[Drug treatment of obesity]

Acceptable adverse effects and a clinical relevant weight loss of 3 to 5 kilograms have been found in long-term randomized clinical trials for sibutramine (Reductil) and orlistat (Xenical); these drugs may be prescribed for treatment of obesity for a duration of one and four years, respectively. This also seems to be the case for rimonabant (Acomplia), which is expected to receive approval in 2005 or 2006. However, until data on morbidity and mortality are available from RCTs, there is no absolute indication for prescribing drugs for treatment of obesity.

[Guidelines for treatment of overweight/obesity, 2006]

Guidelines for evaluation and treatment of overweight and obesity in adults in Denmark are given. These guidelines are evidence-based and are similar to international guidelines.

The impact of idiopathic childhood-onset growth hormone deficiency (GHD) on bone mass in subjects without adult GHD

OBJECTIVE

Despite seemingly adequate growth hormone (GH) treatment during childhood, children with GH deficiency (GHD) have reduced bone mineral density (BMD) at final height. The aim was to evaluate BMD and bone mineral content (BMC) in adults treated for idiopathic childhood-onset (CO) GHD, 18 years after stopping GH treatment.

SUBJECTS AND METHODS

Twenty-six (11 females) patients with idiopathic CO GHD participated. All patients but two had been treated for isolated GHD in childhood. The childhood diagnosis was established by an insulin tolerance test (ITT) and reassessed in adulthood by an ITT (N = 21) or arginine test (n = 5), revealing that 10 patients had GHD according to adult criteria. Accordingly, the patient group was divided into (1) patients who did not have persistent GHD in adulthood and (2) patients who did have persistent adult GHD. Twenty-six healthy subjects acted as age-, gender- and body mass index (BMI)-matched controls.

RESULTS

The patients who did not have persistent GHD had significantly lower IGF-I values and whole-body, femoral neck and lumbar spine BMD compared to controls [0.994 +/- 0.10 vs. 1.114 +/- 0.11 g/cm2 (P = 0.003), 0.842 +/- 0.12 vs. 0.962 +/- 0.11 g/cm2 (P = 0.006) and 1.026 +/- 0.14 vs. 1.127 +/- 0.13 g/cm2 (P = 0.004), respectively]. Femoral neck BMD was significantly reduced in the patients who had persistent GHD, compared to controls (0.842 +/- 0.09 vs. 0.938 +/- 0.11, P = 0.04). Significant correlations were observed between all bone variables and IGF-I in all subjects, whereas no correlations were observed between bone variables and GH peak levels in the 26 patients.

CONCLUSION

In conclusion, we found that (1) patients with idiopathic CO GHD, who at retest in adulthood did not have GHD according to adult criteria, had reduced serum IGF-I and BMD/BMC compared to controls. (2) This observation was also made in the patients who did have persistent GHD in adulthood. The findings may reflect the fact that the present diagnostic criteria for adult GHD (i.e. response to the ITT) do not reflect the clinical consequences of disordered GH-IGF axis in CO GHD young adults who were treated with GH in childhood. Alternatively, despite seemingly adequate GH treatment in childhood an optimal peak bone mass in adolescence may never have been reached in either of the groups. (3) IGF-I levels correlated with clinical signs of the adult GHD syndrome. We believe that further studies on the indications and diagnostic procedures for GH treatment after cessation of linear growth are necessary.

Abnormal bone collagen morphology and decreased bone strength in growth hormone-deficient rats

Patients with growth hormone deficiency (GHD) have an increased risk of bone fractures. In these patients, the well-described decrease in bone mineral density (BMD) and content (BMC) may, however, not alone explain the increase in fracture rate. Accordingly, the aim of this study was to evaluate collagen morphology and bone mineralisation in cortical bone as well as bone strength in GHD rats to try to clarify the explanation for the increased fracture rate. The Dw-4 rat was used as a model for GHD. This strain of rats has an autosomal recessive disorder, reducing GH synthesis to approximately 10% and growth rate to approximately 40-50% when compared to normal control rats. Five male Dw-4 rats were examined at age 12 weeks and five healthy Lewis rats served as age-matched controls. The animals were examined for (1) bone mineral status by dual energy X-ray absorptometry (DXA) and ash weight/bone volume, (2) biomechanical properties, (3) serum insulin-like growth factor I (IGF-I) and IGF binding protein 3 (IGFBP-3), and (4) collagen morphology of cortical bone from the right femurs was examined by scanning and transmission electron microscopy. A significant decrease was found in serum IGF-I, IGFBP-3 and biomechanical properties in GHD rats compared to controls (P < 0.009). While DXA-derived BMD was decreased, no significant difference was found in ash weight/bone volume. Electron microscopy showed a significant decrease in the number and a significant increase in the diameter of collagen microfibrils in GHD rats as compared to their controls (P < 0.009). In conclusion, we report for the first time that collagen morphology in bone is markedly altered in rats with isolated GHD. Whether similar conditions are present in GHD patients need further investigations. The changes described, however, may provide a co-explanation for the increased fracture rate in GHD.

Abnormal sympathoadrenal activity, but normal energy expenditure in hypopituitarism

In this study of 23 hypopituitary patients and 26 healthy controls, we have addressed whether the obese state of substituted hypopituitary patients is facilitated by abnormal sympathoadrenal activity or energy expenditure (EE). All patients received adequate substitution therapy including GH therapy. The investigation program included assessment of sympathoadrenal activity (urinary catecholamines), body composition (dual-energy x-ray absorptiometry), appetite sensations (visual analog scale), and EE (indirect calorimetry in respiration chamber). Twenty-four-hour urinary epinephrine adjusted for lean body mass and fat mass was significantly lower in patients compared with controls. GH and hydrocortisone were single negative predictors of urinary epinephrine. The major determinants of EE in patients were lean body mass and fat mass, explaining 96, 95, and 80% of the variance in 24-h EE, sleeping EE, and basal metabolic rate, respectively. Addition of urinary catecholamines explained another 1-4% of the variance in 24-h EE and basal metabolic rate, respectively. Lean patients exhibited significantly more hunger than obese patients and lean controls. In conclusion, hypopituitary patients have lower sympathoadrenal activity but normal EE, compared with healthy controls. This may reflect a central defect in hypopituitarism, however the possible impact of long-term GH and hydrocortisone treatment requires further attention.

High risk of adrenal insufficiency in adults previously treated for idiopathic childhood onset growth hormone deficiency

The aim was to reevaluate a group of adults treated for idiopathic childhood onset GH deficiency (GHD) after 18 yr without GH treatment. Twenty-six (11 females) patients participated. All but two had isolated GHD. Childhood diagnosis was established by insulin tolerance test (ITT). The patients were retested with an ITT to evaluate adult GH status. In five patients, an arginine and a synacthen test were performed instead of an ITT. Eleven of 25 patients had a subnormal cortisol response to ITT or synacthen. Ten patients had a GH peak less than 3.0 microg/liter (0.5. +/- 0.5 microg/liter), whereas 16 patients displayed a normal GH response (12.3 +/- 10.6 microg/liter) after ITT. IGF-I values were decreased in the patients with a pathological retest as well as in patients with a normal GH response compared with controls (P < 0.005). In 26 idiopathic childhood onset GHD patients, 44% of the patients had developed adrenal insufficiency; 38.5% had persistent GHD in adulthood, using the same test in both childhood and adulthood. Patients having a normal GH test had decreased IGF-I levels, compared with controls, indicating impaired function of a seemingly normal GH axis. It is imperative that pituitary axes other than the GH axis are tested at regular intervals, even in the absence of GHD in adulthood.

Should measurement of body composition influence therapy for obesity?

This paper presents a review on assessment of obesity by measurement of body composition. It is recommended that cross-calibrations between methods are made and that cut-off levels for defining obesity are based on the association between body fat% and morbidity and mortality. The recommendation is made for assessment of obesity to measure body mass index (BMI) and waist circumference in combination with clinical judgment and a disease risk assessment. Assessment of body composition for evaluation of obesity is a valuable tool in research, but currently it does not influence the choice of therapy in an obese individual. An individual who is misclassified by BMI may benefit from measurement of body composition, but not until further evidence and development of current body composition methods are available.

Comparisons of leptin, incretins and body composition in obese and lean patients with hypopituitarism and healthy individuals

OBJECTIVE

To identify possible abnormalities specific for obesity in hypopituitary patients.

STUDY DESIGN

Cross-sectional case-control study. MEASUREMENTS AND STUDY SUBJECTS: Body composition (DEXA) and measurements of fasting plasma levels of glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptides (GLPs), insulin, C-peptide, glucose, leptin and lipids were performed in 25 hypopituitary patients (15 obese, 10 normal weight) and 26 BMI and age-matched healthy controls (16 obese, 10 normal weight). All hypopituitary patients had GH deficiency and received adequate substitution therapy on this and other deficient axes (3 +/- 1).

RESULTS

Fasting GIP-levels were significantly higher in obese hypopituitary patients compared to lean hypopituitary patients (P < 0.01), while the fasting concentrations of GLP-1 and GLP-2 were comparable between obese and lean hypopituitary patients. The same trend was seen in obese healthy controls vs. lean controls. No differences were observed in glucose, insulin or C-peptide between the hypopituitary patients and the controls. Leptin levels were increased in obese hypopituitary patients compared to lean hypopituitary patients when adjusted for gender. At least a 2-fold higher level of leptin was observed in women compared to men in both patient groups and healthy controls. Lean female hypopituitary patients had higher leptin levels than matched controls.

CONCLUSIONS

Fasting levels of GIP were elevated in obese substituted hypopituitary patients, while fasting concentrations of GLPs were similar. Obese hypopituitary patients had the same degree of hyperinsulinaemia, affected glucose tolerance, dyslipoproteinaemia and central obesity as obese healthy controls. Further studies are required to identify the possible biochemical reasons for obesity in patients with apparently well-substituted hypopituitarism.

[Sporadic registration of obesity as secondary diagnosis]

INTRODUCTION

The aim was to examine the extent to which obese patients, who are followed up for an obesity-related disease in an outpatient clinic, are correctly registered with the secondary diagnosis of obesity.

MATERIAL AND METHODS

We investigated the number of patients at the Endocrine Outpatient Clinic, Rigshospitalet, Copenhagen, who were registered in the patient administrative system with the primary diagnosis of type 2 diabetes, and how many of these were registered with the secondary diagnosis of obesity.

RESULTS

Of 233 patients with type 2 diabetes, 79 had a BMI between 25.0 and 29.9 kg/m2 (overweight) and 108 a BMI > 30 kg/m2 (obesity). Thus, 80% of these patients were overweight or obese. Of the 108 patients with a BMI > 30 kg/m2. only 13 (12%) were registered with the secondary diagnosis of obesity, and of 17 severely obese patients with a BMI > 40 kg/m2 only four (24%) were registered with the secondary diagnosis of obesity.

DISCUSSION

Obese patients with type 2 diabetes are seldom correctly registered with the secondary diagnosis of obesity. The actual practice of registration probably causes a large underestimation of the impact, and thereby of the magnitude of the economic cost of and the contribution of obesity to total health care costs. Improved registration of obesity as secondary diagnosis in obesity-related diseases is needed.

[Obesity in Danish hospitals--treatment in the year 2000]

INTRODUCTION

Obesity is of increasing public health concern. The aim of the study was to investigate the treatment of obesity at Danish hospitals in the year 2000, and to compare the results with a similar study from 1987.

MATERIALS AND METHODS

A questionnaire was sent to the heads of departments of internal medicine at all Danish hospitals where such departments exist (64).

RESULTS

Ninety-one percent of the questionnaires were answered. Fewer hospitals (76%) in Denmark treated obesity in 2000 compared to 1987. About 1400 patients were referred, and the treatment of 500-900 patients was concluded yearly. Many departments reject patients when the primary diagnosis for referral is obesity, often because they lack resources or do not have the capacity. Except for university hospitals, obesity was more often treated on an outpatient basis in 2000 than in 1987. Apart from surgery, the same methods were used to treat obesity at the different types of hospitals. Instructions for treatment, long-term outpatient follow-up, quality assurance, evaluation of the treatment, and research in obesity are carried out to some degree at the university hospitals, and only to a small extent at other types of hospitals.

DISCUSSION

Although obesity is becoming an increasing threat to public health, treatment at Danish hospitals has decreased over the last ten years, and in the year 2000 only a few per thousand obese patient were offered treatment by a hospital. Increased focus and resources, as well as development and research targeted specifically on the treatment of obesity are needed.

[Obesity in Danish hospitals--attitudes in the year 2000]

INTRODUCTION

The aim was to investigate the attitudes towards obesity of those responsible for the treatment at Danish hospitals.

MATERIALS AND METHODS

A questionnaire was sent to the heads of departments of internal medicine at all Danish hospitals where such exist (n = 64).

RESULTS

Eighty-nine per cent of the questionnaires were answered. Sixteen per cent believed that obesity is a self-imposed, life-style disease, and 56% answered "perhaps". 66% believed that obesity is a chronic condition or disease, and 32% thought that obese patients should be followed up life-long. Most believed that diseases would be prevented or improved, if obesity were treated, and 72% believed that it was possible to treat obesity. Thirty-five percent answered "perhaps" to whether it is worth the effort to treat obesity, as weight loss seldom lasts in the long term, and 25% answered "perhaps" to whether loss of weight in the obese incurs health risk. Fifty per cent believed that more resources were needed for the treatment of obesity, and that research in obesity should be given more attention, whereas only a few answered in the negative (6-9%). Thirty-three per cent believed that there was a need for public obesity clinics. Only 15% thought that Danish doctors are sufficiently trained to treat obesity, and only 9% answered "no" to whether better treatment of obesity required altered attitudes to obesity among Danish health care personnel.

DISCUSSION

The heads of departments of internal medicine at Danish hospitals had different attitudes to obesity, but most believed that there is a need for altered attitudes, information, and training of Danish doctors and other health care personnel in the treatment of obesity.

Are soft tissue composition of bone and non-bone pixels in spinal bone mineral measurements by DXA similar? Impact of weight loss

Weight loss seems associated with a decrease in bone mineral density (BMD) as measured by absorptiometry, which may be the result of accuracy errors caused by differences in soft tissue between non-bone and bone pixels. The aim was to study the abdominal fat% and thickness in regions corresponding to non-bone, soft tissue-only and bone pixels for spinal BMD measurements by dual energy X-ray absorptiometry (DXA), and to calculate the theoretical errors in measurement of changes in BMD by DXA as a result of changes in soft tissue heterogeneity with weight loss. Abdominal computed tomography (CT) and DXA scans were performed in 34 obese subjects (42.1+/-10.1 years (mean +/- SD), wt: 102.1+/-12.8 kg and BMI: 36.6+/-3.8 kg m(-2)) before and after weight loss (11.3+/-6.9 kg after 1 year). There were some significant differences in fat% and thickness of soft tissue between abdominal regions corresponding to non-bone and bone pixels, respectively, for spinal BMD measurements by DXA, both before and after weight loss. With weight loss there were some changes in the soft tissue heterogeneity, which caused a minor theoretical error (apparent, but false decrease of 1-2%) of borderline significance for the anterior-posterior (AP) spinal BMD by DXA.

Body composition in italian and Danish women

The objective of this cross-sectional study was to compare the body composition and fat distribution measured by dual energy X-ray absorptiometry (DPX, Lunar) in different age decades of age-matched Danish and Italian women. The subjects comprised 133 healthy Italian women (age 20-60 years) age-matched to a representative sub-sample of healthy Danish women (n=375). Total and abdominal body fat tissue mass were measured by dual-energy X-ray absorptiometry. Italian women were shorter and fatter compared with age-matched Danish women, but in middle-age, had a less abdominal fat distribution. There was no difference in total body bone mineral density.

Measurements of body composition by dual-energy X-ray absorptiometry improve prediction of energy expenditure

The prediction of energy expenditure by dual-energy X-ray absorptiometry (DXA) and bioimpedance analysis (BIA) was assessed in 35 healthy individuals of both sexes, with a mean body mass index (BMI) of 23.8 kg/m2 (range 18-33.8), and mean age of 30 years (22-40). Energy expenditure (EE) was measured under standard conditions in a respiration chamber, the total and regional body composition by DXA, and total body composition by BIA. When body composition was measured by BIA, 88.5% of the variation in 24-h EE was explained by lean body mass (LBM); this figure was increased by DXA, where total lean tissue mass (LTM) and total fat tissue mass (FTM) could account for 91.5% of the variation. Also, the prediction of resting energy expenditure (REE) was improved by DXA, from 88.1% to 89.8% (LBM vs. LTM, FTM). Measurements of regional body composition showed that trunk LTM was significantly superior as a predictor, especially of REE and sleeping EE (EE sleep), compared to the peripheral LTM; thus, the predictions of REE were 83% vs. 87% (peripheral vs. trunk), respectively; and the predictions of EE sleep were 83% vs. 89% (peripheral vs. trunk), respectively. Therefore, body composition measurements by DXA improved the prediction of EE. Trunk LTM was a superior predictor, especially of REE and EE sleep, compared to peripheral LTM. In conclusion, the present results suggest that measuring total and regional body composition by DXA can somewhat improve the prediction of EE.

The influence of long-term supplementation with biotin on the prevention of lameness in pasture fed dairy cows

In a double-blind study, the influence of biotin supplementation on lameness in dairy cows was investigated over a 13-mo period. The experimental site was a tropical upland environment and involved over 2705 Holstein and Friesian cows on 20 participating farms. Cows on 10 farms received biotin at a rate of 20 mg/head per day in the concentrate, and cows on 10 other farms received feed without the biotin supplement. Premixes with or without biotin were incorporated into a grain concentrate that was fed at a constant rate to cows at milking. Farmers maintained accurate records of the nature of hoof problems and any treatment applied. Each herd was evaluated for locomotion scores at 8-wk intervals. Locomotion scores were significantly correlated with the number of days with measurable rainfall per month (r = 0.88). The biotin-supplemented herds exhibited better locomotion scores than the unsupplemented herds. In the wet summer period the number of lame cows, as observed by the farmer, were significantly fewer during the rainy period for the biotin-supplemented herds and required fewer antibiotic treatments than unsupplemented herds. Most hoof lesions were most commonly observed in the outer claws of the hind limb. Daily milk production (17.3 vs. 18.5 L) was not affected by biotin supplementation. Reduced milk fat percentage and somatic cell counts of bulk milk were recorded in the biotin supplemented herds during the wet, summer period.

Comparison of resting energy expenditure measurements by ventilated canopy and by respiration chamber

The study compared measurements of resting energy expenditure (REE) by two methods, namely the commercially available ventilated canopy (Medgraphics CCM system) and the respiration chamber. Thirty-five healthy subjects of both sexes with a wide weight range (BMI 18-33.8 kg m-2) were measured on both systems. The linear regression equation was REEcanopy = 0.66 x REEresp.cham. + 61.1 (kJ h-1), and the corresponding SEE% was 8.6%. The correlation was high (r = 0.89). However, the mean REE measured using the ventilated canopy was 41 kJ h-1 (13%) lower than that using the respiration chamber (P < 0.01). The Medgraphics CCM canopy system seems valid for measurements of REE. However, the REE results measured by the canopy were systematically lower than when measured by the respiration chamber, but can be converted by the equation given with an accuracy error of 9%.

Does paracentesis of ascites influence measurements of bone mineral or body composition by dual-energy x-ray absorptiometry?

Measurements of bone mineral content (BMO) and density (BMD) by dual-energy x-ray absorptiometry (DXA) may be affected by changes in soft tissue overlying bone. Furthermore, the accuracy error for body composition determined by DXA may be high in the trunk region due to the complex bone geometry. Our objective was to evaluate the impact of paracentesis on measurements of bone mineral and body composition by DXA. DXA (Norland XR-36; Norland, Fort Atkinson, WI) scans were performed in six patients with cirrhosis of the liver before and after treatment of ascites by paracentesis. There were no significant differences in the spinal BMC (change [delta] = 0.04%) and BMD (delta = -0.9%) (P > .05), nor in total body BMC ([TBBMC] delta = 1.9%) and BMD ([TBBMD] delta = 0.4%) (P > .05). The median volume of ascites drained (6.8 L; range, 1.6 to 14.7) was not significantly different from the median change in total (5.8 kg; range, 2.0 to 16.1) or trunk lean tissue mass ([LTM] 5.8 kg; range, 1.9 to 11.9) (P > .05). The changes in body weight correlated with the changes in trunk LTM (r = .93, standard error of the estimate [SEE] = 1.8 kg, P = .007). Total and regional fat mass were not changed significantly by the paracentesis. We conclude that measurements of total body and spinal bone mineral by DXA are unaffected by large changes in the soft tissue composition and height of the trunk. Furthermore, the change in body composition induced by ascites drainage was accurately determined as a change in total body and trunk LTM on a group level.

Bone mineral in pre- and postmenopausal women with insulin-dependent and non-insulin-dependent diabetes mellitus

The aim of the study was to compare bone mineral density (BMD) and bone turnover in pre- and postmenopausal women with insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM) and normal reference women. In a cross-sectional study 31 and 11 premenopausal and 22 and 21 postmenopausal IDDM and NIDDM patients, respectively, were recruited from an outpatient clinic. BMD in the forearm, spine, femur and total body and biochemical markers of bone turnover were measured and compared with reference values obtained from measurements of normal healthy pre- and postmenopausal women. Postmenopausally, but not premenopausally, IDDM patients had lower BMD values than NIDDM patients. Postmenopausal NIDDM patients had higher BMD value than normal women. The differences in BMD between IDDM and NIDDM patients could be explained statistically by differences in body weight between the NIDMM (obese) and IDDM (lean) women. Markers of bone turnover were significantly higher postmenopausally than premenopausally in both IDDM and NIDDM patients. Osteocalcin was significantly lower in postmenopausal NIDDM compared with postmenopausal IDDM patients and reference values. Otherwise there were no differences in the markers of bone turnover between NIDDM and IDDM patients. In conclusion, postmenopausal IDDM patients have a relatively decreased BMD, whereas NIDDM patients seem to be relatively protected from postmenopausal bone loss.

Leptin in overweight postmenopausal women: no relationship with metabolic syndrome X or effect of exercise in addition to diet

OBJECTIVE

To examine the effect of diet with exercise on serum leptin and whether leptin is associated with the metabolic syndrome X in a high risk population such as overweight postmenopausal women.

STUDY DESIGN AND SUBJECTS

121 healthy overweight, postmenopausal women (aged 49-58y, body mass index (BMI) 25-42 kg/m2) were randomized to: A low-energy-diet, 4.2 MJ/d (n = 51), low-energy-diet + standardized physical exercise (n=49) or no intervention (control: n=21) for 12 weeks, followed by 6 months follow-up without intervention.

MEASUREMENTS

S-leptin was measured by Radio Immuno Assay (RIA), body composition and fat distribution by dual energy X-ray absorptiometry (DEXA) and anthropometry. Factors associated with the metabolic syndrome X and sex hormones were measured.

RESULTS

S-leptin was two-fold higher than in normal-weight postmenopausal women and S-leptin was normalized after weight loss induced by the 12-week low-energy-diet, without any additive effect of the exercise. Of the factors associated with the metabolic syndrome X, serum-leptin correlated significantly only with sex-hormone-binding-globulin and plasminogen-activator-inhibitor-1, whereas factors associated with obesity per se correlated significantly with leptin. Changes in S-leptin correlated with changes in fat tissue mass during the follow-up, but not during the intervention. S-leptin at baseline did not correlate with either short term or long term weight loss.

CONCLUSION

There is no effect of exercise added to diet on S-leptin in overweight postmenopausal women. Leptin does not seem to be associated with the metabolic syndrome X, but rather with fatness. S-leptin is probably associated with both dynamic and static effects of adipose tissue. S-leptin did not predict weight loss.