The emperor's tailors: the failure of the medical weight loss paradigm and its causal role in the obesity of America

Enduring life in between a sense of renewal and loss of courage: lifeworld perspectives one year after hip fracture

Purpose: To explore everyday life experiences of being active in aged adults´ with walking impairment one year after hip fracture (HF).Methods: A phenomenological-hermeneutic study design is based on Heidegger´s and Gadamer´s thinking focusing on aged adults being-in-the-world one year after HF. Individual semi-structured interviews were conducted from May to July 2017 in the homes of nine participants, who were part of a longitudinal qualitative study with four interview-rounds for a period of 18 months after the HF event. The analysis was interpretative and secured that the authors´ pre-understanding was put at stake through a five-step process of meaning condensation.Results: One theme, "Enduring life in between a sense of renewal and loss of courage", described aged adults´ experiences of being active in three sub-themes: "Facing loss and losing courage", "Taking up the challenge and maintaining courage ", and "Renewing the energy to be active". Living with being under change and increased vulnerability created a challenge in maintaining courage and reaching for possibilities to unfold their own being in life.Conclusion: This study contributes knowledge on how the aged adults´ experiences of the balance between courage and loss in being active one year after HF are profoundly connected with experiences of well-being.

Effect of bariatric surgery on fatty liver disease in obese patients: A prospective one year follow-up study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD), often associated with obesity and metabolic syndrome, manifests itself as steatosis, hepatic fibrosis, cirrhosis, or even end-stage liver disease. NAFLD causes inflammation, insulin resistance and cardiovascular complications. The current study aimed to evaluate the beneficial effects of bariatric surgery on biochemical parameters of hepatic functions in obese patients by comparing them before and one-year after the surgery.

METHODS

A total of 72 morbidly obese patients underwent bariatric surgery between 2016 and 2018. The incidence of diabetes mellitus in this group was 29%, median body weight was 124.5 kg (109.0-140.0) and mean body mass index (BMI) was 44.38 ± 6.770 kg/m². The used surgical procedures included gastric bypass, sleeve gastrectomy, laparoscopic gastric plication, and single anastomosis duodeno-ileal bypass-sleeve gastrectomy. Biochemical parameters including ALT/AST ratio (AAR), NAFLD fibrosis score (NFS), hepatic fibrosis index (FIB-4) and Fatty Liver Index (FLI) were evaluated in all patients at the time of surgery and one year after the intervention.

RESULTS

Significant improvement after the intervention was observed in 64 patients. A significant reduction in body weight (P<0.0001), waist circumference (P<0.0001), and body mass index (P<0.0001) were observed. NAFLD liver fibrosis index changed significantly (P<0.0001), suggesting a trend of improvement from advanced fibrosis towards stages 0-2. The FIB-4 fibrosis index indicated significant improvement (P=0.0136). Besides, a significant decline in hepatic steatosis (P<0.0001) was observed after bariatric surgery as compared to the pre-surgery fatty liver conditions.

CONCLUSION

Among the strategies to overcome NAFLD-associated impediments, bariatric surgery can be considered effective in reducing obesity and metabolic co-morbidities.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04569396).

Interrelated In Vitro Mechanisms of Sibutramine-Induced Cardiotoxicity

Consumption of illicit pharmaceutical products containing sibutramine has been reported to cause cardiovascular toxicity problems. This study aimed to demonstrate the toxicity profile of sibutramine, and thereby provide important implications for the development of more effective strategies in both clinical approaches and drug design studies. Action potentials (APs) were determined from freshly isolated ventricular cardiomyocytes with whole-cell configuration of current clamp as online. The maximum amplitude of APs (MAPs), the resting membrane potential (RMP), and AP duration from the repolarization phases were calculated from original records. The voltage-dependent K+-channel currents (IK) were recorded in the presence of external Cd2+ and both inward and outward parts of the current were calculated, while their expression levels were determined with qPCR. The levels of intracellular free Ca2+ and H+ (pHi) as well as reactive oxygen species (ROS) were measured using either a ratiometric micro-spectrofluorometer or confocal microscope. The mechanical activity of isolated hearts was observed with Langendorff-perfusion system. Acute sibutramine applications (10-8-10-5 M) induced significant alterations in both MAPs and RMP as well as the repolarization phases of APs and IK in a concentration-dependent manner. Sibutramine (10 μM) induced Ca2+-release from the sarcoplasmic reticulum under either electrical or caffeine stimulation, whereas it depressed left ventricular developed pressure with a marked decrease in the end-diastolic pressure. pHi inhibition by sibutramine supports the observed negative alterations in contractility. Changes in mRNA levels of different IK subunits are consistent with the acute inhibition of the repolarizing IK, affecting AP parameters, and provoke the cardiotoxicity.

An intensive lifestyle intervention reduces circulating oxidised low-density lipoprotein and increases human paraoxonase activity in obese subjects

OBJECTIVE

Obesity has a great impact on cardiovascular morbidity and mortality, the treatment of this pathological state is important given the significant health consequences. Lifestyle and behaviour changes play a significant role in weight management. The purpose of this study was to investigate the impact of an intensive multidisciplinary lifestyle intervention on well-known atherogenic factors in a group of overweight and obese subjects.

METHODS

A total of 44 people with overweight/obesity underwent a lifestyle intervention based on nutritional education, psychological support and a 3-month exercise training program with a frequency of twice a week. Several anthropometric and biochemical parameters were measured before and after the lifestyle intervention.

RESULTS

Lifestyle intervention led to a significant reduction in metabolic profile including body mass index (BMI), waist circumference, systolic and diastolic blood pressure, plasma glucose, and plasma triglycerides. These reductions were also accompanied by a significant increase in maximal oxygen consumption and muscle strength. Furthermore, paraoxonase and lactonase activities and the concentration of Apoliproteins A1 (APO A1) were significantly increased and the serum levels of oxLDL reduced without any changes in the circulating levels of LDL and HDL.

CONCLUSION

In conclusion, our study suggests that an intensive lifestyle intervention in obese subjects promotes a series of beneficial antiatherogenic changes which included increased enzyme activites of paraoxonase and lactonase, concentration of Apoliproteins A1 and decreased circulating levels of oxLDL.

Bariatric Surgery and Non-Alcoholic Fatty Liver Disease: a Systematic Review of Liver Biochemistry and Histology

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is becoming a leading cause of global liver disease that is associated with the rising prevalence of obesity worldwide. There is now increasing clinical and mechanistic evidence reporting on the metabolic and weight loss effects of bariatric surgery on improving NAFLD in obese patients.

OBJECTIVES

The aim of this paper was to quantify the effects of bariatric surgery on NAFLD by appraising the modulation between pre- and post-operative liver enzyme levels (as markers of liver injury) and liver histology.

METHODS

A systematic review of studies reporting pre-operative and post-operative liver enzymes or liver histology was done in obese patients with NAFLD undergoing bariatric surgery. Data were meta-analysed using random-effects modelling. Subgroup analysis, quality scoring and risk of bias were assessed.

RESULTS

Bariatric surgery is associated with a significant reduction in the weighted incidence of a number of histological features of NAFLD including steatosis (50.2 and 95 %CI of 35.5-65.0), fibrosis (11.9 and 95 %CI of 7.4-16.3 %), hepatocyte ballooning (67.7 and 95 %CI 56.9-78.5) and lobular inflammation (50.7 and 95 %CI 26.6-74.8 %). Surgery is also associated with a reduction in liver enzyme levels, with statistically significant reductions in ALT (11.36 u/l, 95 %CI 8.36-14.39), AST (3.91 u/l, 95 %CI 2.23-5.59), ALP (10.55 u/l, 95 %CI 4.40-16.70) and gamma-GT (18.39 u/l, 95 %CI 12.62-24.16). Heterogeneity in results was high.

CONCLUSIONS

Bariatric surgery is associated with a significant improvement in both histological and biochemical markers of NAFLD. Future studies must focus on higher levels of evidence to better identify the benefits of bariatric surgery on liver disease in order to enhance future treatment strategies in the management of NAFLD.

Reducing Societal Obesity: Establishing a Separate Exercise Model through Studies of Group Behavior

The past 50 years has brought attention to high and increasing levels of human obesity in most of the industrialized world. The medical profession has noticed, has evaluated, and has developed models for studying, preventing, and reversing obesity. The current model prescribes activity in specific quantities such as days, minutes, heart rates, and footfalls. Although decreased levels of activity have come from changes revolving around built environments and social networks, the existing medical model to lower body weights by increasing activity remains individually prescriptive. It is not working. The study of societal obesity precludes the individual and must involve group behavioral studies. Such studies necessitate acquiring separate tools and, therefore, require a significant change in the evaluation and treatment of obesity. Finding groups with common activities and lower levels of obesity would allow the development of new models of land use and encourage active lifestyles through shared interests.

Roux-en-Y gastric bypass reduces lipid overaccumulation in liver by upregulating hepatic autophagy in obese diabetic rats

BACKGROUND

The decrease in lipotoxicity is one of the crucial mechanisms by which Roux-en-Y gastric bypass (RYGB) improves insulin sensitivity. Little work, however, has been performed to elucidate the exact mechanism of RYGB reducing hepatic lipid overaccumulation in response to heavy lipid and glucose challenge. Here, we explored the effects of RYGB on hepatic autophagy in obese diabetic rats.

METHODS

Sprague-Dawley rats were divided into five groups: diabetic RYGB, diabetic RYGB sham, diabetic food restriction (FR), diabetic rats, and non-diabetic controls (n = 12/group). At 4-week post-operation, genetic and protein expressions of autophagy markers including Atg7 and Beclin 1 and the conversion of LC3 were examined with quantitative RT-PCR and Western blotting. Plasma glucagon-like peptide-1 (GLP-1) and triglyceride and total cholesterol levels in liver tissue were tested.

RESULTS

In both genetic and protein levels, we observed a significant upregulated autophagy in liver at 4 weeks after RYGB. Restored autophagy in liver played a key role in reducing the hepatic lipid burden in obese diabetic rats. The marked increase of autophagy in liver after RYGB correlated well with the plasma GLP-1 level.

CONCLUSIONS

Our data demonstrate that RYGB significantly upregulated hepatic autophagy. We suggest that the effects of RYGB on autophagy in liver may be due to the increased GLP-1 level after surgery. Moreover, the activated autophagy in liver might play a key role in reducing the hepatic lipid overaccumulation after RYGB.

Bariatric surgery and nonalcoholic fatty liver disease

The rising prevalence of nonalcoholic fatty liver disease (NAFLD) is associated with the increasing global pandemic of obesity. These conditions cluster with type II diabetes mellitus and the metabolic syndrome to result in obesity-associated liver disease. The benefits of bariatric procedures on diabetes and the metabolic syndrome have been recognized for some time, and there is now mounting evidence to suggest that bariatric procedures improve liver histology and contribute to the beneficial resolution of NAFLD in obese patients. These beneficial effects derive from a number of weight-dependent and weight-independent mechanisms including surgical BRAVE actions (bile flow changes, restriction of stomach size, anatomical gastrointestinal rearrangement, vagal manipulation, enteric hormonal modulation) and subsequent effects such as reduced lipid intake, adipocytokine secretion, modulation of gut flora, improvements in insulin resistance and reduced inflammation. Here, we review the clinical investigations on bariatric procedures for NAFLD, in addition to the mounting mechanistic data supporting these findings. Elucidating the mechanisms by which bariatric procedures may resolve NAFLD can help enhance surgical approaches for metabolic hepatic dysfunction and also contribute toward developing the next generation of therapies aimed at reducing the burden of obesity-associated liver disease.

"It's a balance of just getting things right": mothers' views about pre-school childhood obesity and obesity prevention in Scotland

Background

The high prevalence of childhood obesity is a concern for policy makers and health professionals, leading to a focus on early prevention. The beliefs and perspectives of parents about early childhood obesity, and their views and opinions about the need for weight management interventions for this age group are poorly understood.

Methods

A formative qualitative focus group study with parents of pre-school children took place in eight community-based locations throughout North-East Scotland to explore their ideas about the causes of early childhood obesity, personal experiences of effective weight management strategies, and views about the format and content of a possible child-orientated weight management programme. Study participants were recruited via pre-school nurseries.

Results

Thirty-four mothers (median age 37 years) took part in the study, but only two believed their child had a weight problem. Participants (who focussed primarily on dietary issues) expressed a strong sense of personal responsibility to ‘get the balance right’ regarding their child’s weight, and were generally resistant to the idea of attending a weight management programme aimed at very young children. At the same time, they described a range of challenges to their weight management intentions. These included dealing with intrinsic uncertainties such as knowing when to stop ‘demand feeding’ for weight gain, and judging appropriate portion sizes - for themselves and their children. In addition they faced a range of extrinsic challenges associated with complex family life, i.e. catering to differing family members dietary needs, food preferences, practices and values, and keeping their ‘family food rules’ (associated with weight management) when tired or pressed for time.

Conclusions

The findings have important implications for health professionals and policy makers wishing to engage with parents on this issue, or who are currently developing ‘family-centred’ early childhood weight management interventions. The challenge lies in the fact that mothers believe themselves to be the primary (and capable) agents of obesity prevention in the early years – but, who are at the same time, attempting to deal with many mixed and conflicting messages and pressures emanating from their social and cultural environments that may be undermining their weight management intentions.

Obesity-related cardiorenal disease: the benefits of bariatric surgery

The inexorable increase in the prevalence of obesity is a global health concern, which will result in a concomitant escalation in health-care costs. Obesity-related metabolic syndrome affects approximately 25% of adults and is associated with cardiovascular and renal disease. The heart and kidneys are physiologically interdependent, and the pathological effects of obesity can lead to cardiorenal syndrome and, ultimately, kidney and heart failure. Weight loss can prevent or ameliorate obesity-related cardiorenal syndrome, but long-term maintenance of a healthy weight has been difficult to achieve through lifestyle changes or pharmacotherapy. Bariatric surgery offers both sustained weight loss and favourable metabolic changes, including dramatic improvements in glycaemic control and symptoms of type 2 diabetes mellitus. Procedures such as Roux-en-Y gastric bypass offer immediate multisystemic benefits, including bile flow alteration, reduced gastric size, anatomical gut rearrangement and altered flow of nutrients, vagal manipulation and enteric hormone modulation. In patients with cardiorenal syndrome, bariatric surgery also offers renoprotection and cardioprotection, and attenuates both kidney and heart failure by improving organ perfusion and reversing metabolic dysfunction. However, further research is required to understand how bariatric surgery acts on the cardiorenal axis, and its pioneering role in novel treatments and interventions for cardiorenal disease.

Multidisciplinary lifestyle intervention in the obese: its impact on patients' perception of the disease, food and physical exercise

BACKGROUND AND AIMS

To be successful, lifestyle intervention in obesity must take into account patients' views. The aim of the present study, conducted using a narrative-autobiographical approach, was to report on the perception of disease, food and physical exercise in a group of 80 obese patients during a structured multidisciplinary lifestyle intervention.

METHODS AND RESULTS

Patients underwent lifestyle intervention, of three months' duration, structured in the following steps: 1) an initial medical examination; 2) an interview by a psychologist; 3) an assessment by a dietician, 4) a physical examination by a specialist in sports medicine; 5) an individualized program consisting of 24 sessions (two per week) of structured indoor exercise 6) eight sessions of group therapeutic education; 7) Nordic walking activity combined with walking excursions during weekends. All the narrative autobiographic texts obtained during the lifestyle intervention were submitted for content analysis; data were analysed according to the ''grounded theory'' method. According to patients' descriptions at the end of the intervention, lifestyle intervention resulted in enhanced self-efficacy and a reduction in their dependency on food and people; their fear of change was also diminished because, by undergoing intervention, they had experienced change.

CONCLUSION

The findings made in the present qualitative analysis suggest that whenever multidisciplinary lifestyle intervention is planned for patients with obesity, it is of the utmost importance to tailor the approach while taking the following key aspects into account: motivation, barriers and/or facilitators in lifestyle change, patients' perceptions of obesity and relationship with food, diet and exercise.

Associations between diet quality, health status and diabetic complications in patients with type 2 diabetes and comorbid obesity

OBJECTIVE

Patients with type 2 diabetes (T2DM) demonstrate low dietary adherence and this is further aggravated with comorbid obesity. The aim of the present study was to assess diet quality in patients with T2DM and comorbid obesity compared to patients with T2DM alone and to examine the associations between comorbidities and diet quality.

METHODS

The sample consisted of 59 adult patients with diabesity (T2DM and comorbid obesity) and 94 patients with T2DM alone. All diabetes comorbidities and complications were recorded and diet quality was assessed with the Healthy Eating Index (HEI).

RESULTS

Mean raw HEI of the diabese subjects was 81.9±7.1 and the diabetic subjects was 80.2±6.9. When HEI was adjusted to the sex, age and weight status, the diabese demonstrated a higher HEI. Among comorbidities, only renal disease decreased HEI. According to the principal component analysis of the total sample, adequate diet quality was explained by cardiovascular disease, cigarette smoking, alcohol consumption, peptic ulcer, sex, diabesity and diabetic foot syndrome. In the diabese, adequate HEI was explained by diabetic foot syndrome, smoking, drinking alcohol and having a family history of diabetes.

CONCLUSIONS

Adult patients with T2DM demonstrate adequate diet quality. Different factors are associated with the adoption of a high quality diet between the diabese and the T2DM alone.

Programming of host metabolism by the gut microbiota

The human gut harbors a vast ensemble of bacteria that has co-evolved with the human host and performs several important functions that affect our physiology and metabolism. The human gut is sterile at birth and is subsequently colonized with bacteria from the mother and the environment. The complexity of the gut microbiota is increased during childhood, and adult humans contain 150-fold more bacterial genes than human genes. Recent advances in next-generation sequencing technology and mechanistic testing in gnotobiotic mice have identified the gut microbiota as an environmental factor that contributes to obesity. Germ-free mice are protected against developing diet-induced obesity and the underlying mechanisms whereby the gut microbiota contributes to host metabolism are beginning to be clarified. The obese phenotype is associated with increased microbial fermentation and energy extraction; however, other microbially modulated mechanisms contribute to disease progression as well. The gut microbiota has profound effects on host gene expression in the enterohepatic system, including genes involved in immunity and metabolism. For example, the gut microbiota affects expression of secreted proteins in the gut, which modulate lipid metabolism in peripheral organs. In addition, the gut microbiota is also a source of proinflammatory molecules that augment adipose inflammation and macrophage recruitment by signaling through the innate immune system. TLRs (Toll-like receptors) are integral parts of the innate immune system and are expressed by both macrophages and epithelial cells. Activation of TLRs in macrophages dramatically impairs glucose homeostasis, whereas TLRs in the gut may alter the gut microbial composition that may have profound effects on host metabolism. Accordingly, reprogramming the gut microbiota, or its function, in early life may have beneficial effects on host metabolism later in life.

Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass

The global prevalence of type 2 diabetes mellitus and impaired glucose metabolism continues to rise in conjunction with the pandemic of obesity. The metabolic Roux-en-Y gastric bypass operation offers the successful resolution of diabetes in addition to sustained weight loss and excellent long-term outcomes in morbidly obese individuals. The procedure consists of the physiological BRAVE effects: (i) Bile flow alteration; (ii) Reduction of gastric size; (iii) Anatomical gut rearrangement and altered flow of nutrients; (iv) Vagal manipulation and (v) Enteric gut hormone modulation. This operation provides anti-diabetic effects through decreasing insulin resistance and increasing the efficiency of insulin secretion. These metabolic outcomes are achieved through weight-independent and weight-dependent mechanisms. These include the foregut, midgut and hindgut mechanisms, decreased inflammation, fat, adipokine and bile metabolism, metabolic modulation, shifts in gut microbial composition and intestinal gluconeogenesis. In a small minority of patients, gastric bypass results in hyperinsulinaemic hypoglycaemia that may lead to nesidioblastosis (pancreatic beta-cell hypertrophy with islet hyperplasia). Elucidating the precise metabolic mechanisms of diabetes resolution and hyperinsulinaemia after surgery can lead to improved operations and disease-specific procedures including 'diabetes surgery'. It can also improve our understanding of diabetes pathogenesis that may provide novel strategies for the management of metabolic syndrome and impaired glucose metabolism.