Health-related quality of life in obese outpatients losing weight with very-low-energy diet and behaviour modification--a 2-y follow-up study

OBJECTIVE

To study health-related quality of life (HRQL) in a clinically selected sample of obese outpatients.

DESIGN

A single-strand before and after study with 2-y follow-up after treatment comprising 10 weeks on very-low-energy diet (VLED) and 4 months of behaviour modification in groups.

SUBJECTS

A total of 126 (mean (s.d.) age 48.2 (11.1) y and body mass index 42.8 (6.2) kg/m(2) obese patients (63% women) referred for treatment in an obesity clinic.

MEASUREMENTS

Weight and HRQL using questionnaires (RAND 36-Item Health Survey 1.0 and Obesity-related Psychosocial problems scale (OP-scale)).

RESULTS

A total of 100 patients (61% women) completed the treatment and 67 (71% women) completed the 2-y follow-up. The mean (s.d.) weight loss was 12.5 (5.6)% at the end of group therapy, 6.0 (7.1)% at 1 y, and 2.6 (7.5)% at 2 y. At baseline, the mean (s.d.) score for the OP-scale was 61.9 (24.6). The mean scores on every RAND-36 scale were markedly lower than in the Finns without chronic conditions. All the scales in HRQL improved markedly during the treatment. During the follow-up, all the scales started to return towards baseline levels, and at 2 y only obesity-related psychosocial problems and physical functioning were still improved relative to baseline. In categories of weight change at 2 y (>or=10% weight loss, 0-9.9% weight loss, weight gain), obesity-related psychosocial functioning, physical functioning, and general health showed dose-response improvement with increasing weight loss. A >or=10% weight loss at 2 y after treatment was associated with clear improvement in obesity-related psychosocial problems, physical functioning, physical role functioning, bodily pain, general health, mental health, and vitality. A 0-9.9% weight loss was associated with improvement in obesity-related psychosocial problems and physical functioning. Weight gain was associated with improvement in obesity-related psychosocial problems and social functioning. The study population was too small to examine possible gender differences.

CONCLUSIONS

Treatment with VLED and behaviour modification produces marked short-term weight loss and clear improvement in all aspects of HRQL. At 2 y after treatment, the average maintained weight loss is modest. However, 1/3 of patients maintained a >or=5% weight loss. Improvement in obesity-related psychosocial problems and physical functioning is associated even with less than 10% of maintained weight loss. Since the pattern of HRQL changes only partly followed the pattern of weight change as expected, other factors, such as the therapeutic effect of participating in the weight loss programme or increase in physical activity, may affect HRQL responses.

Health-related quality of life in obese outpatients losing weight with very-low-energy diet and behaviour modification: a 2-y follow-up study

OBJECTIVE

To study health-related quality of life (HRQL) in a clinically selected sample obese outpatients.

DESIGN

A single-strand before and after study with 2-y follow-up after treatment comprising 10 weeks on very-low-energy diet (VLED) and 4 months of behaviour modification in groups.

SUBJECTS

A total of 126 patients (mean (s.d.) age 48.2 (11.1) y and body mass index (BMI) 42.8 (6.2) kg/m(2) (63% women)) referred for treatment in an obesity clinic.

MEASUREMENTS

Weight and HRQL using questionnaires (RAND 36-Item Health Survey 1.0 and Obesity-related Psychosocial problems-scale).

RESULTS

In all, 100 patients (61% women) completed the treatment and 67 (71% women) completed the 2-y follow-up. The mean (s.d.) weight loss was 12.5 (5.6)% at the end of group therapy, 6.0 (7.1)% at 1 y, and 2.6 (7.5)% at 2 y. At baseline, the mean (s.d.) score for OP-scale was 61.9 (24.6). The mean scores on every RAND-36 scale were markedly lower than in the Finns without chronic conditions. All the scales in HRQL improved markedly during the treatment. During the follow-up, all the scales started to return back towards baseline levels and at 2 y, only obesity-related psychosocial problems and physical functioning were still improved relative to baseline. In categories of weight change at 2 y (> or =10% weight loss, 0-9.9% weight loss, weight gain), obesity-related psychosocial functioning, physical functioning, and general health showed dose-response improvement with increasing weight loss. A > or =10% weight loss at 2 y after treatment was associated with clear improvement in obesity-related psychosocial problems, physical functioning, physical role functioning, bodily pain, general health, mental health, and vitality. A 0-9.9% weight loss was associated with improvement in obesity-related psychosocial problems and physical functioning. Weight gain was associated with improvement in obesity-related psychosocial problems and social functioning. The study population was too small to examine possible gender differences.

CONCLUSIONS

Treatment with VLED and behaviour modification produces marked short-term weight loss and clear improvement in all aspects of HRQL. At 2 y after treatment, the average maintained weight loss is modest. However, one-third of patients maintain > or =5% weight loss. Improvement in obesity-related psychosocial problems and physical functioning is associated even with &<10% of maintained weight loss. Since the pattern of HRQL changes did only partly follow the pattern of weight change as expected, other factors, such as the therapeutic effect of participating in the weight loss programme or increase in physical activity, may affect HRQL responses.

Sex hormones and sexual function in obese men losing weight

OBJECTIVE

To study the impact of a weight-loss program on sex hormones and sexual function among 38 middle-aged obese men (BMI >or=35 kg/m(2)).

RESEARCH METHODS AND PROCEDURES

A randomized controlled clinical trial was conducted. The treatment group (n = 19) participated in a 4-month weight-loss program including 10 weeks on a very-low-energy diet (VLED) and 17 behavior modification visits. There was no intervention in the control group (n = 19). Both groups were followed for 8 months, i.e., 22 weeks after the active weight loss in the treatment group. The outcome measures (weight, sex hormones, sexual function, leptin, and metabolic variables) were obtained at baseline and at three time-points during follow-up.

RESULTS

The mean weight loss in the treatment group was 21 kg at the end of the 10-week VLED. At the end of follow-up, the maintained weight loss was 17 kg of baseline weight. The control group was weight stable throughout the study. In the treatment group, increases in sex hormone-binding globulin, testosterone, and high-density lipoprotein-cholesterol, as well as decreases in insulin and leptin, were maintained until the end of follow-up, although with VLED, the level of several hormones and metabolic variables improved transiently during the rapid weight loss. There were no significant changes in the questionnaire scores on sexual function in either group.

DISCUSSION

We conclude that obese men lose weight and increase their serum testosterone level on a weight-loss program with VLED and behavior modification. However, they do not change their sexual function scores.

Melanocortin-3-receptor gene variants in morbid obesity

BACKGROUND

Linkage and knock-out mice studies suggest that the melanocortin-3-receptor (MC3R) is a candidate gene for obesity.

OBJECTIVE

To evaluate whether MC3R mutations underlie morbid obesity.

SUBJECTS AND METHODS

MC3R coding and 5(')-flanking regions were sequenced in 48 subjects and the detected variants genotyped in 252 morbidly obese (BMI>/=40 kg/m(2)) Finns. Gel shifts were used to examine whether a mutation in the putative promoter alters GATA-factor binding.

RESULTS

Three common MC3R variants were found: a 17C>A variant, changing Thr6-->Lys in 16%, a 241G>A variant changing Val81-->Ile in 15%, and a -239A>G substitution in the GATA binding site in 21% of the subjects. Four other variants were detected in the 5(') flanking region. Frequencies of the three common variants did not differ between obese and contol subjects. Among the obese, the 17C>A and 241G>A variants were coinherited and associated with increased insulin-glucose ratios (P<0.05) and leptin levels (P<0.05). GATA-4 bound efficiently to wild type oligonucleotide, but only weakly to the oligonucleotide with the -239A>G mutation.

CONCLUSIONS

MC3R gene variants are common and do not explain human morbid obesity. These variants associated with subtle changes in onset of weight gain, hyperleptinemia and insulin-glucose ratios. The -239A>G mutation abolishes binding of GATA-4 to the MC3R promoter region.

Clinical and biochemical characteristics and genotype-phenotype correlation in Finnish variegate porphyria patients

Variegate porphyria (VP) is an inherited metabolic disease resulting from the partial deficiency of protoporphyrinogen oxidase, the penultimate enzyme in the heme biosynthetic pathway. We have evaluated the clinical and biochemical outcome of 103 Finnish VP patients diagnosed between 1966 and 2001. Fifty-two per cent of patients had experienced clinical symptoms: 40% had photosensitivity, 27% acute attacks and 14% both manifestations. The proportion of patients with acute attacks has decreased dramatically from 38 to 14% in patients diagnosed before and after 1980, whereas the prevalence of skin symptoms had decreased only subtly from 45 to 34%. We have studied the correlation between PPOX genotype and clinical outcome of 90 patients with the three most common Finnish mutations I12T, R152C and 338G-->C. The patients with the I12T mutation experienced no photosensitivity and acute attacks were rare (8%). Therefore, the occurrence of photosensitivity was lower in the I12T group compared to the R152C group (P=0.001), whereas no significant differences between the R152C and 338G-->C groups could be observed. Biochemical abnormalities were significantly milder suggesting a milder form of the disease in patients with the I12T mutation. In all VP patients, normal excretion of protoporphyrin in faeces in adulthood predicted freedom from both skin symptoms and acute attacks. The most valuable test predicting an increased risk of symptoms was urinary coproporphyrin, but only a substantially increased excretion exceeding 1,000 nmol/day was associated with an increased risk of both skin symptoms and acute attacks. All patients with an excretion of more than 1,000 nmol/day experienced either skin symptoms, acute attacks, or both.

Health-related quality of life in WHO class II-III obese men losing weight with very-low-energy diet and behaviour modification: a randomised clinical trial

OBJECTIVE

To study health-related quality of life responses to marked weight loss in WHO Class II-III (body mass index (BMI) > or = 35 kg/m2) obese men.

DESIGN

An 8 month randomised clinical trial with a 4 month weight loss programme (10 weeks on a very-low-energy diet (VLED) and 17 behaviour modification visits) in the treatment group and no intervention in the control group.

SUBJECTS

Nineteen men (mean age 45.9 y, mean BMI 39.3 kg/m2) in the treatment group and 19 men (47.2 y, 39.4 kg/m2) in the control group.

MEASUREMENTS

Weight and questionnaires measuring health-related quality of life (RAND 36-Item Health Survey 1.0 and obesity-related psychosocial problems scale).

RESULTS

In the treatment group, the mean (s.d.) weight loss was 17.0 (7.4)% at the end of the 4 month therapy. At the end of follow-up, nearly 6 months after the end of VLED in the treatment group, the average maintained weight loss was 13.9 (7.8)% of baseline weight. The control group was weight stable throughout the study. During treatment, there was only transient improvement in general health, bodily pain, mental health, emotional role functioning and vitality (all increases in the scores were not statistically significant). Improvements in physical functioning, social functioning and obesity-related psychosocial problems were maintained until the end of follow-up. The treatment group also reported improvement in perceived health in the past year. There was only minor fluctuation in questionnaire scores in the control group.

CONCLUSION

The short-term and maintained health-related quality of life effects of weight loss may differ. Marked weight loss in WHO Class II-III obese men leads to improvements in physical functioning, social functioning, obesity-related psychosocial problems, and perceived health; these improvements were maintained at 4 month post-intervention follow-up.

Comparison between repaglinide and glipizide in Type 2 diabetes mellitus: a 1-year multicentre study

AIMS

To evaluate the long-term effectiveness and safety of repaglinide, a novel prandial glucose regulator, in comparison with glipizide in the treatment of patients with Type 2 diabetes.

METHODS

Diet or tablet-treated patients with Type 2 diabetes (n = 256; age 40-75 years, body mass index (BMI) 20-35 kg/m2, HbA1c 4.2-12.8%), without signs of severe microvascular or macrovascular complications, were included in this double-blind, multicentre, parallel-group comparative trial. Patients were randomized at a 2:1 ratio to repaglinide, 1-4 mg at mealtimes, or glipizide, 5-15 mg daily.

RESULTS

Changes in fasting blood glucose (FBG) and HbA1c during the 12 months of treatment showed a significant difference in favour of repaglinide. In oral hypoglycaemic agents (OHA)-naive patients, HbA1c decreased in the repaglinide and glipizide groups by 1.5% and 0.3%, respectively (P < 0.05 between groups). Fasting blood glucose decreased in the repaglinide group by 2.4 mmol/l and increased in the glipizide group by 1.0 mmol/l (P < 0.05 between groups). In the study population as a whole, repaglinide was able to maintain glycaemic control (HbA1c level) during the 1-year study period, whereas control deteriorated significantly with glipizide. Change in HbA1c from baseline was significantly better with repaglinide than with glipizide after 12 months (P < 0.05). In addition, FBG deteriorated significantly in the glipizide group compared with the repaglinide group (P < 0.05). No patients in either group experienced a major hypoglycaemic event; the number of patients experiencing minor hypoglycaemia was similar in the repaglinide and glipizide groups (15% and 19%, respectively).

CONCLUSIONS

Repaglinide, given as a prandial glucose regulator, is shown to be an effective and safe treatment of patients with Type 2 diabetes, and is better than glipizide in controlling HbA1c and FBG levels, overall, and in OHA-naive patients.

Homozygous variegate porphyria: 20 y follow-up and characterization of molecular defect

The long-term follow-up of a homozygous variegate porphyria patient revealed severe photosensitivity accompanied by mild sensory neuropathy and IgA nephropathy. A 35T to C transition in exon 2 (I12T) and a 767C to G transversion in exon 7 (P256R) of the protoporphyrinogen oxidase gene were identified from both alleles of the patient's cDNA and genomic DNA samples. Both prokaryotic and eukaryotic expression studies showed that the first mutation in the evolutionary conserved region resulted in a decrease in the protoporphyrinogen oxidase activity in contrast to the polymorphic substitution in exon 7, which affected the function of the enzyme assayed in Escherichia coli but not COS-1 cells.

Very low energy diets in the treatment of obesity

Very low energy diets (VLEDs) are defined as diets which contain energy levels of less than 3.4 MJ (800 kcal) per day and contain daily allowances of all essential nutritional requirements. These diets have been in clinical use for more than 20 years. They are used as the only source of nutrition for 8-16 weeks, which usually achieves a weight loss of 1.5-2.5 kg per week. Before using this type of diet a medical investigation is necessary to evaluate contraindications and to check medication use during the diet. To facilitate maintenance, cognitive behavioural counselling should always be included in a weight reduction programme using a very low energy diet. VLEDs have no serious harmful effects and can safely be used in patients with various chronic diseases. Programmes using VLEDs produce better short-term weight loss than programmes without the diet. However, in randomized controlled trials VLED-based programmes have not achieved significantly better long-term maintenance than conventional programmes. VLEDs are used when rapid weight loss is necessary because of an obesity-related disease. In other patients with obesity it is an alternative to other conservative approaches for treatment of obesity. In type 2 diabetes it may improve long-term glucose metabolism better than conventional weight reducing diets. Some studies suggest that after a VLED-based programme long-term maintenance is better among men than women. This possible gender difference is an important topic for further research.

Genome-wide scan of obesity in Finnish sibpairs reveals linkage to chromosome Xq24

Obesity is a multifactorial trait with evidence of a genetic component. Obesity is very common in all westernized countries, including Finland, where 10% of the adult population has a body mass index of 32 kg/m2 or more. Here we report results from a three-stage genome-wide scan of obesity in 188 affected subjects (body mass index, > or =32 kg/m2) from 87 Finnish families. Initially, 374 markers with an average density of 10 centimorgans were genotyped. The strongest evidence for linkage to obesity was detected on chromosome Xq24, with the marker DXS6804 providing a maximum likelihood score (MLS) 3.14 in a model-free 2-point sibpair analysis. Fine-mapping in an extended sample set of 367 affected subjects from 166 families yielded a multipoint MLS of 3.48 over this X-chromosomal region. The Xq24 region contains a plausible candidate gene, serotonin 2C receptor, variants of which have been shown to predispose to obesity and type II diabetes in mice. Another chromosomal region also provided suggestive evidence of linkage, an area on 18q21, flanking the melanocortin-4 receptor, where a 2-point MLS of 2.42 with marker D18S1155 was obtained with a set of 367 affected subjects. In conclusion, our results in this Finnish study sample suggest that a locus on chromosome Xq24 influences the risk of obesity.

Acute intermittent porphyria: expression of mutant and wild-type porphobilinogen deaminase in COS-1 cells

BACKGROUND

Acute intermittent porphyria (AIP) is an autosomal dominant disorder that results from the partial deficiency of porphobilinogen deaminase (PBGD) in the heme biosynthetic pathway. Patients with AIP can experience acute attacks consisting of abdominal pain and various neuropsychiatric symptoms. Although molecular biological studies on the porphobilinogen deaminase (PBGD) gene have revealed several mutations responsible for AIP, the properties of mutant PBGD in eukaryotic expression systems have not been studied previously.

MATERIALS AND METHODS

Seven mutations were analyzed using transient expression of the mutated polypeptides in COS-1 cells. The properties of mutated polypeptides were studied by enzyme activity measurement, Western blot analysis, pulse-chase experiments, and immunofluorescence staining.

RESULTS

Of the mutants studied, R26C, R167W, R173W, R173Q, and R225X resulted in a decreased enzyme activity (0-5%), but R225G and 1073delA (elongated protein) displayed a significant residual activity of 16% and 50%, respectively. In Western blot analysis, the polyclonal PBGD antibody detected all mutant polypeptides except R225X, which was predicted to result in a truncated protein. In the pulse-chase experiment, the mutant polypeptides were as stable as the wild-type enzyme. In the immunofluorescence staining both wild-type and mutant polypeptides were diffusely dispersed in the cytoplasm and, thus, no accumulation of mutated proteins in the cellular compartments could be observed.

CONCLUSIONS

The results confirm the causality of mutations for the half normal enzyme activity measured in the patients' erythrocytes. In contrast to the decreased enzyme activity, the majority of the mutations produced a detectable polypeptide, and the stability and the intracellular processing of the mutated polypeptides were both comparable to that of the wild-type PBGD and independent of the cross-reacting immunological material (CRIM) class.

Insertion of Alu element responsible for acute intermittent porphyria

In this study, we report a large Finnish family in which an Alu element interferes with the coding region of the porphobilinogen deaminase (PBGD) gene resulting in acute intermittent porphyria (AIP). Polymerase chain reaction (PCR) and single-strand conformation polymorphism (SSCP) analysis of exon 5 among patients showed an abnormal band around 350 bp apart from the normal bands. Subcloning and sequencing of the fragment revealed a 333-bp Alu sequence that was directly inserted into exon 5 in antisense orientation. The junction sequences included a 13-bp target site duplication. This Alu cassette belongs to a Ya5 subfamily, one of the youngest and currently most active Alu subfamilies in evolution. The Alu insertion resulted in a dramatically decreased steady-state level of the allelic transcript, as this Alu sequence could not be demonstrated by direct sequencing of the amplified cDNA synthesized from total RNA extracted from the patients' lymphoblast cell lines. A stop codon present in the reading frame causes premature termination of PBGD synthesis. The predicted polypeptide contains 64 of the 361 amino acids of PBGD, followed by 13 amino acids that are not identical to the PBGD polypeptide. To further characterize the consequences of the insertion, the Alu sequence was inserted into exon 5 of the PBGD cDNA and expressed in the eukaryotic COS-1 cell line. The mutated construct expressed no enzyme activity comparable to that of the wild-type PBGD; furthermore, no mutant protein could be detected by Western blot analysis.

Diagnostic strategy, genetic diagnosis and identification of new mutations in intermittent porphyria by denaturing gradient gel electrophoresis

Acute intermittent porphyria (AIP) is an autosomal dominant inherited disease of heme metabolism caused by mutations in the hydroxymethylbilane synthase gene. Diagnosing AIP during an acute attack using traditional biochemical markers is unproblematic, but it can be difficult to obtain a definite diagnosis in asymptomatic carriers. These limitations may, however, be solved through a genetic approach for diagnosing AIP carrier status. A mutation screening assay based on the denaturing gradient gel electrophoresis (DGGE) principle was established in a setup that allows within 24 hr to pinpoint which of the 15 exons of the hydroxymethylbilane synthase gene carries the underlying mutation, and thereby reduces subsequent sequencing, needed to determine the specific mutation, to this particular gene region. To evaluate sensitivity and specificity of the DGGE assay, samples from 22 AIP patients with known mutations and six healthy controls were examined in a blinded design. Following unblinding, it was revealed that in all 22 AIP samples the correct mutation carrying region had been pointed out. In two samples containing a previously undescribed polymorphism, this additional region was also pointed out. All controls were correctly characterized as normal in the DGGE assay. Subsequently, to evaluate the assay in the clinical setting, samples from six previously uncharacterized Danish AIP probands were examined and the underlying mutation detected in all six. In conclusion, a simple and sensitive mutation screening assay based on the DGGE principle allows genetic diagnosis of AIP in a routine setting and may be used as an additional tool in genetic counseling of AIP families.