Fatness and fitness: how do they influence health-related quality of life in type 2 diabetes mellitus?

OBJECTIVE

We examined whether adiposity and fitness explain the decrease in health-related quality of life (HRQOL) associated with type 2 diabetes mellitus.

METHODS

This was a cross-sectional study using baseline data from two exercise training interventions. One study enrolled people with and the other without type 2 diabetes. We assessed aerobic fitness ("fitness") as peak oxygen uptake during treadmill testing, adiposity ("fatness") as percentage of total body fat by dual-energy x-ray absorptiometry, and HRQOL by the Medical Outcomes Study SF-36. Bivariate and multivariate linear regression analyses were used examine determinants of HRQOL were used to examine determinants of HRQOL.

RESULTS

There were 98 participants with and 119 participants without type 2 diabetes. Participants with type 2 diabetes had a mean hemoglobin A1c of 6.6% and, compared with participants without diabetes had lower HRQOL on the physical component summary score (P = 0.004), role-physical (P = 0.035), vitality (P = 0.062) and general health (P < 0.001) scales after adjusting for age, sex and race. These associations of HRQOL with type 2 diabetes were attenuated by higher fitness, even more than reduced fatness. Only general health remained positively associated with type 2 diabetes after accounting for fatness or fitness (P = 0.003). There were no significant differences between participants with and without diabetes in the mental component score.

CONCLUSION

Improved fitness, even more than reduced fatness, attenuated the association of type 2 diabetes with HRQOL. The potential to improve HRQOL may motivate patients with type 2 diabetes to engage in physical activity aimed at increasing fitness. Findings from this cross-sectional analysis will be addressed in the ongoing trial of exercise training in this cohort of participants with type 2 diabetes.

TRIAL REGISTRATION

NCT00212303.

Decreased exercise blood pressure in older adults after exercise training: contributions of increased fitness and decreased fatness

OBJECTIVE

To describe the contribution of changes in fitness and fatness resulting from exercise training on changes in submaximal exercise blood pressure (BP) during treadmill testing.

DESIGN AND SETTING

Prospective, randomised, controlled trial.

PARTICIPANTS

Sedentary older adults (n = 115) with untreated prehypertension or mild hypertension.

INTERVENTION

Six-month supervised aerobic and strength training.

MAIN OUTCOME MEASUREMENT

Systolic BP (SBP) was assessed at rest and during each stage of a maximal graded exercise test (GXT) that determined Vo(2)peak. General and regional fatness was assessed by anthropometry, dual-energy x-ray absorptiometry and MRI. BP changes were calculated for each GXT stage, and multivariate regression models were used to describe the association of changes in exercise BP with changes in fitness and fatness.

RESULTS

After training, exercisers versus controls had significantly increased Vo(2)peak and significantly lower measures of general and regional fatness. Also, stage-specific SBP was significantly lower at stage 3 (-9.4 vs -1.6 mm Hg, p = 0.03) and stage 4 (-7.9 vs -1.2 mm Hg, p = 0.03). Pooled regression analysis across all stages showed that exercisers had a 7.1 mm Hg reduction in SBP, but this reduction fell short of statistical significance (p = 0.12) compared with controls. A 1.0 ml/kg/min increase in Vo(2)peak and a 1.0 cm decrease in waist circumference independently predicted a 1.0 mm Hg decrease in exercise SBP (p = 0.04 and p = 0.001, respectively).

CONCLUSIONS

Decreased exercise SBP was independently associated with decreased waist circumference, a marker of abdominal obesity and increased fitness. These findings suggest that exercise training improves multiple factors that have an independent influence on SBP.

Plastic surgical options for HIV-associated lipodystrophy

With the reported prevalence of HIV-associated lipodystrophy approaching 80%, this patient group presents an increasing challenge to plastic surgeons. Based on a literature search conducted using OVID Medline, this review shall describe the various treatment options employed by plastic surgeons to deal with the problems of fat distribution in patients suffering from HIV-lipodystrophy, and examine the evidence for each treatment.

Experience in the treatment of HIV-associated lipodystrophy

AIM

To evaluate the outcome of patients with HIV-associated lipodystrophy treated within the Edinburgh unit to date.

METHODS

Information was collected from the medical case notes on the clinical features, method of treatment, postoperative complications, and length of follow up for each patient. A questionnaire was devised to assess patient satisfaction and facial volume was evaluated using three-dimensional imaging.

RESULTS

Forty-six patients with HIV-associated lipodystrophy were treated over a 3-year period. Twenty-six patients received Coleman fat injections, 10 patients were treated with Newfill, eight patients were treated with Bio-alcamid, 21 patients received liposuction, and three patients had a minimal access cranial suspension facelift. Follow up ranged from 1 to 14 months. Patient and surgeon satisfaction was high with autologous fat injections although fat resorption occurred in nine patients. Aesthetic improvement with Newfill was moderate and required up to seven treatment sessions. The results of treatment with Bio-alcamid were good immediately postoperatively, although two patients required further corrective procedures. Two patients who had liposuction to the dorso-cervical fat pad reported recurrence at 5 and 9 months, respectively.

CONCLUSIONS

Based on our experience, a treatment algorithm has been devised to aid management decisions. We favour the use of autologous fat injections for facial lipoatrophy but have found fillers to be useful in patients with inadequate fat reserves.

Paraileostomy recontouring by collagen sealant injection: a novel approach to one aspect of ileostomy morbidity. Report of a case

INTRODUCTION

Poorly fitting stoma appliances, resulting in stomal leakage and subsequent skin excoriation, remain a significant cause of ileostomy-related morbidity. One cause of ill-fitting stoma bags is the presence of parastomal dermal contour defects/irregularities. These may occur after surgical complications or change in patient weight and body habitus.

METHODS

We report the case of a 29-year-old man who, after panproctocolectomy and formation of ileostomy for ulcerative colitis, experienced significant problems with stoma bag application because of dermal contour defects. As a result, he suffered from significant stomal leakage and skin excoriation. After a single treatment of cutaneous parastomal infiltration of porcine collagen (Permacol Injection), applied stoma bags achieved a watertight seal, and the patient experienced complete and sustained resolution of his symptoms.

CONCLUSIONS

Porcine collagen is a safe, versatile, and relatively easy method of restoring irregular skin defects surrounding abdominal stomas, thus resolving the significant patient morbidity associated with ill-fitting stomal appliances. Such a technique avoids the need for surgical stoma refashioning, which may be associated with significant morbidity and unsatisfactory outcomes.

Exercise capacity and cardiovascular/metabolic characteristics of overweight and obese individuals with type 2 diabetes: the Look AHEAD clinical trial

OBJECTIVE

We examined associations of cardiovascular, metabolic, and body composition measures with exercise capacity using baseline data from 5,145 overweight and/or obese (BMI > or = 25.0 kg/m2) men and women with type 2 diabetes who were randomized participants for the Look AHEAD (Action for Health in Diabetes) clinical trial.

RESEARCH DESIGN AND METHODS

Peak exercise capacity expressed as METs and estimated from treadmill speed and grade was measured during a graded exercise test designed to elicit a maximal effort. Other measures included waist circumference, BMI, type 2 diabetes duration, types of medication used, A1C, history of cardiovascular disease, metabolic syndrome, beta-blocker use, and race/ethnicity.

RESULTS

Peak exercise capacity was higher for men (8.0 +/- 2.1 METs) than for women (6.7 +/- 1.7 METs) (P < 0.001). Exercise capacity also decreased across each decade of age (P < 0.001) and with increasing BMI and waist circumference levels in both sexes. Older age, increased waist circumference and BMI, a longer duration of diabetes, increased A1C, a history of cardiovascular disease, having metabolic syndrome, beta-blocker use, and being African American compared with being Caucasian were associated with a lower peak exercise capacity for both sexes. Hypertension and use of diabetes medications were associated with lower peak exercise capacity in women.

CONCLUSIONS

Individuals with diabetes who are overweight or obese have impaired exercise capacity, which is primarily related to age, female sex, and race, as well as poor metabolic control, BMI, and central obesity.

Body composition, gender, and illicit drug use in an urban cohort

This cross-sectional study of adult (137 male, 128 female), urban, community dwelling users and nonusers of illicit drugs evaluated associations of demographic, medical, and drug factors with body composition. The population was 49% HIV-positive and 94% African-American. In multivariate analysis, there were no body composition differences among males based on drug use. Among females, the highest tertile of drug use had less fat (12.3 vs.19.9 kg, p = .01) and lower body mass index (21.9 vs. 25.1, p = .01) versus less frequent or nonusers. These data suggest a sex difference in body composition associated with drug use.

Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism

Prescribed and supervised resistance training (RT) enhances muscular strength and endurance, functional capacity and independence, and quality of life while reducing disability in persons with and without cardiovascular disease. These benefits have made RT an accepted component of programs for health and fitness. The American Heart Association recommendations describing the rationale for participation in and considerations for prescribing RT were published in 2000. This update provides current information regarding the (1) health benefits of RT, (2) impact of RT on the cardiovascular system structure and function, (3) role of RT in modifying cardiovascular disease risk factors, (4) benefits in selected populations, (5) process of medical evaluation for participation in RT, and (6) prescriptive methods. The purpose of this update is to provide clinicians with recommendations to facilitate the use of this valuable modality.

Performance characteristics of depression screening instruments in survivors of acute myocardial infarction: review of the evidence

Authors conducted a systematic review to assess performance characteristics of depression screening instruments after acute myocardial infarction (AMI). Among the seven studies identified, the Beck Depression Inventory (BDI) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) were used most frequently. Studies were generally of low quality, and no screening instrument performed notably better than others. Future research should compare the BDI and the HADS-D with instruments such as the Patient Health Questionnaire (PHQ-9 and PHQ-2) in post-AMI patients, should attend to important elements of the screening process, including when, where, and how often to screen patients, and should evaluate serial screening.

Development of a guarded liquid ionization chamber for clinical dosimetry

Liquid ionization chambers are considered superior to air-filled chambers in terms of size, energy dependence and perturbation effects. We constructed and tested a liquid ionization chamber for clinical dosimetry, the GLIC-03, with a sensitive volume of approximately 2 mm3. We also examined two methods to correct for general ion recombination in pulsed photon beams: that of Johansson et al, which modifies Boag's theory for recombination in gases, and an empirical method relating recombination to dose per pulse. The second method can be used even in cases where the first method is not applicable. The response of the GLIC-03 showed a stable, linear and reproducible decrease of 1% over 10 h. The liquid-filled GLIC-03 had a 1.1 +/- 0.4% energy dependence while that of the air-filled GLIC-03 was 2.1 +/- 0.3% between the 6 and 18 MV beams from a Clinac 21EX. The two methods for recombination correction agreed within 0.2% for measurements at 18 MV, 700 V, 100 MU min(-1). Measurements with the GLIC-03 in Solid Water in the build-up region of an 18 MV beam agreed with extrapolation chamber measurements within 1.4%, indicating that the GLIC-03 causes minimal perturbation.

Randomized trial of hormone therapy in women after coronary bypass surgery

Clinical trials indicate that hormone therapy (HT) does not decrease cardiovascular disease events or angiographic coronary disease progression. The effects of HT on SVG vessels are unknown. To determine whether postmenopausal hormone therapy started after coronary bypass surgery (CABG) decreases saphenous vein graft (SVG) disease, we conducted a multicenter randomized placebo-controlled angiographic study of estradiol+/-medroxyprogesterone started within 6 months of CABG in 83 postmenopausal women. Angiographic and intravascular ultrasound (IVUS) assessment at 6 and 42 months was planned to assess SVG disease progression. The study was stopped early following publication of the Women's Health Initiative Estrogen/Progestin study. Eighty-three subjects underwent a 6-month angiogram with 63 undergoing IVUS. Forty-five subjects completed the 42-month angiogram (20 underwent 42-month IVUS). In analysis of paired 6- and 42-month angiogram and IVUS studies, HT slowed angiographic progression of SVG disease assessed by mean percent stenosis (p<0.001), minimal lumen diameter (p=0.029), and total plaque volume (p=0.006). In contrast, HT accelerated disease progression in non-bypassed native coronary arteries (minimum lumen diameter, p=0.01). SVG disease and closure occurred in 38% subjects within 1-year post-CABG. The groups had similar frequency of cardiovascular events expect for angioplasty that occurred in eight HT compared to one placebo subject (p<0.05). In HT subjects angioplasty was indicated for native coronary arterial stenoses while in the placebo subject angioplasty was indicated for SVG stenosis. This study suggests that hormone treatment may slow SVG disease progression while accelerating atherosclerosis in non-bypassed native coronary arteries.

Established and evolving medical therapies for claudication in patients with peripheral arterial disease

Claudication resulting from peripheral arterial disease causes substantial impairment in the ability to carry out normal daily activities. The medical treatments for claudication that are currently available are exercise rehabilitation and one drug, cilostazol. Pentoxifylline, which improves red cell deformability, lowers fibrinogen levels and decreases platelet aggregation, has been used historically, but frequency of use has declined because of limited effectiveness. Exercise rehabilitation, while efficacious, has been underused in the past. This therapy is, however, currently the subject of several large research projects. These studies are investigating mechanisms by which exercise therapy could benefit people with claudication and are also directly comparing it with other therapies. Concurrently, several new drug therapies for claudication are in the process of being evaluated. These research efforts might increase the available armamentarium and thereby help to alleviate the impairments associated with this symptom. The aim of this article is to discuss the current medical treatments being developed for use in patients with claudication resulting from peripheral arterial disease.

Complications of 278 consecutive abdominoplasties

The case notes of 278 consecutive patients who underwent abdominoplasty, during a five-year period, in one institution under the care of four surgeons were reviewed. Patient details, early and late complications and revision procedures were noted. Seventy-five percent of patients had a 'full' abdominoplasty with undermining to costal cartilage and repositioning of the umbilicus and 23% had 'mini abdominoplasties', 2% were revision operations. Eighteen percent of patients suffered from early complications the most common of which were seroma (5%), haematoma (3%), infection (3%), skin or fat necrosis (2.5%) and delayed healing (2%). Twenty-five percent of patients had late complications which were often relatively minor. These included 'dog ears' (12%), localised fatty excess (10%) and unsatisfactory scars (8%). Twenty-four percent of patients underwent revision surgery. Most commonly further liposuction (12%), dog ear revision (10%) and scar revision (5%). Analysis failed to reveal significant risk factors. Despite an apparently high complication and revision rate the subjective impression is of a satisfied patient cohort.

Comparison of cartilage scoring and cartilage sparing otoplasty – A study of 203 cases

The Edinburgh experience of different methods of otoplasty techniques in 203 patients (406 ears) over a five-year period is reviewed.

MATERIALS AND METHODS

The patients were divided into three groups - Group A (anterior cartilage scoring), Group B (cartilage sparing in the fashion of posterior suturing) and Group C (posterior suturing refined with posterior fascial flap). Demographic details, operation technique, operation time, grade of the surgeon, suture materials, early and late complications, recurrence and revision rates, patients' and physicians' comments at the follow-up clinic were retrieved from the case notes. The pre- and the post-operative photographs were assessed by a blinded lay observer and a physician and scored on a visual analogue scale. Median follow-up was 11 months.

RESULTS

The recurrence rate was 11.0%, 8.0% and 4.8% in Groups A, B and C, respectively (p = 0.0214). Complications were more common in Group A (8.8%) and Group B (7.9%) compared to Group C (1.2%) (p = 0.0208). The cosmetic result was judged best in Group C. In our experience, cartilage-sparing otoplasty refined with the post-auricular fascial flap results in significantly reduced complication rate and improved aesthetic outcome.

A church-based physical activity intervention for African American women

This trial evaluated a 6-month, church-based aerobic exercise intervention to increase physical activity among African American women relative to a health lecture and stretching condition. Participants were 196 women from 11 churches. Churches were randomized to an Aerobic Exercise or Health N Stretch intervention. Results indicated that physical activity was not different in Aerobic Exercise and Stretch N Health, although attendance in both interventions was low. Both groups reduced physical inactivity prevalence from baseline (26% and 18% decline, respectively). Higher baseline social support predicted change in physical activity, regardless of treatment assignment. Researchers must continue to work to identify successful intervention strategies to increase physical activity in African American women who are at disproportionate risk of chronic diseases associated with physical inactivity.

Prevalence of depression in survivors of acute myocardial infarction

OBJECTIVES

To assess the prevalence and persistence of depression in patients with acute myocardial infarction (AMI) and the relationship between assessment modality and prevalence.

DATA SOURCES

MEDLINE, Cochrane, CINAHL, PsycINFO, and EMBASE.

REVIEW METHODS

A comprehensive search was conducted in March 2004 to identify original research studies published since 1980 that used a standardized interview or validated questionnaire to assess depression. The search was augmented by hand searching of selected journals from October 2003 through April 2004 and references of identified articles and reviews. Studies were excluded if only an abstract was provided, if not in English, or if depression was not measured by a validated method.

RESULTS

Major depression was identified in 19.8% (95% confidence interval [CI] 19.1% to 20.6%) of patients using structured interviews (N=10,785, 8 studies). The prevalence of significant depressive symptoms based on a Beck Depression Inventory score > or =10 was 31.1% (CI 29.2% to 33.0%; N=2,273, 6 studies), using a Hospital Anxiety and Depression Scale (HADS) score > or =8%, 15.5% (CI 13.2% to 18.0%; N=863, 4 studies), and with a HADS score > or =11%, 7.3% (CI 5.5% to 9.3%; N=830, 4 studies). Although a significant proportion of patients continued to be depressed in the year after discharge, the limited number of studies and variable follow-up times precluded specification of prevalence rates at given time points.

CONCLUSIONS

Depression is common and persistent in AMI survivors. Prevalence varies depending on assessment method, likely reflecting treatment of somatic symptoms.

Physical Activity and Aging

Most human beings experience peak physical performance in their late teens and begin a slow decline in their early 20s, whose course is greatly affected by the activity levels undertaken by individuals in the years that follow. Many studies provide evidence that in developed nations such as the U.S., a sedentary lifestyle contributes significantly to development of the major risk factors for age-related disease, prominent among them obesity, diabetes, and hypertension. Conversely, numerous studies document the benefits of physical activity, and in particular structured exercise programs, not only for reducing disease risk and improving physical performance, but also for enhancing substantially the quality of daily life. Aerobic and resistance training have complementary benefits, and can be undertaken at almost any age and physical condition, given appropriate medical clearance and supervision as warranted.