Bodyweight change as an adverse effect of drug treatment. Mechanisms and management

Assessment of factors associated with antipsychotic-induced weight gain: A nationwide cohort study

BACKGROUND

The incidence of antipsychotic-induced weight gain (AIWG) is difficult to predict in real-world practice because various factors influence it. This study aimed to explore background and medication-related factors associated with weight gain in patients newly prescribed with antipsychotic medication.

METHODS

This nationwide, multicenter, prospective cohort study was conducted in Japan. The primary endpoint was the incidence of AIWG (≥7 % weight gain) over 12 months after initiation of antipsychotic treatment. Factors influencing AIWG incidence were assessed using Cox proportional hazards regression analysis stratified by facility characteristics.

RESULTS

Of the 865 enrolled participants, 262 developed AIWG. Compared with aripiprazole, clozapine and olanzapine were related to a higher AIWG incidence (hazard ratio [HR] = 2.17, 95 % confidence interval [CI] = 1.05-4.51; HR = 2.01, 95 % CI = 1.36-2.96, respectively), whereas blonanserin was related to a lower AIWG incidence (HR = 0.49, 95 % CI = 0.24-0.98). Furthermore, co-administration of antidepressants and mood stabilizers increased the AIWG incidence (HR = 1.94, 95 % CI = 1.35-2.77; HR = 1.47, 95 % CI = 1.07-2.01, respectively). The impact of concomitant medications on AIWG incidence varied by the pharmacological characteristics of the newly initiated antipsychotic, in addition to the type and duration of concomitant medications.

CONCLUSIONS

The findings of this study suggest that the risk of AIWG incidence may be estimated by assessing the type of concomitant medication and its duration of use, type of newly initiated antipsychotic, and background factors prior to initiation of antipsychotic treatment.

Network toxicology, molecular docking technology, and experimental verification revealed the mechanism of cantharidin-induced testicular injury in mice

As a protein kinase inhibitor, cantharidin (CTD) exhibits antitumor activities. However, CTD is highly toxic, thereby limiting clinical applications. Moreover, relatively few studies have investigated CTD-induced reproductive toxicity, thus the underlying mechanism remains unclear. In this study, the toxic effects of CTD on mouse testis were confirmed in vivo and the potential mechanism was predicted by network toxicology (NT) and molecular docking technology. Proteins involved in the signaling pathways and core targets were verified. The results showed that different concentrations of CTD induced weight loss increased the testicular coefficient, and caused obvious pathological damage to testicular cells. The NT results showed that the main targets of CTD-induced testicular injury (TI) included AKT1, Caspase 3, Bcl-2, and Bax. The results of pathway enrichment analysis showed that CTD-induced TI was closely related to apoptosis and the PI3K/AKT and HIF-1 signaling pathways. Molecular docking methods confirmed high affinity between CTD and key targets. Western blot analysis showed that CTD inhibited expression of PI3K, AKT, and the anti-apoptotic protein Bcl-2, while promoting expression of the pro-apoptotic proteins Bax and Caspase 3. These results suggest that CTD-induced TI involves multiple targets and pathways, and the underlying mechanism was associated with inhibition of the apoptosis-related PI3K/AKT signaling pathway.

Protective effects of Stephania pierrei tuber-derived oxocrebanine against LPS-induced acute lung injury in mice

Acute lung injury and acute respiratory distress syndrome (ALI/ARDS) have high mortality rates. Though corticosteroids are commonly used for the treatment of these conditions, their efficacy has not been conclusively demonstrated and their use can induce various adverse reactions. Hence, the application of corticosteroids as therapeutic modalities for ALI/ARDS is limited. Meanwhile, the aporphine alkaloid oxocrebanine isolated from Stephania pierrei tubers has demonstrated anti-inflammatory efficacy in murine/human macrophage cell lines stimulated by lipopolysaccharide (LPS). Accordingly, the primary objectives of the present study are to investigate the anti-inflammatory effects of oxocrebanine on LPS-induced murine alveolar epithelial (MLE-12) cells and its efficacy against LPS-induced murine ALI. Results show that oxocrebanine downregulates the abundance of interleukin (IL)-1beta, IL-6, and inducible nitric oxide synthase, as well as the phosphorylation of nuclear factor-kappaB (NF-κB), stress-activated protein kinase (SAPK)/c-Jun N-terminal kinase (JNK), p38, protein kinase B (Akt), and glycogen synthase kinase-3beta signalling proteins in LPS-induced MLE-12 cells. Moreover, in a murine ALI model, oxocrebanine lowers lung injury scores and lung wet/dry weight ratios while reducing inflammatory cell infiltration. It also suppresses LPS-induced tumour necrosis factor-alpha and IL-6 in the bronchoalveolar lavage fluid and plasma. Moreover, oxocrebanine downregulates NF-κB, SAPK/JNK, p38, and Akt phosphorylation in the lung tissues of LPS-treated mice. Taken together, the foregoing results show that oxocrebanine provides significant protection against LPS-induced ALI in mice primarily by suppressing various inflammatory signalling pathways in alveolar epithelial cells and lung tissues. Hence, oxocrebanine might prove effective as an anti-inflammatory agent for the treatment of lung inflammation.

Long-term treatment of antipsychotics and combined therapy with other psychotropic medications inducing weight gain in patients with non-affective psychotic disorder: Evidence from GROUP, a longitudinal study

INTRODUCTION

Antipsychotics (APs) can cause weight gain. Little is known about changes in weight when APs are combined with other psychotropics. This study examines the weight change in patients undergoing long-term treatment with APs or with AP combined with other psychotropics.

METHODS

Patients with non-affective psychotic disorder from the GROUP study were divided into three groups: AP medication group (APm) (n = 100), AP in combination with other psychotropics (APc) (n = 73), and medication-free (Meds-free) (n = 100). Weight change was examined at inclusion and after three years using a paired-sample t-test. An Independent-sample t-test was performed to evaluate weight change among patients taking clozapine, olanzapine, and quetiapine and individuals not taking these medications. Linear regression was performed to evaluate the association between covariates and weight.

RESULTS

Patients in the APm group [mean = 1.800 kg, t(99)=2.849, 95% CI(0.546, 3.054), p = 0.005] and the APc group [mean = 1.877 kg, t(72)=2.688, 95% CI(0.485, 3.268), p = 0.009] showed significant weight gain. Patients taking clozapine, olanzapine or quetiapine showed significant weight gain compared to those not taking these medications [mean difference=1.707 kg, t(271)= 2.061, 95% CI(0.077, 3.337), p = 0.040)].

CONCLUSION

Patients receiving APs and APs with other psychotropics gain weight during long-term treatment. It is possible that weight gain is mainly driven by APs.

The Role of the UPR Pathway in the Pathophysiology and Treatment of Bipolar Disorder

Bipolar disorder (BD) is a mood disorder that affects millions worldwide and is associated with severe mood swings between mania and depression. The mood stabilizers valproate (VPA) and lithium (Li) are among the main drugs that are used to treat BD patients. However, these drugs are not effective for all patients and cause serious side effects. Therefore, better drugs are needed to treat BD patients. The main barrier to developing new drugs is the lack of knowledge about the therapeutic mechanism of currently available drugs. Several hypotheses have been proposed for the mechanism of action of mood stabilizers. However, it is still not known how they act to alleviate both mania and depression. The pathology of BD is characterized by mitochondrial dysfunction, oxidative stress, and abnormalities in calcium signaling. A deficiency in the unfolded protein response (UPR) pathway may be a shared mechanism that leads to these cellular dysfunctions. This is supported by reported abnormalities in the UPR pathway in lymphoblasts from BD patients. Additionally, studies have demonstrated that mood stabilizers alter the expression of several UPR target genes in mouse and human neuronal cells. In this review, we outline a new perspective wherein mood stabilizers exert their therapeutic mechanism by activating the UPR. Furthermore, we discuss UPR abnormalities in BD patients and suggest future research directions to resolve discrepancies in the literature.

Low Body Weight Increases the Risk of Ischemic Stroke and Major Bleeding in Atrial Fibrillation: The COOL-AF Registry

We aimed to determine if low body weight (LBW) status (<50 kg) is independently associated with increased risk of ischemic stroke and bleeding in Thai patients with non-valvular atrial fibrillation (NVAF). (1) Background: It has been unclear whether LBW influence clinical outcome of patients with NVAF. (2) Methods: This prospective multicenter cohort study included patients enrolled in the COOL-AF Registry. The following data were collected: demographic data, medical history, risk factors and comorbid conditions, laboratory and investigation data, and medications. Follow-up data were collected every 6 months. Clinical events during follow-up were confirmed by the adjudication committee. (3) Results: A total of 3367 patients were enrolled. The mean age was 67.2 ± 11.2 years. LBW was present in 338 patients (11.3%). Anticoagulant and antiplatelet was prescribed in 75.3% and 26.2% of patients, respectively. Ischemic stroke, major bleeding, intracerebral hemorrhage (ICH), and death occurred during follow-up in 2.9%, 4.4%, 1.4%, and 7.7% of patients, respectively, during 25.7 months follow-up. LBW was an independent predictor of ischemic stroke, major bleeding, ICH, and death, with a hazard ratio of 2.40, 1.79, 2.37, and 2.65, respectively. (4) Conclusions: LBW was independently associated with increased risk of adverse outcomes in Thai patients with NVAF. This should be carefully considered when balancing the risks and benefits of stroke prevention among patients with different body weights.

Glucocorticoid-Induced Fatty Liver Disease

Glucocorticoids (GCs) are commonly used at high doses and for prolonged periods (weeks to months) in the treatment of a variety of diseases. Among the many side effects are increased insulin resistance with disturbances in glucose/insulin homeostasis and increased deposition of lipids (mostly triglycerides) in the liver. Here, we review the metabolic pathways of lipid deposition and removal from the liver that become altered by excess glucocorticoids. Pathways of lipid deposition stimulated by excess glucocorticoids include 1) increase in appetite and high caloric intake; 2) increased blood glucose levels due to GC-induced stimulation of gluconeogenesis; 3) stimulation of de novo lipogenesis that is augmented by the high glucose and insulin levels and by GC itself; and 4) increased release of free fatty acids from adipose stores and stimulation of their uptake by the liver. Pathways that decrease hepatic lipids affected by glucocorticoids include a modest stimulation of very-low-density lipoprotein synthesis and secretion into the circulation and inhibition of β-oxidation of fatty acids. Role of 11β-hydroxysteroid dehydrogenases-1 and -2 and the reversible conversion of cortisol to cortisone on intracellular levels of cortisol is examined. In addition, GC control of osteocalcin expression and the effect of this bone-derived hormone in increasing insulin sensitivity are discussed. Finally, research focused on gaining a better understanding of the dose and duration of treatment with glucocorticoids, which leads to increased triglyceride deposition in the liver, and the reversibility of the condition is highlighted.

The effects of provider-prescribed obesogenic drugs on post-laparoscopic sleeve gastrectomy outcomes: a retrospective cohort study

Background:

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures and has proven effective in providing weight loss. However, considerable variance has been noted in the degree of weight loss. Physician prescription practices may be negatively affecting weight loss post-LSG and, thus, contributing to the broad range of weight loss outcomes. The aim of our study was to determine whether commonly prescribed obesogenic medications negatively affect weight loss outcomes post-LSG.

Subjects/Methods:

This single center retrospective cohort study performed at a University hospital included 323 patients (≥18 years) within University California, San Diego Healthcare System who underwent LSG between 2007 and 2016. We identified a list of 32 commonly prescribed medications that have weight gain as a side effect. We compared the percent excess weight loss (%EWL) of patients divided into two groups based on post-LSG exposure to obesogenic medications. A linear regression model was used to analyze %EWL at 12 months post-LSG while controlling for age, initial body mass index (BMI), and use of leptogenic medications.

Results:

150 patients (Meds group) were prescribed obesogenic medications within the one-year post-LSG follow up period, whereas 173 patients (Control group) were not prescribed obesogenic medications. The Meds group lost significantly less weight compared to the Control group (%EWL ± SEM at 12 months 53.8 ± 2.4 n=78, 65.0 ± 2.6, n=84 respectively, P = 0.002). This difference could not be attributed to differences in age, gender, initial BMI, co-morbidities, or prescription of leptogenic medications between the two groups.

Conclusions:

The use of provider-prescribed obesogenic medications was associated with worse weight loss outcomes post-LSG. Closer scrutiny of patient medications may be necessary to help improve outcomes of weight loss treatments.

The Investigation of Insulin Resistance in Two Groups of Epileptic Patients Treated with Sodium Valproate and Carbamazepine

BACKGROUND

Valproic acid (VPA) is a widely used broad-spectrum antiepileptic drug for therapy of generalized and focal epilepsies. Cross-sectional studies have suggested that valproate treatment may be associated with hyperinsulinemia. We decided to investigate hyperinsulinemia as a health-threatening side effect of VPA in Iranian epileptic patients.

MATERIALS AND METHODS

Body mass index (BMI), lipid profile, fasting serum insulin, fasting blood glucose (FBS), and homeostatic model assessment-insulin resistance (HOMA-IR) were measured in 30 VPA-treated epileptic patients and 30 controls (CBZ-treated). The Chi-square test, t-test, and Pearson correlation test were used.

RESULTS

BMI was higher in VPA group than in control group (25.7 ± 3.5 > 21.7 ± 4.1) (0.000 < 0.05). Prevalence of obesity was 16.6% in VPA group that was almost the same and even lower than general Iranian population. Serum triglyceride (TG) (150 ± 77.2) was higher than CBZ group (114 ± 35.2) (P = 0.023 < 0.05). However, serum high-density lipoprotein level was lower in VPA group than controls (45.2 ± 11.7 < 54.4 ± 13.9) (P = 0.008 < 0.05). Serum insulin, FBS, HOMA-IR, cholesterol, and low-density lipoprotein did not demonstrate statistically significant differences between the two groups (P > 0.05).

CONCLUSION

Despite the majority of previous studies that are against VPA and according to our study, VPA could be prescribed safely and it may not cause IR and its complications.

Naturalistic Impact of Second-Generation Antipsychotics on Weight Gain

Background:

While second-generation antipsychotics (SGAs) have had benefits over earlier antipsychotic treatments, their use has been associated with reports of weight gain. Body mass index (BMI) has been studied in clinical trials with limited comparison between drugs.

Objective:

To investigate the impact of each SGA on the risk of weight increase in an adult population.

Methods:

Using a national electronic medical records database, a naturalistic impact of SGAs on BMI was evaluated. Patients (aged ≥ 18 y) receiving a prescription for an antipsychotic drug between January 1995 and March 2004 were identified. An adverse event was defined as at least a 7% increase in BMI from baseline within one year of antipsychotic prescription and a post-increase BMI of at least 25 kg/m2.

Results:

A total of 9394 patients were identified, with 1514 cases of increased BMI after initial prescription. Risperidone (OR 1.39; 95% CI 1.16 to 1.66), quetiapine (OR 1.36; 95% CI 1.13 to 1.64), and olanzapine (OR 1.76; 95% CI 1.50 to 2.07)were significantly more likely to cause BMI increase compared with first-generation antipsychotics (FGAs). Aripiprazole (OR 0.72; 95% CI 0.36 to 1.46), ziprasidone (OR 0.68; 95% CI 0.39 to 1.18), and clozapine (OR 1.01; 95% CI 0.56 to 1.81) were less likely to induce weight gain compared with FGAs.

Conclusions:

This study provides a foundation for understanding how SGAs impact weight gain in a naturalistic, as opposed to a clinical trial, setting and provides evidence that there are differential risks of weight gain between SGAs. Because of negative long-term health effects of weight gain, physicians need to take all factors into consideration when recommending pharmaceutical therapy for patients with severe mental illness.

Preventive Treatment of Migraine: Effect on Weight

Weight gain is a side-effect commonly associated with drugs used for headache prophylaxis. Weight gain can adversely affect patient health, exacerbate comorbid metabolic disorders and encourage noncompliance. Few studies have been conducted specifically on the effect of headache medications on weight, and it is important for physicians to have accurate information about weight-gain side-effects when identifying appropriate pharmacological regimens. This review discusses the potential effects on weight of the more common headache medications.

Lamivudine-Induced Liver Injury

BACKGROUND

Lamivudine is a nucleoside analogue antiretroviral drug, known for its low toxicity at clinically prescribed dose. However, the toxicity or mechanism of toxicity and target tissue effects during prolonged administration of higher doses were hardly given sufficient laboratory attention.

AIM

The present work was designed to investigate the biochemical and histopathological changes in the liver of rat administered with prolonged doses of lamivudine.

MATERIAL AND METHODS

Lamivudine in multiple doses of five ranging from 4 mg/kg to 2500 mg/kg were administered, in vitro, by injection into the air-sac of 10-day old fertile embryonated eggs of Gallus domesticus. Also, female rats of the Wistar strain received oral doses, up to 500 mg/kg singly or repeatedly for 15 or 45 days, respectively. Spectrophotometric techniques were employed to monitor activities of the aminotransferases (ALT and AST), γ-glutamyltransferase (GGT) and total protein concentration in serum while activities of glutathione S-transferase (GST), GGT and superoxide dismutase (SOD) as well as concentrations of malondialdehyde (MDA) and protein were determined in liver. Histopathological studies were carried out on liver. Data were analysed using ANOVA and were considered significant when p < 0.05.

RESULTS

The LD50 for the drug calculated from the incubation experiment was 427 mg/kg. Total serum protein concentration significantly reduced while enzymes activities significantly increased at 500 mg/kg only among the repeat-dosed rats. Hepatic GGT, GST and SOD activities as well as MDA concentration were significantly elevated at 20 mg/kg. Histopathological studies showed multifocal lymphoid cell population in the liver sinusoid of the chicken and hydropic degeneration of hepatocytes were recorded among rats repeatedly exposed to the drug respectively at doses ≥ 100 mg/kg.

CONCLUSION

Lamivudine toxicity in rat liver appeared to be mediated by oxidative stress.

Relationship between indices of obesity obtained by anthropometry and dual-energy X-ray absorptiometry: The Fourth and Fifth Korea National Health and Nutrition Examination Survey (KNHANES IV and V, 2008-2011)

BACKGROUND

Body mass index (BMI), waist circumference (WC), and even dual-energy X-ray absorptiometry (DXA) are used for obesity diagnosis. However, it is not known which DXA-derived index of obesity correlates best with BMI and/or WC and it is not clear whether such an index is accurate or not.

OBJECTIVES

The aim of this study is to show the relationship between anthropometric measurements (BMI, WC) and body fat indices from DXA and to determine which DXA indices are strongly related to BMI and WC.

SUBJECTS

This study was based on data obtained from the Fourth and Fifth Korea National Health and Nutrition Examination Survey (KNHANES IV-V). DXA measurements were performed on survey subjects over 10 years old from July 2008 through to May 2011. Of these, 18 198 individuals, aged 19 years and older for whom DXA data were available, were included.

METHODS

Weighted Pearson's correlated coefficients (r) were calculated among indices, according to sex, age group and menopause, and the coefficients were compared with each other.

RESULTS

BMI correlates most with trunk body fat mass in kg (r=0.831) and then with total body fat in kg (r=0.774, P<0.00043 for difference of r). In the older age group, BMI correlates with total body fat mass (r=0.822) better than with trunk fat mass (r=0.817, P<0.00043). WC correlates with trunk body fat mass most in both genders and all age groups (0.804≤r≤0.906). Correlations of BMI (r=0.645 for men, 0.689 for women) and WC (r=0.678 for men, 0.634 for women) to body fat percentages (%) were less robust than those to body fat mass.

CONCLUSIONS

BMI and WC reflect trunk and total body fat in kg more than body fat percentage derived by DXA.

Carbamazepine directly inhibits adipocyte differentiation through activation of the ERK 1/2 pathway

BACKGROUND AND PURPOSE

Carbamazepine (CBZ), known for its anti-epileptic, analgesic and mood-stabilizing properties, is also known to induce weight gain but the pathophysiology of this adverse effect is still largely unknown. We tested the hypothesis that CBZ could have a direct effect on adipocyte development and metabolism. EXPERIMENTAL RESEARCH: We studied the effects of CBZ on morphological biochemical and molecular markers of adipogenesis, using several pre-adipocyte murine cell lines (3T3-L1, 3T3-F442A and T37i cells) and primary cultures of human pre-adipocytes. To delineate the mechanisms underlying the effect of CBZ, clonal expansion of pre-adipocytes, pro-adipogenic transcription factors, glucose uptake and lipolysis were also examined.

KEY RESULTS

CBZ strongly inhibited pre-adipocyte differentiation and triglyceride accumulation in a time- and dose-dependent manner in all models. Pleiotropic mechanisms were at the basis of the inhibitory effects of CBZ on adipogenesis and cell lipid accumulation. They included suppression of both clonal expansion and major adipogenic transcription factors such as PPAR-γ and CCAAT/enhancer binding protein-α, activation of basal lipolysis and decrease in insulin-stimulated glucose transport.

CONCLUSIONS AND IMPLICATIONS

The effect of CBZ on adipogenesis involves activation of the ERK1/2 pathway. Our results show that CBZ acts directly on pre-adipocytes and adipocytes to alter adipose tissue development and metabolism.

Dietary fructose-related adiposity and glucocorticoid receptor function in visceral adipose tissue of female rats

PURPOSE

Excessive fructose intake coincides with the growing rate of obesity and metabolic syndrome, with women being more prone to these disorders than men. Findings that detrimental effects of fructose might be mediated by glucocorticoid regeneration in adipose tissue only indirectly implicated glucocorticoid receptor (GR) in the phenomenon. The aim of the present study was to elucidate whether fructose overconsumption induces derangements in GR expression and function that might be associated with fructose-induced adiposity in females.

METHODS

We examined effects of fructose-enriched diet on GR expression and function in visceral adipose tissue of female rats. Additionally, we analyzed the expression of genes involved in glucocorticoid prereceptor metabolism [11β-hydroxysteroid dehydrogenase type 1 (11βHSD1) and hexose-6-phosphate dehydrogenase], lipolysis (hormone-sensitive lipase) and lipogenesis (sterol regulatory element binding protein 1 and peroxisomal proliferator-activated receptor γ).

RESULTS

Fructose-fed rats had elevated energy intake that resulted in visceral adiposity, as indicated by increased visceral adipose tissue mass and its share in the whole-body weight. GR hormone binding capacity and affinity, as well as the expression of GR gene at both mRNA and protein levels were reduced in visceral adipose tissue of the rats on fructose diet. The glucocorticoid prereceptor metabolism was stimulated, as evidenced by elevated tissue corticosterone, while the key regulators of lipolysis and lipogenesis remained unaffected by fructose diet.

CONCLUSIONS

The results suggest that the 11βHSD1-mediated elevation of intracellular corticosterone may induce GR downregulation, which may be associated with failure of GR to stimulate lipolysis in fructose-fed female rats.

In vivo pharmacological evaluations of novel olanzapine analogues in rats: a potential new avenue for the treatment of schizophrenia

Olanzapine (Olz) is one of the most effective antipsychotic drugs commonly used for treating schizophrenia. Unfortunately, Olz administration is associated with severe weight gain and metabolic disturbances. Both patients and clinicians are highly interested in the development of new antipsychotics which are as effective as atypical antipsychotics but which have a lower propensity to induce metabolic side effects. In the present study, we examined two new derivatives of Olz; OlzEt (2-ethyl-4-(4'-methylpiperazin-1'-yl)-10Hbenzo[b]thieno[2,3-e][1,4]diazepine), and OlzHomo (2-ethyl-4-(4'-methyl-1',4'-diazepan-1'-yl)-10H-benzo[b]thieno[2,3-e] [1,4]diazepine), for their tendency to induce weight gain in rats. Weight gain and metabolic changes were measured in female Sprague Dawley rats. Animals were treated orally with Olz, OlzEt, OlzHomo (3 or 6 mg/kg/day), or vehicle (n = 8), three times daily at eight-hour intervals for 5 weeks. Furthermore, a phencyclidine (PCP)-treated rat model was used to examine the prevention of PCP-induced hyperlocomotor activity relevant for schizophrenia therapy. Male Sprague Dawley rats were pre-treated with a single dose (3 mg/kg/day) of Olz, OlzEt, OlzHomo, or vehicle (n = 12), for 2 weeks. Locomotor activity was recorded following a subcutaneous injection with either saline or PCP (10 mg/kg). Olz was found to induce weight gain, hyperphagia, visceral fat accumulation, and metabolic changes associated with reduced histamatergic H1 receptor density in the hypothalamus of treated rats. In contrast, OlzEt and OlzHomo presented promising antipsychotic effects, which did not induce weight gain or fat deposition in the treated animals. Behavioural analysis showed OlzEt to attenuate PCP-induced hyperactivity to a level similar to that of Olz; however, OlzHomo showed a lower propensity to inhibit these stereotyped behaviours. Our data suggest that the therapeutic effectiveness of OlzHomo may be delivered at a higher dose than that of Olz and OlzEt. Overall, OlzEt and OlzHomo may offer a better pharmacological profile than Olz for treating patients with schizophrenia. Clinical trials are needed to test this hypothesis.

Metabolic control through glucocorticoid hormones: an update

In the past decades, glucocorticoid (GC) hormones and their cognate, intracellular receptor, the glucocorticoid receptor (GR), have been well established as critical checkpoints in mammalian energy homeostasis. Whereas many aspects in healthy nutrient metabolism require physiological levels and/or action of GC, aberrant GC/GR signalling has been linked to severe metabolic dysfunction, including obesity, insulin resistance and type 2 diabetes. Consequently, studies of the molecular mechanisms within the GC signalling axis have become a major focus in biomedical research, up-to-date particularly focusing on systemic glucose and lipid handling. However, with the availability of novel high throughput technologies and more sophisticated metabolic phenotyping capabilities, as-yet non-appreciated, metabolic functions of GC have been recently discovered, including regulatory roles of the GC/GR axis in protein and bile acid homeostasis as well as metabolic inter-organ communication. Therefore, this review summarises recent advances in GC/GR biology, and summarises findings relevant for basic and translational metabolic research.

Sex Differences in the Effects of Inhaled Corticosteroids on Weight Gain among Patients with Asthma

Background. Studies have shown that asthma and asthma exacerbations are related to body weight and that this relationship might be sex-specific. While oral corticosteroids have been associated with weight gain, little is known about the effect of inhaled corticosteroid (ICS) use on short-term weight gain. The purpose of the present study was to examine whether ICSs would be associated with weight gain among asthmatic patients. Methods. A total of 180 adult patients with physician-diagnosed asthma provided details of their medical history and demographic information, along with height and weight at baseline and at one year. Weight change was defined as follow-up minus baseline weight. General linear models were used to assess the relationship between ICS dose (fluticasone propionate equivalent) and sex. Results. Significant main effects of sex (P=.005) and ICS dose (P=.036) and an interaction effect of sex and ICS dose (P=.003) on weight change were observed. Further analysis of the interaction indicated that women had greater weight gain, while men had decreased weight with increased ICS dose. Conclusions. Findings suggest that ICSs may trigger weight gain in females and highlight the need for studies to confirm this relationship and examine the potential underlying mechanisms.

Weight Change in Monozygotic Twins Treated with Valproate

OBJECTIVE

To evaluate whether genetic factors contribute to weight gain associated with valproate (VPA) therapy.

RESEARCH METHODS AND PROCEDURES

We retrospectively and prospectively evaluated five pairs of monozygotic twins concordant for epilepsy and treated with VPA regarding weight course.

RESULTS

In all twin pairs, both twins showed similar weight courses under therapy with VPA.

DISCUSSION

These results suggest that genetic factors may have an influence on the weight change induced by VPA. Further studies are necessary to obtain heritability estimates regarding this effect of VPA therapy and to identify the relevant genes.

Novel olanzapine analogues presenting a reduced H1 receptor affinity and retained 5HT2A/D2 binding affinity ratio

Background

Olanzapine is an atypical antipsychotic drug with high clinical efficacy, but which can cause severe weight gain and metabolic disorders in treated patients. Blockade of the histamine 1 (H₁) receptors is believed to play a crucial role in olanzapine induced weight gain, whereas the therapeutic effects of this drug are mainly attributed to its favourable serotoninergic 2A and dopamine 2 (5HT_2A/D₂) receptor binding affinity ratios.

Results

We have synthesized novel olanzapine analogues 8a and 8b together with the already known derivative 8c and we have examined their respective in vitro affinities for the 5HT_2A, D₂, and H₁ receptors.

Conclusions

We suggest that thienobenzodiazepines 8b and 8c with lower binding affinity for the H₁ receptors, but similar 5HT_2A/D₂ receptor binding affinity ratios to those of olanzapine. These compounds may offer a better pharmacological profile than olanzapine for treating patients with schizophrenia.

Structural contributions of antipsychotic drugs to their therapeutic profiles and metabolic side effects

Antipsychotic drugs have various neuropharmacological properties as a result of their structural diversity. Despite their therapeutic benefits, most of the prescribed atypical antipsychotics can induce severe side effects, including weight gain, type II diabetes mellitus, and cardiovascular diseases. Among the developed atypical antipsychotic agents, tetracyclic dibenzodiazepine and thienobenzodiazepine compounds, particularly clozapine and olanzapine, are associated with the greatest weight gain and metabolic disturbances. However, the unique chemical structure of these compounds causes the low risk of side effects reported for typical antipsychotics (e.g. extrapyramidal symptoms and tardive dyskinesia). This report reviews the recent discovery of the potential role of the chemical structure of antipsychotics in their therapeutic properties and metabolic disturbances. By developing structure-activity relationship studies for atypical antipsychotics, we will improve our understanding of the structural modifications of these chemical classes that lead to reduced weight gain, which will be an invaluable step toward the discovery of the next generation of atypical antipsychotics. In this review, we suggest that a novel dibenzodiazepine or thienobenzodiazepine antipsychotic drug with lower affinity for H(1) receptors may significantly advance schizophrenia therapy.

Obesity and psychotropics

Weight gain is on the rise in the United States as is the diagnosis and treatment of mental disorders. These two phenomena are distinctly separate but tend to overlap in that most psychotropic agents approved for use in the United States are associated with the potential to induce weight gain. Metabolic disorders such as diabetes, hypercholesterolemia, and hypertension are also on the rise and often associated with weight gain and clearly associated with certain psychotropic medications. This article serves to provide a succinct review regarding the epidemiology, etiology, and treatment options for psychotropic-induced obesity.

Overweight and obesity in women with physical disabilities: associations with demographic and disability characteristics and secondary conditions

BACKGROUND

This cross-sectional study was designed to examine weight in association with demographic and disability characteristics and secondary conditions in a sample of community living women with physical disabilities.

METHODS

443 predominantly ethnic minority women with physical disabilities were recruited through public and private health clinics and community organizations. They completed questionnaires including measures of body mass index and a health conditions checklist.

RESULTS

Data showed that nearly three-quarters of the sample were overweight (26.6%) or obese (47.6%) with 14% extremely obese. Obesity was highest among middle aged women (aged 45-54, 52.7%; aged 55-64, 52.5%; compared to aged 18-44, 37.8%; or aged ≥65, 39.1%). Black (84.0%) and Hispanic women (83.8%) were more likely to be overweight or obese compared to non-Hispanic white women (56.7%). Women with joint and connective tissue diseases and women with more extensive functional limitations were more likely to have excess weight. Disability factors were more strongly associated with excess weight than demographic factors other than age. Weight classification was significantly related to whether or not the women had ever had diabetes or blood pressure problems. Diabetes was reported 4 times as often as among women in general (36.3% versus 8.9%), and hypertension nearly twice as often (56.2% versus 30.9%).

CONCLUSIONS

These findings indicate extremely high rates of overweight and obesity in women with physical disabilities, a growing population greatly in need of effective weight management interventions. Overweight and obesity in combination with disability in women was associated with disproportionately high rates of diabetes and hypertension.

Weight gain, obesity, and psychotropic prescribing

A majority of psychiatric medications are known to generate weight gain and ultimately obesity in some patients. There is much speculation about the prevalence of weight gain and the degree of weight gain during acute and longitudinal treatment with these agents. There is newer literature looking at the etiology of this weight gain and the potential treatments being used to alleviate this side effect. The authors undertook a comprehensive literature review in order to present epidemiology, etiology, and treatment options of weight gain associated with antipsychotics, mood stabilizers, and antidepressants.

Role of glucocorticoids and the glucocorticoid receptor in metabolism: insights from genetic manipulations

Since the discovery of the beneficial effects of adrenocortical extracts for treating adrenal insufficiency more than 80 years ago, glucocorticoids and their cognate, intracellular receptor, the glucocorticoid receptor have been characterized as critical checkpoints in the delicate hormonal control of energy homeostasis in mammals. Whereas physiological levels of glucocorticoids are required for proper metabolic control, aberrant glucocorticoid action has been linked to a variety of pandemic metabolic diseases, such as type II diabetes and obesity. Based on its importance for human health, studies of the molecular mechanisms of within the glucocorticoid signaling axis have become a major focus in biomedical research. In particular, the understanding of tissue-specific functions of the glucocorticoid receptor pathway has been proven to be of substantial value for the development of novel therapies in the treatment of chronic metabolic disorders. Therefore, this review focuses on the consequences of endogenous and experimental modulation of glucocorticoid receptor expression for metabolic homeostasis and dysregulation, particularly emphasizing tissue-specific contributions of the glucocorticoid pathway to the control of energy metabolism.

The Scandinavian Solutions for Wellness study - a two-arm observational study on the effectiveness of lifestyle intervention on subjective well-being and weight among persons with psychiatric disorders

BACKGROUND

Solutions for Wellness (SfW) is an educational 3-month program concerning nutrition and exercise for persons with psychiatric disorders on psychotropic medication, who have weight problems. This observational study assessed the impact of SfW on subjective well-being, weight and waist circumference (WC).

METHODS

Data was collected at 49 psychiatric clinics. Where the SfW program was offered patients could enter the intervention group; where not, the control group. Subjective well-being was measured by the Subjective Well-being under Neuroleptics scale (SWN), at baseline, at the end of SfW participation, and at a follow-up 6 months after baseline. Demographic, disease and treatment data was also collected.

RESULTS

314 patients enrolled in the SfW group, 59 in the control group. 54% of the patients had schizophrenia, 67% received atypical antipsychotics, 56% were female. They averaged 41 +/- 12.06 years and had a BMI of 31.4 +/- 6.35. There were significant differences at baseline between groups for weight, SWN total score and other factors. Stepwise logistic models controlling for baseline covariates yielded an adjusted non-significant association between SfW program participation and response in subjective well-being (SWN increase). However, statistically significant associations were found between program participation and weight-response (weight loss or gain < 1 kg) OR = 2; 95% CI [1.1; 3.7] and between program participation and WC-response (WC decrease or increase < 2 cm) OR = 5; 95% CI [2.4; 10.3]), at 3 months after baseline.

CONCLUSIONS

SfW program participation was associated with maintaining or decreasing weight and WC but not with improved subjective well-being as measured with the SWN scale.

Propagation of adipogenic signals through an epigenomic transition state

The transcriptional mechanisms by which temporary exposure to developmental signals instigates adipocyte differentiation are unknown. During early adipogenesis, we find transient enrichment of the glucocorticoid receptor (GR), CCAAT/enhancer-binding protein beta (CEBPbeta), p300, mediator subunit 1, and histone H3 acetylation near genes involved in cell proliferation, development, and differentiation, including the gene encoding the master regulator of adipocyte differentiation, peroxisome proliferator-activated receptor gamma2 (PPARgamma2). Occupancy and enhancer function are triggered by adipogenic signals, and diminish upon their removal. GR, which is important for adipogenesis but need not be active in the mature adipocyte, functions transiently with other enhancer proteins to propagate a new program of gene expression that includes induction of PPARgamma2, thereby providing a memory of the earlier adipogenic signal. Thus, the conversion of preadipocyte to adipocyte involves the formation of an epigenomic transition state that is not observed in cells at the beginning or end of the differentiation process.

A generalist's guide to treating patients with depression with an emphasis on using side effects to tailor antidepressant therapy

This review provides a guide to the primary care physician for diagnosing and managing depression. To identify relevant articles, a PubMed search (ending date parameter, October 15, 2009) was conducted using the keywords depression, antidepressants, side effects, adverse effects, weight gain, sexual dysfunction, and sleep disturbance, and the reference lists of relevant articles were hand searched. This review explores the challenges in diagnosing depression that will and will not respond to antidepressants (ADs) and describes the value of 2-question screening instruments followed by in-depth questioning for positive screening results. It underscores the implications of veiled somatic presentations in which underlying depression is missed, leading to fruitless and expensive medical work-ups. Following this survey of the difficulties in diagnosing depression, the 4 options generalists have for treating a patient with depression are discussed: watchful waiting, antidepressant therapy, psychotherapy, and psychiatric referral. This review proposes that physicians, once they decide to prescribe, use AD side effects to advantage by selecting medications to minimize negative and maximize positive possibilities, thereby improving adherence. It focuses on the 3 most troubling adverse effects-sleep disturbance, sexual dysfunction, and weight gain. It provides AD-prescribing principles to assist primary care physicians in successfully managing depression and appropriately referring patients to a psychiatrist. Antidepressant therapy is not a panacea for treating patients with depression. An approach blending enlightened observation, medications, and psychotherapy often helps depressed patients recover to their former baselines.

Modification in body weight associated with antiepileptic drugs

Antiepileptic drugs (AED) may cause body weight changes. OBJECTIVE: To evaluate the dietary habits and body weight associated with AED in epileptic patients. METHOD: Sixty-six patients were subjected to two interviews, and had their weight and body mass index calculated and compared at both times, interval between six to eight months. RESULTS: It was observed that 59.1% showed weight gain. The patients who had no weight gain had a greater proportion of individuals who engaged in some form of physical activity. However, of the 45 patients who maintained their initial dietary and medication pattern, 75.6% recorded a weight gain. Weight gain was seen in 66.7% of patients on carbamazepine (n=18), 60% on valproate (n=5), 50% on carbamazepine+clobazam treatment (n=14), and 58.3% of patients on other(s) polytherapy (n=12). CONCLUSION: The patient should be alerted to possible weight gain, and should be advised about dieting and participating in regular physical activity.

Preventing obesity: challenges and pitfalls for health promotion

OBJECTIVE

To explore challenges to health promotion strategies against obesity, with special attention to the Scandinavian context.

METHODS

Analytic induction, a procedure for verifying theories and propositions, based on purposefully selected literature references, with subsequent critical reflection.

RESULTS

Health promotion efforts against obesity face challenges related to the unequal distribution of vulnerability to weight gain within the population, and to the complex neuroregulatory determinants that explain why obesity is not just a simple matter of lifestyle. Cultural understandings of identity and morality may create victim blaming and disempowerment, thus obstructing clinical health promotion strategies for weight control. Finally, the conceptual validity of obesity measurements and their predictive power deserves attention.

CONCLUSION

Preventing obesity is difficult. Awareness of individual vulnerability and neurobiological mechanisms that lead to weight gain must be taken into account when strategies for health promotion are developed. These strategies must transcend a simplistic energy balance view.

PRACTICE IMPLICATIONS

Clinical health promotion needs to be highly individualized and tailored. Preventing weight gain requires attention to the person's sociodemographic, cultural and genetic characteristics. Cultural trends such as sedentary lifestyles and the nutrition transition should be counteracted without turning body weight control into a question of morality and inferior identity.

Antidepressive-drug-induced bodyweight gain is associated with polymorphisms in genes coding for COMT and TPH1

Bodyweight gain is a common side effect of treatment with antidepressive drugs; however, little is known about the mechanisms behind this weight gain. Genetic differences may contribute to the susceptibility for bodyweight gain during antidepressive treatment. The objective of this study was to examine the association of antidepressive-drug-induced bodyweight gain with polymorphisms in genes within the serotonin or catecholamine systems. Participants (N = 165) were selected from the Danish Psychiatric Central Research Register from June 2005 through May 2007 as patients with a diagnosis of a single depressive episode and who were under antidepressive treatment. Weight gainers were identified based on rating with the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale. Polymorphisms in catechol-O-methyltransferase, tryptophan hydroxylase (TPH1), serotonin receptor 2C (HTR2C) and serotonin transporter (SLC6A4) genes were identified and associated with bodyweight gain during treatment. The AG genotype of catechol-O-methyltransferase rs4680 and the AA genotype of TPH1 rs18532 were significantly associated with bodyweight gain during antidepressive treatment, when adjusted for age and sex. These new findings may aid the understanding of susceptibility to side effects such as weight gain during clinical antidepressive treatment.

Preventive treatment of migraine: effect on weight

Weight gain is a common side effect of drugs used for headache prevention. Weight gain can adversely affect patient health, exacerbate comorbid metabolic disorders, and encourage noncompliance. Additionally, obesity may promote the chronification of episodic migraine. Few studies have looked specifically at the effect that headache medications have on weight. The practicing physician needs accurate information about important side effects, including weight gain, when selecting appropriate pharmacologic regimens. This article discusses the potential effects the more common headache medications have on weight.

Long-term consequences of drugs on the paediatric cardiovascular system

Many pharmacological and toxicological actions of drugs in children cannot be fully predicted from adult clinical experience or from standard non-clinical toxicology studies. Numerous drugs have direct or indirect pharmacological effects on the heart and are prescribed for children of all ages. Toxicity or secondary effects may be immediate or delayed for years after drug exposure has ceased. Originally, the aim of this review was to compile information on the effect of specific drugs on the post-natal development of the cardiovascular system and to examine long-term follow-up of the use of cardio-active drugs in children. The limited database of published information caused the original question to evolve into an examination of the medical literature for three areas of information: (i) whether vulnerable developmental windows have been identified that reflect the substantial functional development that the cardiovascular system undergoes after birth; (ii) what is known about pharmacological perturbation of development; and (iii) what the likelihood is of drug exposure during childhood. We examined different scenarios for exposure including random, isolated exposure, conditions historically associated with adults, primary or secondary cardiac disease, psychiatric and neurological conditions, asthma, cancer and HIV. Except for random, isolated drug exposures, each category of possible exposure contained numerous drugs known to have either primary or secondary effects on the cardiovascular system or to influence factors associated with atherosclerosis. It is likely that a significant number of children will be prescribed drugs having either direct or indirect effects upon the immature cardiovascular system. A confounding factor is the simultaneous use of over-the-counter medications and herbal or nutraceutical preparations that a patient, parent or guardian does not mention to a prescribing physician. Metabolism is also important in assessing drug effects in children. Differences in body water : body fat ratio, age-related gastrointestinal absorption, distribution, excretion, renal function and drug metabolizing capabilities make it possible for children to have a different metabolite profile for a drug compared with adults. There is little examination of drug effects on the interdependent processes of cardiac maturation and less examination of metabolite effects. It is difficult to identify delayed toxicities in children as these adverse events may take years to manifest with many patients lost to follow-up. Clearly this is an area of study where intermediate endpoints and surrogate markers would be of great benefit. Pharmacogenomics may be useful in providing markers of increased risk or susceptibility. A perspective must be kept in balancing the possibility of a problem with the very real benefits that many children experience from the use of these pharmaceuticals.

Effect of augmented atypical antipsychotics on weight change in patients with major depressive disorder in a naturalistic setting

OBJECTIVE

The extent of weight changes in depressed patients who use atypical antipsychotics (AAP) as augmentation could not be easily predicted due to weight related symptoms of depression and the interaction with antidepressants which have weight reducing effects.

METHODS

Patients were treated with either antidepressants augmented with AAP for more than 2 weeks (AAP group, n = 100) or only with antidepressants (non-AAP group, n = 172) during the admission between 2002 and 2006, and the differences in weight were analyzed.

RESULTS

Mean weight gains of AAP group were significantly higher than those of non-AAP group (2.98 +/- 1.87 kg vs. 1.70 +/- 1.85 kg, p = 0.001). When stratified by antidepressants, the significant difference between the two groups was shown among the subjects who had taken serotonin reuptake inhibitors (SSRIs), but not mirtazapine and venlafaxine (3.42 +/- 2.01 kg vs. 1.48 +/- 1.79 kg, p < 0.001). Comparing among different combinations in AAP group showed that subjects treated with SSRIs and olanzapine had the greatest weight gain (4.21 +/- 1.90 kg), significantly higher than that of the other subgroups (p < 0.001).

CONCLUSIONS

Our findings suggest that AAP used in patients with depression could severely aggravate preexisting weight-related problems of antidepressants use and the possibility that the combined use with specific antidepressants could have a unique effect on weight by drug-drug interactions.

Extent of emphysema on HRCT affects loss of fat-free mass and fat mass in COPD

BACKGROUND

Although muscle loss is thought to be a prognostic factor in chronic obstructive pulmonary disease (COPD), its determinants remain unclear.

AIM

To verify the hypothesis that fat-free mass (FFM) and fat mass (FM) are associated with the extent of emphysema in COPD patients.

PATIENTS AND METHODS

A total of 112 stable, male current or ex-smokers with or without COPD attending a secondary care specialist COPD clinic were studied. FFM and FM were measured by bioelectrical impedance analysis. We also assessed the nutrition status, muscle strength by the handgrip test, exercise tolerance by the 6-minute walking test, airflow limitation and diffusion capacity, the extent of emphysema by high-resolution CT scan, systemic inflammation status using C-reactive protein, and a lipid-related hormone (adiponectin).

RESULTS

The FFM index (FFMI), which was defined as the FFM divided by the square of the body height, was significantly correlated with age, the total number of lymphocytes, handgrip strength, distance on 6-minute walking, airflow limitation, diffusion capacity, extent of emphysema, and C-reactive protein. On multivariate analysis, the FFMI was associated with handgrip strength and inversely correlated with the extent of emphysema. The FM index (FMI) was positively correlated with pack-years, and was inversely correlated with the extent of emphysema and concentrations of adiponectin.

CONCLUSION

The extent of emphysema was correlated with skeletal muscle loss and also the FM.

Weight change associated with the use of migraine-preventive medications

BACKGROUND

Medications administered long term, such as those used for migraine prophylaxis, are often associated with weight change as a side effect. Such effects may compromise general health status, exacerbate coexisting medical conditions, and affect medication adherence. Weight gain should be of particular concern in patients with migraine, as there is evidence that overweight and obese patients with migraine are at risk for an increased frequency and severity of migraine attacks.

OBJECTIVE

This article reviews weight-change data from recent clinical studies of migraine-preventive medications in children, adolescents, and adults with migraine.

METHODS

A PubMed search was conducted for English-language articles published between January 1970 and November 2007. Among the search terms were migraine prevention, migraine prophylaxis, migraine treatment, antidepressant drug, beta-adrenergic-receptor blockers, antiepileptic drug, anticonvulsant drug, weight gain, and weight loss. Studies that reported weight-change data (gain, loss, or neutral) were included. When available, double-blind, placebo-controlled studies were selected for review. Open-label, retrospective or prospective trials may also have been included.

RESULTS

Most of the migraine-preventive medications classified by the United States Headache Consortium as group 1 based on the high level of evidence for their efficacy--for instance, amitriptyline, propranolol, and divalproex sodium-have been associated with varying degrees of weight gain. The exceptions are timolol, which is weight neutral, and topiramate, which is associated with weight loss. Among the drugs that have been associated with weight gain, a higher incidence of weight gain was observed with amitriptyline and divalproex sodium than with propranolol.

CONCLUSION

Weight-change effects require careful consideration when selecting migraine-preventive medications, and weight should be monitored carefully over the course of any migraine treatment plan.

Weight gain in bipolar disorder: pharmacological treatment as a contributing factor

OBJECTIVE

The aim of this paper was to review the association of most commonly used psychopharmacological drugs with weight gain in bipolar disorder.

METHOD

Information was retrieved from a PubMed/Medline literature search reviewing weight gain in pharmacological studies in bipolar disorder.

RESULTS

Obesity and overweight in bipolar disorder are partly related to prescribed drugs with a strong effect of clozapine and olanzapine. Lesser but still relevant weight gain is caused by quetiapine, risperidone, lithium, valproate, gabapentin and by some antidepressants. Ziprasidone, aripiprazole, carbamazepine and lamotrigine do not seem to cause significant overweight.

CONCLUSION

Careful monitoring of weight changes in patients before and after drug prescription should be implemented in the clinical routine and drugs which potentially cause weight gain should be avoided in overweight patients with bipolar disorder. Furthermore, eating habits and daily activities should be targeted as they may also have a significant impact on overall health and weight-related issues.

Overweight and obesity among children with developmental disabilities

BACKGROUND

The aim of this study was to determine the prevalence of overweight and obesity in children with developmental disabilities attending a metropolitan Diagnosis and Assessment Service.

METHOD

A retrospective chart review was carried out for 98 children (67 male) aged 2-18 years. Data on age, sex, weight, height, and severity of intellectual disability or global developmental delay were collected from medical records. Body mass index (BMI, weight/height2) was calculated, and overweight and obesity defined using standard international criteria.

RESULTS

Data indicated that 24% of the children were overweight and a further 15% were obese (i.e., a total of 40% either overweight or obese), which is significantly higher than the prevalence rate for Australian school children in the New South Wales Schools Physical Activity and Nutrition Survey (SPANS) 2004, which found that 17% were overweight (p = .05) and 6% were obese (p = .0003) (i.e., 23% either overweight or obese, p = .0001).

CONCLUSIONS

The prevalence of overweight and obesity is higher among children with developmental disabilities than in the general population. Community-based studies with larger sample sizes are required to confirm this finding. The results also highlight the need to develop health care strategies for the prevention, early identification and management of excess weight gain for this group.

Changes in the hypothalamic-pituitary-adrenal axis and leptin levels during antidepressant treatment

BACKGROUND

In depressed patients, overstimulation of the hypothalamo-pituitary-adrenocortical (HPA) system, probably caused by glucocorticoid receptor resistance, is the most consistent neurobiological finding. Glucocorticoids themselves are reported to increase leptin synthesis and secretion in humans.

METHODS

We examined alterations in plasma levels of leptin as well as changes in the HPA system function using the combined dexamethasone/corticotropin-releasing hormone (dex/CRH) test on admission and at discharge in 74 depressed inpatients.

RESULTS

Mean leptin concentration did not change significantly between admission and discharge. However, changes in ACTH response and partial cortisol response to the combined dex/CRH test between admission and discharge were significantly correlated with leptin levels at discharge.

CONCLUSIONS

Leptin levels at discharge rise as the HPA axis normalizes. These findings may be explained by an improvement in glucocorticoid receptor sensitivity among depressed patients during antidepressant therapy and a consecutively increased influence of glucocorticoids on leptin levels via the glucocorticoid receptor.

Glucocorticoids, metabolism and metabolic diseases

Since the discovery of the beneficial effects of adrenocortical extracts for treating adrenal insufficiency more than 80 years ago, glucocorticoids (GC) and their cognate, intracellular receptor, the glucocorticoid receptor (GR) have been characterized as critical components of the delicate hormonal control system that determines energy homeostasis in mammals. Whereas physiological levels of GCs are required for proper metabolic control, excessive GC action has been tied to a variety of pandemic metabolic diseases, such as type II diabetes and obesity. Highlighted by its importance for human health, the investigation of molecular mechanisms of GC/GR action has become a major focus in biomedical research. In particular, the understanding of tissue-specific functions of the GC-GR pathway has been proven to be of substantial value for the identification of novel therapeutic options in the treatment of severe metabolic disorders. Therefore, this review focuses on the role of the GC-GR axis for metabolic homeostasis and dysregulation, emphasizing tissue-specific functions of GCs in the control of energy metabolism.

Antidepressants induce cellular insulin resistance by activation of IRS-1 kinases

Certain selective serotonin reuptake inhibitors (SSRIs) induce the clinical and biochemical manifestations of a metabolic syndrome by as yet unknown mechanism. Here we demonstrate that incubation (1 h) of rat hepatoma Fao cells with the SSRIs paroxetine and sertraline, but not with the atypical antipsychotic drug olanzapine, inhibited the insulin-stimulated Tyr phosphorylation of the insulin receptor substrate-1 (IRS-1) with half-maximal effects at approximately 10 microM. This inhibition correlated with a rapid phosphorylation and activation of a number of Ser/Thr IRS-1 kinases including JNK, S6K1, ERK and p38 MAPK, but not PKB (Akt). JNK appears as a key player activated by SSRIs because specific JNK inhibitors partially eliminated the effects of these drugs. The SSRIs induced the phosphorylation of IRS-1 on S307 and S408, which inhibits IRS-1 function and insulin signaling. These results implicate selected SSRIs as inhibitors of insulin signaling and as potential inducers of cellular insulin resistance.

What does the epidemic of childhood obesity mean for children with special health care needs?

Bringing the 12.8% of children with special healthcare needs into the national response to the childhood obesity epidemic will require new information, a view of health promotion beyond that which occurs within healthcare systems, and services and supports in addition to the multi-sectoral strategies presently designed for children overall. These efforts are necessary to protect the health of the nation's 9.4 million children with special health care needs now and long-term.

Appropriate intervention strategies for weight gain induced by olanzapine: a randomized controlled study

Weight gain induced by antipsychotics is the second most frequently given reason for noncompliance with pharmacologic therapy; excessive sedative effects rank first, with extrapyramidal side effects ranking third. Frequently, weight gain leads to inconsistent pharmacologic treatment; this exposes patients to the risk of recurrent symptoms. In fact, one of the key contributors to good clinical outcomes in schizophrenic patients is compliance with pharmacologic treatment. The goals of this study were to evaluate weight gain in a group of patients treated with olanzapine, diet modifications, and moderate physical activity and to compare the findings with those from a second group of patients who were given only olanzapine treatment. For 8 wk, investigators followed 2 groups of patients suffering from schizophrenia and hypomania in bipolar disorder, according to the nosographic criteria of The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The first group (A) of 18 patients (9 female, 9 male) affected by manic episodes in bipolar disorder received olanzapine (10-20 mg/d), jogged lightly for 30 min 3 times a week, and complied with a diet that consisted of 500 kcal/d less than usual. The second group (B) of 10 patients (4 female, 6 male) with schizophrenia received only olanzapine (10-20 mg/d). All patients from both groups were weighed at the beginning of the observation period and weekly thereafter for 2 mo. After 2 mo of observation, group A showed a mean weight gain of 1.47 kg, whereas group B exhibited a mean weight gain of 3.5 kg; the difference between the 2 groups was almost 2 kg (P<.005). Group A showed a statistically significant reduction in weight gain compared with group B, clearly demonstrating the effectiveness of moderate physical activity and diet therapy in reducing weight gain in atypical antipsychotic treatment. Therefore, patient weight and body mass index must be monitored during the first weeks of antipsychotic treatment, with the goals of avoiding significant weight gain and treatment interruption.

Antidepressant-induced undesirable weight gain: Prevention with rimonabant without interference with behavioral effectiveness

Antidepressant pharmacotherapy has dramatically improved the quality of life for many patients. However, prolonged use may induce weight gain, resulting in enhanced risk for treatment noncompliance. Cannabinoid CB(1) receptor antagonists decrease food intake and body weight, but may also affect mood. We investigated in female Sabra mice first, whether acute treatment with the cannabinoid receptor antagonist rimonabant (5-(4-Chlorophenyl)-1-(2,4-dichlorophenyl)-4-methyl-N-(piperidin-1-yl)-1H-pyrazole-3-carboxamide, SR141716, 5 mg/kg) interfered with the tricyclic antidepressant desipramine (15 mg/kg) or the selective serotonin reuptake inhibitor fluoxetine (20 mg/kg) in the Porsolt forced swimming test. Second, whether chronic treatment (3 months) with desipramine (5 mg/kg) enhanced weight gain and whether cotreatment with rimonabant (2 mg/kg), prevented the excessive weight gain, while retaining antidepressant effectiveness. Motor activity and anxiety-like behavior were also investigated. The acute studies indicated that rimonabant did not influence 'antidepressant' activity of desipramine or fluoxetine. In the chronic studies, desipramine enhanced weight gain, despite the observation that the injection procedure reduced weight gain. The enhanced weight gain continued at least 35 days after treatment ended. Rimonabant reduced weight gain to which no tolerance developed and which persisted at least 30 days beyond treatment. Mice cotreated with rimonabant and desipramine had body weights closer to controls or to those receiving rimonabant alone than to those treated with desipramine alone. The antidepressant effects of desipramine were maintained throughout treatment; this was not altered by the chronic rimonabant treatment at any time, although rimonabant together with desipramine transiently enhanced anxiety-like behavior. These observations suggest that combined treatment with antidepressants and cannabinoid CB(1) receptor antagonist to prevent undesirable weight gain, should be further investigated.

Weight gain and insulin requirement in type 2 diabetic patients during the first year after initiating insulin therapy dependent on baseline BMI

AIM

The aim of this study was to determine differences, if any, in weight gain and increased insulin requirements in insulin-treated type 2 diabetic patients with a normal and an elevated body mass index (BMI).

METHODS

A total of 192 patients with newly insulinized type 2 diabetes were included in the study. The patients were divided into three groups: those with BMI <26 (n = 102), BMI 26-30 (n = 50) and those with BMI >30 (n = 40). At the beginning of insulin therapy and 12 months later, we compared HbA1c, BMI and required insulin doses in each group and evaluated weight gain and the increase in insulin requirement during the observation period. Moreover, we investigated the influence of additional metformin therapy on weight gain and insulin requirement.

RESULTS

Body weight increased in the group with normal BMI from 68.8 +/- 9.2 to 70.8 +/- 9.4 kg (+2.9%) and in the other groups from 79.0 +/- 9.3 to 81.2 +/- 8.4 (+2.8%) and from 96.2 +/- 11.2 to 99.1 +/- 16.5 kg (+3.0%) respectively. The differences between the groups were not significant. The insulin requirement increased by 22% in the normal-weighted group and by 23% in both groups with overweight. The reduction in mean HbA1c was similar in the three groups (22, 18 and 22%). Under additional metformin therapy, the increment of insulin requirement of all patients (n = 40) was significantly lower (11 vs. 26%, p < 0.01), and there was no significant difference between the groups with different BMIs. During the same period, the gain in body weight and the decrease of HbA1c were not significantly different in the patients with and without metformin independent on the BMI.

CONCLUSIONS

The risk for weight gain and increase in insulin requirement is similar in insulin-treated type 2 diabetic patients with normal and elevated BMI. Additional metformin therapy reduces insulin requirement in patients with and without overweight.

Effect of an aerobic exercise training program on resting metabolic rate in chronically beta-adrenergic blocked hypertensive patients

PURPOSE

There is substantial evidence that the use of beta-adrenergic receptor blockers (beta-blockers) is associated with a reduction in resting metabolic rate (RMR) and that a weight gain usually occurs in the first few months of treatment. The purpose of this study was to determine if RMR of overweight and sedentary subjects consuming beta-blockers can be increased following an aerobic exercise training program.

METHODS

Twenty-four subjects participated in the study; 11 (6 women, 5 men) were treated with beta-blockers for hypertension and 13 (9 women, 4 men) were nonmedicated (control group). Body composition, RMR, and peak oxygen uptake (VO2peak) were assessed for all subjects before and after a 12-week aerobic exercise training program. Weekly exercise energy expenditure equaled 83.68 kJ (20 kcal) per kg of body weight while exercise intensity was maintained between 60% and 70% of the VO2 reserve.

RESULTS

Body composition, RMR, and VO2peak did not differ among groups at the beginning of the study. Body weight (-1.4 kg for beta-blockers, P < .05; -2.5 kg for control, P < .05) and VO2peak (+2.2 mL x kg(-1) x min(-1) for beta-blockers, P < .05; +4.1 mL x kg(-1) x min(-1) for control, P < .001) were significantly improved in both groups, whereas RMR (-272 kJ x day(-1) for beta-blockers, NS; +573 kJ x day(-1) for control, P < .05) was increased only in the control group after the aerobic exercise training program.

CONCLUSIONS

These results suggest that beta-blockers limit the increase in RMR normally observed following an aerobic exercise training program. Consequently, obtaining a negative energy balance in an attempt to lose weight may be more difficult.