groups according to therapy in the last month. Subjects were classified as being Hp-positive if two test results (histology and UBT) were positive, and Hp-negative if the same two test results were negative.

RESULTS

The sensitivity and specificity of the HpSA test compared with two tests (histology and UBT) were respectively 76 and 95%. In the group of patients who had not received drugs, the sensitivity and specificity of the HpSA test were respectively 76 and 96%. Instead, in the group of patients who had received pharmacological therapy, sensitivity and specificity values were respectively 67 and 100%. HpSA-positive patients had received acid suppression for 9.2 +/- 8.9 days, and false-negative patients for 27.2 +/- 9.9 days.

CONCLUSIONS

The HpSA test is simple, inexpensive, and non-invasive for Hp detection, especially in elderly subjects with no compliance. It is influenced only after several days by therapy common in the elderly.

Treatment of morbid obesity with the Transcend Implantable Gastric Stimulator (IGS): a prospective survey

BACKGROUND

The implantable gastric stimulator (IGS), a pacemaker-like device, has been found to be safe and effective to induce and maintain weight loss. We present our experience with 20 morbidly obese patients.

METHODS

Between September 20 and November 22, 2002, 20 patients (F/M 12/8), mean age 40.3 years (23-62) underwent IGS implantation. Mean BMI was 40.9 (33.9-48.2), mean weight 115.0 kg (87.0-137.0) and mean excess weight (EW) 51.3 kg (35.6-70.1).Co-morbitidies were: 3 cases of hypertension, 1 diabetes, 1 dislipidemia and 1 depression. Mean operative time was 58.5 min (37-85). The IGS was actived 30 days after implantation. Patients were advised to follow a low calorie diet and behavior modification (to avoid fat and to ingest more liquids during meals, to chew slowly, to eat vegetables before main meals, and to perform exercise daily).

RESULTS

Mean +/- standard error percent excess weight loss (%EWL) was: 10.6+/-1.8 at 1 month; 15.0+/-2.3 at 2 months; 16.6+/-2.6 at 3 months; 18.1+/-3.5 at 4 months; 15.5+/-3.5 at 6 months; 18.9+/-3.5 at 8 months; and 23.8+/-5.0 at 10 months. There were no intra-operative surgical or long-term complications. There were 3 intra-operative gastric penetrations, observed by gastroscopy, without sequelae. One patient with hypertension ceased his medical therapy at the 4th month.

CONCLUSION

IGS can be implanted laparoscopically with minimal perioperative complications. The observed weight loss is comparable to other noninvasive procedures. If weight loss is maintained, IGS could be considered as a first choice therapy in the treatment of morbid obesity in selected patients.

Preoperative weight loss by intragastric balloon in super-obese patients treated with laparoscopic gastric banding: a case-control study

BACKGROUND

The authors investigated the usefulness of preoperative treatment with the BIB intragastric balloon in super-obese patients before undergoing laparoscopic adjustable gastric banding (LAGB).

METHODS

The case-control study involved 43 case patients treated with the intragastric balloon followed by LAGB ("Case" group) and 43 sex-, age- and BMI-matched historical controls treated with LAGB alone.

RESULTS

Mean length of the intragastric balloon treatment was 164.4+/-39.7 days, with a fill volume of 609+/-95 ml. Total complication rate with balloon was 7.0% and percent excess weight loss (%EWL) was 26.1 +/- SD 9.3 %. At the time of gastric band placement, both operative time and hospital stay were shorter in patients treated previously with the balloon (Case group) than in the Control group patients. No Case patients required conversion to open surgery or had intraoperative complications. In the Control group, the rate of conversion was 16.3% (P<0.05) and the rate of intraoperative complications was 7.0%. Postoperative follow-up length was 1.1+/-1.0 years in Case patients and 4.4+/-1.8 years in Control patients (P<0.001). The %EWL produced by the intragastric balloon in the Case patients was identical to the %EWL observed in the first 6 months after LAGB in the Control group (26.1+/-9.3 vs 25.3+/-12.4%). %EWL 6 months after banding was higher in the Case patients than in Controls (33.6+/-12.5 vs 25.3+/-12.4%, P<0.01). However, no significant difference in %EWL between the two groups was observed at the subsequent postoperative evaluations.

CONCLUSION

Preoperative treatment with the intragastric balloon reduced the risk of conversion to open surgery and the risk of intraoperative complications in super-obese patients treated with LAGB. Preoperative treatment with the intragastric balloon did not change the total weight loss after LAGB.

Body fluid distribution in elderly subjects with congestive heart failure

The aims of this study were to investigate body fluid changes in elderly patients suffering from congestive heart failure (CHF) and to identify the fluid measurement that best characterizes fluid overload states in CHF patients by comparison with normal hydration in the elderly. In a case-controlled experimental design, 72 elderly subjects (65-98 yr), 38 healthy and 34 with CHF, were studied. Total body water (TBW) and extracellular water (ECW) were determined by dilution methods; fat-free mass (FFM) and fat mass (FM) were determined by dual-energy X-ray absorptiometry (DEXA). In healthy subjects, the FFM hydration expressed as TBW% FFM (males 72.0 +/- 4.3 vs females 72.4 +/- 5.0%) and ECW% TBW (males 47.3 +/- 3.4 vs females 47.8 +/- 5.1) were similar in both genders. ECW in liters for FFM and for TBW (ECW% TBW), corrected for body weight, was greater in the group with CHF than in the control group, in both sexes. Among the relative fluid measures, only ECW% TBW [odds ratio (OR) 1.5] independently predicted fluid retention. Having an ECW% TBW greater than 50% corresponded to an OR of about 10. In conclusion, elderly patients suffering from CHF have a characteristic increase in body fluid levels, mainly affecting the extracellular compartment, and ECW% TBW is a useful indicator of fluid retention.