[Weight loss: when the body image does not keep up]

The body image, defined as an individual's 'inner vision' of himself, stems from the combination of multiple factors. The body dissatisfaction, which represents its negative version, is associated with eating disorders, a sedentary lifestyle and weight gain. Several patients suffering from obesity consider weight loss as a strategy to work on their body image. Multiples studies confirm a positive association between weight loss and improved body images. Nevertheless, few elements seem to predispose to body dissatisfaction persistence, such as a history of strict diets, eating disorders or other psychopathologies. To treat body dissatisfaction, we need to focus our attention on self-esteem, a balanced lifestyle, and media education.

[Awakening the senses to change our relationship with the body. A group experiment with people suffering from obesity]

People living with obesity frequently have low self-esteem and a negative body image. Their relationship with their body is painful, which can lead them to dissociate themselves from it. This detachment is not conducive to lasting behavioural change. The "Awakening the Senses" programme offered to a group of patients at the Therapeutic Patient Education Unit combines aspects of cognitive behavioural therapy, mindfulness and art therapy. Its aim is to help patients reconnect with their bodies through sensory and creative experiences. This article presents the programme, the clinical observations made and the results of the various evaluations carried out.

[Weight gain during menopause: physiology and practical implications]

Fluctuations in sex hormones at different stages of reproductive life, such as the menopausal transition, have been suggested as players in weight regulation. Indeed, the transition from a predominantly estrogenic state to an androgenic state characteristic of the menopausal transition contributes to changes in body composition with accumulation of fat and simultaneous loss of lean mass. However, whether these changes contribute to the weight gain remains debatable. Other physiological and psychosocial factors come into play. It is therefore important to offer individualized support with the objective to minimize the risk of weight gain and associated complications.

[Nutrition-obesity. New program about behavioural issues involved in weight loss through surgery]

Bariatric surgery is an effective treatment to improve metabolic health as long as behavioural changes are made. Opting for this therapeutic choice represents a real commitment on the part of patients which is complementary to the informative bariatric surgery consultation. After all, what practitioner has not been confronted with an urgent request from patients suffering from obesity who are over-investing in this operation? Therapeutic Patient Education offers the opportunity to work with patients to develop their status as committed actors through a new outpatient educational program. Increased feelings of self-efficacy and socio-cognitive conflict are ingredients that allow patients to invest in long-term changes.

A randomized controlled trial investigating the effect of liraglutide on self-reported liking and neural responses to food stimuli in participants with obesity

BACKGROUND/OBJECTIVES

Obesity is a complex condition and the mechanisms involved in weight gain and loss are not fully understood. Liraglutide, a GLP-1 receptor agonist, has been demonstrated to successfully promote weight loss in patients with obesity (OB). Yet, it is unclear whether the observed weight loss is driven by an alteration of food liking. Here we investigated the effects of liraglutide on food liking and the cerebral correlates of liking in OB.

SUBJECTS/METHODS

This study was a randomized, single-center, double-blind, placebo-controlled, parallel group, prospective clinical trial. 73 participants with OB and without diabetes following a multidisciplinary weight loss program, were randomly assigned (1:1) to receive liraglutide 3.0 mg (37.40 ± 11.18 years old, BMI = 35.89 ± 3.01 kg) or a placebo (40.04 ± 14.10 years old, BMI = 34.88 ± 2.87 kg) subcutaneously once daily for 16 weeks.

INTERVENTIONS/METHODS

We investigated liking during food consumption. Participants reported their hedonic experience while consuming a high-calorie food (milkshake) and a tasteless solution. The solutions were administered inside the scanner with a Magnetic Resonance Imaging (MRI)-compatible gustometer to assess neural responses during consumption. The same procedure was repeated during the pre- and post-intervention sessions.

RESULTS

None of the effects involving the intervention factor reached significance when comparing liking between the pre- and post-intervention sessions or groups. Liking during food reward consumption was associated with the activation of the ventromedial prefrontal cortex (vmPFC) and the amygdala. The liraglutide group lost more weight (BMI post-pre = -3.19 ± 1.28 kg/m2) than the placebo group (BMI post-pre = -0.60 ± 1.26 kg/m2).

CONCLUSIONS

These results suggest that liraglutide leads to weight loss without self-report or neural evidence supporting a concomitant reduction of food liking in participants with OB.

Intelligent plantar pressure offloading for the prevention of diabetic foot ulcers and amputations

The high prevalence of lower extremity ulceration and amputation in people with diabetes is strongly linked to difficulties in achieving and maintaining a reduction of high plantar pressures (PPs) which remains an important risk factor. The effectiveness of current offloading footwear is opposed in part by poor patient adherence to these interventions which have an impact on everyday living activities of patients. Moreover, the offloading devices currently available utilize primarily passive techniques, whereas PP distribution is a dynamically changing process with frequent shifts of high PP areas under different areas of the foot. Thus, there is a need for pressure offloading footwear capable of regularly and autonomously adapting to PPs of people with diabetes. The aim of this article is to summarize the concepts of intelligent pressure offloading footwear under development which will regulate PPs in people with diabetes to prevent and treat diabetic foot ulcers. Our team is creating this intelligent footwear with an auto-contouring insole which will continuously read PPs and adapt its shape in the forefoot and heel regions to redistribute high PP areas. The PP-redistribution process is to be performed consistently while the footwear is being worn. To improve adherence, the footwear is designed to resemble a conventional shoe worn by patients in everyday life. Preliminary pressure offloading and user perceptions assessments in people without and with diabetes, respectively, exhibit encouraging results for the future directions of the footwear. Overall, this intelligent footwear is designed to prevent and treat diabetic foot ulcers while enhancing patient usability for the ultimate prevention of lower limb amputations.

[The evolution of the perception of obesity: the "weight" of social norms]

The perception of obesity and the ideal body image has evolved over time, largely due to social norms that are not always guided by scientific knowledge. The use of social media for health promotion is an emerging area of investigation. Preliminary research suggests that they have the potential to both serve as a platform for combating the stigma of obesity and promoting positive body image. But there is also evidence that supports the contrary. In particular, the dissemination of digitally altered images that convey ideals of the slim female form can be detrimental to physical and psychological health. Further research is needed to determine how best to use social networks and media as a health promotion tool.

[Preparation program for bariatric surgery designed with patients: challenges and benefits]

Despite the weight and metabolic efficiency of bariatric surgery, nearly 35 % of operated patients regain weight due to insufficient behavioral changes. Collaborating with patient partners to co-construct an educational preparation program represents an opportunity to promote patient involvement adjusted to societal developments. This partnership starts with an exploration of the partners' needs and follows a progressive and tailored process that responds to the issues of place and power raised. It leads to the creation of a day of teaching, at the beginning of the course, aimed at informed consent and to a program, at the end of the course, focused on behavioral changes in their concrete dimension in support of a new and recognized health actor: the patient partner.

[What is the relationship between alcohol and obesity?]

The prevalence of alcohol consumption and obesity continues to increase. The aim of this literature review was to give an overview of the association between these two health and socioeconomic problems. Ethanol must be considered as an orexigenic molecule, acting on the cerebral regulation of hunger and satiety and on the mesolimbic reward system. Moreover, studies showed that alcohol blocks the fatty acid beta oxidation, promoting the storage of lipids. Observational and experimental studies struggle to find a solid correlation between the two entities, but they have several biases and limitations. Experts agree to consider ethanol ingestion as a potential contributing factor of the higher obesity rates observed in the last decades.

Effectiveness of therapeutic patient education interventions for chronic diseases: A systematic review and meta-analyses of randomized controlled trials

Background

Chronic disorders are highly prevalent and are a major contributor to death and disability worldwide. Evidence has shown that therapeutic patient education (TPE) interventions are effective in improving a range of biomedical and psychological outcomes for a variety of chronic disorders. This has been demonstrated in scores of randomized controlled and evidence-synthesis studies. However, no quantitative evidence has been published so far on the content and effective teaching strategies in TPE programs. The present systematic review and meta-analysis aim to bridge this gap by answering the who, what, and how of TPE programs.

Methods

Using a pretested search strategy, we searched the Web of Science, MEDLINE, CINAHL, PsycINFO, and the COCHRANE databases, from inception to August 2019. The search strategy was based on four comprehensive search concepts (patient education, chronic diseases, study design, and outcomes). After a careful screening for eligible studies, two reviewers extracted qualitative and quantitative data from the randomized controlled trials on the TPE interventions. We also developed a taxonomy of curriculum skills and intervention delivery techniques to aid the extraction of data in these domains.

Results

We found that these interventions were effective in improving biological outcomes (SMD = 0.48; 95% CI: 0.38-0.57), adherence to the treatment regimen (SMD = 0.73; 95% CI: 0.46-1.002), knowledge (SMD = 1.22; 95% CI: 0.79-1.65), self-efficacy (SMD = 0.43; 95% CI: 0.30-0.56), and psychological health (SMD = -0.41; 95% CI: -0.53 to -0.29). This effectiveness was consistent across different delivery formats (individual, group, and electronic) and delivery agents (non-specialists vs. specialists).

Conclusion

The flexibility in the choice of mode of delivery and curriculum development gives stakeholders an opportunity to scale up TPE interventions in healthcare settings.

Systematic review registration

Identifier: CRD42019141294.

Cardiovascular outcomes trials: a paradigm shift in the current management of type 2 diabetes

Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in patients with type 2 diabetes (T2D). Historical concerns about cardiovascular (CV) risks associated with certain glucose-lowering medications gave rise to the introduction of cardiovascular outcomes trials (CVOTs). Initially implemented to help monitor the CV safety of glucose-lowering drugs in patients with T2D, who either had established CVD or were at high risk of CVD, data that emerged from some of these trials started to show benefits. Alongside the anticipated CV safety of many of these agents, evidence for certain sodium-glucose transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have revealed potential cardioprotective effects in patients with T2D who are at high risk of CVD events. Reductions in 3-point major adverse CV events (3P-MACE) and CV death have been noted in some of these CVOTs, with additional benefits including reduced risks of hospitalisation for heart failure, progression of renal disease, and all-cause mortality. These new data are leading to a paradigm shift in the current management of T2D, with international guidelines now prioritising SGLT2 inhibitors and/or GLP-1 RAs in certain patient populations. However, clinicians are faced with a large volume of CVOT data when seeking to use this evidence base to bring opportunities to improve CV, heart failure and renal outcomes, and even reduce mortality, in their patients with T2D. The aim of this review is to provide an in-depth summary of CVOT data-crystallising the key findings, from safety to efficacy-and to offer a practical perspective for physicians. Finally, we discuss the next steps for the post-CVOT era, with ongoing studies that may further transform clinical practice and improve outcomes for people with T2D, heart failure or renal disease.

Sex-specific modulation of circulating growth differentiation factor-15 in patients with type 2 diabetes and/or obesity

OBJECTIVE

Growth differentiation factor-15 (GDF15), a key metabolic regulator, is associated with obesity and diabetes in which sex-specific differences have been reported. Thus, we assessed whether GDF15 could be dependent on sex in diabetes and/or obesity groups.

METHODS

We measured serum GDF15 levels by ELISA in eight lean women and men (n = 16), eight women and eight men having obesity (n = 16), eight women and eight men with type 2 diabetes (T2D, n = 16), and seven women and nine men with both diabetes and obesity (n = 16). Estimation of the difference in the means of each group was performed by two-way ANOVA. The interdependence of the different variates was addressed by multivariate analysis. Correlations between GDF15 levels and HOMA-IR, HbA1c, triglycerides, HDL, and LDL were explored by linear regression.

RESULTS

Being a woman and having obesity alone or in combination with diabetes decreased GDF15 serum levels (β = -0.47, CI = -0.95, 0.00, P = 0.052; β = -0.45, CI = -0.94, 0.05, P= 0.075). Diabetes independently of metformin treatment and obesity were not predictive of low GDF15 levels (β = 0.10, CI = -0.36, 0.57, P = 0.7). Correlation analysis showed that HOMA-IR (r = 0.45, P = 0.008) and triglycerides (r = 0.41, P = 0.017) were positively correlated and HDL (r = -0.48, P = 0.005) was negatively correlated with GDF15 levels in men.

CONCLUSIONS/INTERPRETATION

GDF15 level was significantly different between men and women, as well as between the groups. Sex and group interaction revealed that being a woman and having obesity alone or in combination with diabetes decreased GDF15 levels.

[Evolution and effectiveness of therapeutic patient education for obesity and diabetes]

Therapeutic patient education (TPE) aims to help patients acquire or maintain the skills they need to best manage their lives with a chronic disease. Through a scientometric analysis of the literature, we identified the most influential bibliographic data related to TPE research that have strengthened the field and increased its effectiveness. These were studies from the fields of education, philosophy, psychology, anthropology and medical sociology. We have conducted a meta-analysis that has demonstrated the effectiveness of TPE for the management of obesity and diabetes on biological and psychological parameters. It allowed patients to improve their knowledge, their therapeutic adherence and their sense of self-efficacy.

[Weight-loss promoting dietary supplements : overview of their efficacy and safety]

Due to the increase in the prevalence of obesity, the consumption of dietary supplements promoting weight loss has increased in the last few years. Many dietary supplements are available on the market, such as L-carnitine, glucomanan, chitosan, and Hoodia gordonii. The safety and clinical effectiveness of most of these supplements have not been assessed by high-quality trials. The scientific evidence of their benefit remains weak. The risk of adverse effects and drug interactions, most often unknown to patients, exists and must be carefully considered before initiating supplementation, in consultation with a physician, in the same way as other aspects of the treatment of obese patients.

[How to manage obesity in the general practitioner's office ?]

The prevalence of obesity continues to increase and only a change in behavior can lead to a reduction in weight and an improvement of the cardio-metabolic profile. The general practitioner plays an important role in preventing excess weight and in identifying patients at risk. He is often on the front line to provide hygiene- dietetic advice and long-term support. The purpose of this article is to give the primary care physician some guidelines from reception at the office to referral to a specialist center if necessary.

Female Sex and Angiotensin-Converting Enzyme (ACE) Insertion/Deletion Polymorphism Amplify the Effects of Adiposity on Blood Pressure

The pathophysiological link between adiposity and blood pressure is not completely understood, and evidence suggests an influence of sex and genetic determinants. We aimed to identify the relationship between adiposity and blood pressure, independent of a robust set of lifestyle and metabolic factors, and to examine the modulating role of sex and Angiotensin-Converting Enzyme (ACE) insertion/deletion (I/D) polymorphisms. In the Relationship Between Insulin Sensitivity and Cardiovascular Disease (RISC) study cohort, 1211 normotensive individuals, aged 30 to 60 years and followed-up after 3.3 years, were characterized for lifestyle and metabolic factors, body composition, and ACE genotype. Body mass index (BMI) and waist circumference (WC) were independently associated with mean arterial pressure, with a stronger relationship in women than men (BMI: r=0.40 versus 0.30; WC: r=0.40 versus 0.30, both P<0.01) and in individuals with the ID and II ACE genotypes in both sexes (P<0.01). The associations of BMI and WC with mean arterial pressure were independent of age, sex, lifestyle, and metabolic variables (standardized regression coefficient=0.17 and 0.18 for BMI and WC, respectively) and showed a significant interaction with the ACE genotype only in women (P=0.03). A 5 cm larger WC at baseline increased the risk of developing hypertension at follow-up only in women (odds ratio, 1.56 [95% CI, 1.15-2.10], P=0.004) and in II genotype carriers (odds ratio, 1.87 [95% CI, 1.09-3.20], P=0.023). The hypertensive effect of adiposity is more pronounced in women and in people carrying the II variant of the ACE genotype, a marker of salt sensitivity.

Ether lipids, sphingolipids and toxic 1-deoxyceramides as hallmarks for lean and obese type 2 diabetic patients

AIM

The worldwide increase in obesity and type 2 diabetes (T2D) represents a major health challenge. Chronically altered lipids induced by obesity further promote the development of T2D, and the accumulation of toxic lipid metabolites in serum and peripheral organs may contribute to the diabetic phenotype.

METHODS

To better understand the complex metabolic pattern of lean and obese T2D and non-T2D individuals, we analysed the lipid profile of human serum, skeletal muscle and visceral adipose tissue of two cohorts by systematic mass spectrometry-based lipid analysis.

RESULTS

Lipid homeostasis was strongly altered in a disease- and tissue-specific manner, allowing us to define T2D signatures associated with obesity from those that were obesity independent. Lipid changes encompassed lyso-, diacyl- and ether-phospholipids. Moreover, strong changes in sphingolipids included cytotoxic 1-deoxyceramide accumulation in a disease-specific manner in serum and visceral adipose tissue. The high amounts of non-canonical 1-deoxyceramide present in human adipose tissue most likely come from cell-autonomous synthesis because 1-deoxyceramide production increased upon differentiation to adipocytes in mouse cell culture experiments.

CONCLUSION

Taken together, the observed lipidome changes in obesity and T2D will facilitate the identification of T2D patient subgroups and represent an important step towards personalized medicine in diabetes.

Sphingosine-1-phosphate as a key player of insulin secretion induced by high-density lipoprotein treatment

Beta cell failure is one of the most important features of type 2 diabetes mellitus (T2DM). High‐density lipoprotein (HDL) has been proposed to improve β‐cell function. However, the mechanisms involved in this process are still poorly understood. The aim of this study was to investigate the contribution of sphingosine‐1‐phosphate (S1P) in the impact of HDL treatment on insulin secretion by pancreatic β‐cells and to determine its mechanisms. Primary cultures of β‐cells isolated from rat were treated with or without HDL in the presence or absence of S1P pathway inhibitors and insulin secretion response was analyzed. The S1P content of HDL (HDL‐S1P) isolated from T2DM patients was analyzed and correlated to the HDL‐induced insulin secretion. The expression of genes involved in the biosynthesis of the insulin was also evaluated. HDL as well as S1P treatment enhanced glucose‐stimulated insulin secretion (GSIS). In HDL isolated from T2DM patients, while HDL‐S1P was strongly correlated to its pro‐secretory capacity (r = 0.633, p = 0.005), HDL‐cholesterol and apolipoprotein AI levels were not. HDL‐induced GSIS was blocked by the S1P1/3 antagonist but not by the S1P2 antagonist, and was also accompanied by increased intracellular S1P in β‐cells. We also observed that HDL improved GSIS without significant changes in expression levels of insulin biosynthesis genes. Our present study highlights the importance HDL‐S1P in GSIS in T2DM patients and demonstrates that HDL induces insulin secretion by a process involving both intra‐ and extra‐cellular sources of S1P independently of an effect on insulin biosynthesis genes.

[Brain food reward alterations in obesity]

Obesity, defined by body fat excess, results from a food intake which exceeds energy needs. The control of this intake is compromised in people suffering from obesity. There is a disturbance of the food reward brain network, in the form of an abnormal reactivity to visual and gustatory food signals and a disrupted influence of the state of hunger on its activity as well as an alteration in the dopaminergic neurotransmission. Eating would thus be leaded more by its hedonic supply rather than physiological needs and this imbalance would appear among the mechanisms underlying overeating behavior. A better understanding of obesity neurobiology would ultimately contribute to the improvement of therapies and preventive measures.

[A double pandemic : the impact of anti-Covid measures on obesity]

To deal with the COVID-19 pandemic, several restrictive measures have been put in place that cause significant disruption to lifestyle habits. We conducted a review of the literature to study the impact of these changes on the body weight of populations. We observed changes in eating habits (increase in the number of snacks and consumption of sugary products), a decrease in physical activity and an increase in stress that can exacerbate eating disorders. Increased efforts must be made to support patients during this difficult time, including public health measures to counteract these behaviours in order to prevent health complications.

[Efficacy of smartphone applications for weight loss]

In recent years, smartphone applications (« apps ») for weight loss have emerged on the market. Their potential in the management of overweight or obesity is interesting thanks to their various features discussed in the article. The analyzed studies show that apps allow significant weight reduction, however without showing any difference with other interventions. In the future, functions based on artificial intelligence may be useful tools to improve patients' adherence to weight loss programs. Moreover, these apps present deficiencies in terms of respect of scientific evidence and the contribution of health experts in their design. In the future, interdisciplinary collaboration between developers, researchers and clinicians is necessary before considering the use of these apps in current practice.

[The role of stress in obesity]

Stress is known to favour weight gain. This can be explained by various physiopathological and behavioural mechanisms. Specifically, chronic stress induces a dysfunction of the sympathetic nervous system and of the hypothalamic-pituitary-adrenal axis which favours obesity, and the other way around. Furthermore, stress promotes eating disorders and a decrease in physical activity. Various studies using strategies that act specifically on stress have shown benefits in terms of weight loss. It is therefore important to evaluate stress in any patient suffering from obesity and to propose a treatment adapted to the patient's needs.

[Intermittent fasting : A solution for metabolic disorders?]

The management of obesity comprises lifestyle changes targeting nutrient content, eating behavior and regular physical activity. Medication (orlistat, liraglutide) and bariatric surgery can later be used, but they require a clear indication and a close follow-up. Studies in chronobiology are now exploring the metabolic benefits of intermittent fasting, which restricts food intake and calorie-containing beverages to a certain window of the 24h cycle, or to certain days of the week/month, thus reinstating the alternance between anabolism and catabolism. However, the current scientific evidence is limited by the sample size and duration of the studies. It is therefore too early for a blanket strategy based on intermittent fasting in all patients with metabolic disorders.

Bariatric Surgery: Consequences on Functional Capacities in Patients With Obesity

INTRODUCTION

Bariatric surgery leads to loss of fat and fat-free mass (FFM). To preserve FFM it is recommended that weight loss interventions are accompanied by physical activity. However, it remains unknown if functional capacities spontaneously improve after a substantial weight loss. Study's aim was to assess the effect of bariatric surgery on strength, functional capacities and quality of life of participants with a body mass index (BMI) ≥ 35 kg/m².

METHOD

Anthropometric parameters (weight, BMI, waist circumference), physical functions (quadriceps strength, walking capacity, spatio-temporal gait parameters, dynamic balance, lower limb power) and quality of life were assessed before and at three months after the bariatric surgery in 33 individuals who did not follow any physical activity program.

RESULTS

The anthropometric parameters, quality of life and three functional abilities (walking capacity, normal gait speed and lower limb power) improved significantly three months post-surgery. In contrast, fast gait speed, absolute strength, normalized strength, and dynamic balance did not improve.

DISCUSSION

A massive weight loss should be accompanied by an exercise program aiming to maintain FFM and to enhance muscle strength and balance. Such a program might also enhance functional capacities and help to sustain the weight loss over time.

Telemedicine to deliver diabetes care in low- and middle-income countries: a systematic review and meta-analysis

Objective

To determine the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries.

Methods

We searched seven databases up to July 2020 for randomized controlled trials investigating the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries. We extracted data on the study characteristics, primary end-points and effect sizes of outcomes. Using random effects analyses, we ran a series of meta-analyses for both biochemical outcomes and related patient properties.

Findings

We included 31 interventions in our meta-analysis. We observed significant standardized mean differences of −0.38 for glycated haemoglobin (95% confidence interval, CI: −0.52 to −0.23; I² = 86.70%), −0.20 for fasting blood sugar (95% CI: −0.32 to −0.08; I² = 64.28%), 0.81 for adherence to treatment (95% CI: 0.19 to 1.42; I² = 93.75%), 0.55 for diabetes knowledge (95% CI: −0.10 to 1.20; I² = 92.65%) and 1.68 for self-efficacy (95% CI: 1.06 to 2.30; I² = 97.15%). We observed no significant treatment effects for other outcomes, with standardized mean differences of −0.04 for body mass index (95% CI: −0.13 to 0.05; I² = 35.94%), −0.06 for total cholesterol (95% CI: −0.16 to 0.04; I² = 59.93%) and −0.02 for triglycerides (95% CI: −0.12 to 0.09; I² = 0%). Interventions via telephone and short message service yielded the highest treatment effects compared with services based on telemetry and smartphone applications.

Conclusion

Although we determined that telemedicine is effective in improving several diabetes-related outcomes, the certainty of evidence was very low due to substantial heterogeneity and risk of bias.

MON-126 Telemedicine Interventions for Treatment of Diabetes Mellitus in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Diabetes mellitus (DM) is associated with significant morbidity, mortality and poor quality of life. It also has substantial social and financial implications because over 75% of patients with DM live in low- and middle-income countries (LMIC). In this context, it is often opined that diabetes care can be improved by employing telemedicine interventions. The present systematic review and meta-analysis aims to estimate the clinical effectiveness of telemedicine in improving biochemical and treatment adherence outcomes related to DM and provide the certainty of evidence for these interventions. Using a pretested search strategy, nine academic databases were searched from their inception to August 2019: Web of Science, PubMed, Medline, Global Health Library, Cochrane Central Register of Controlled Trials (CENTRAL), New York Academy of Medicine (NYAM) and Popline. We only included RCTs and cluster RCTs testing the effectiveness of tele-medicine-based interventions in type 1, 2 and gestational diabetes in LMIC. Risk of bias in the included RCTs was assessed using the Cochrane tool for assessment of risk of bias in randomized controlled trials. A series of meta-analyses for each individual outcome was run using random effects analyses. Certainty of evidence for these interventions was assessed using the GRADE guidelines. A total of 22 studies describing 23 interventions were included. We identified five modes of interventions delivered using telephone calls (n=6), SMS (n=5), telemetry (n=5) web-based systems (n=3) and smartphone apps (n=3). Major strategies included health record keeping, follow ups, reminders, psychoeducation, glucose monitoring, monitoring prompts, alerts and online consultations Overall, a significant treatment effect was seen among outcomes of HbA1c (SMD=-0.30, 95% CI= -0.42 to -0.17, n=6548, I²= 80.21%) and fasting blood sugar levels (SMD=-0.17, 95% CI= -0.32 to -0.01, n=4709, I²=60.49%), self-efficacy (SMD= 1.94, 95% CI= 1.31 to 2.58, n=626, I²= 95.99) and treatment adherence (SMD= 1.16, 95% CI= 0.78 to 1.54, n=437, I²= 84.8%). A marginally significant effect was seen in improvement of knowledge regarding diabetes (SMD= 0.66, 95% CI= -0.006 to 1.33, n=1345, I²= 93.38%). No significant treatment effect was seen in outcomes of serum triglyceride levels (SMD= -0.02, 95% CI= -0.18 to 0.14, n= 1535, I²=2.98%), serum total cholesterol levels (SMD= -0.05, 95% CI= -0.20 to 0.09, n= 4862, I²=66.45%) and BMI (SMD= -0.03, 95% CI= -0.13 to 0.07, n= 5372, I²=41.78 %). Telephone calls and SMS based telemedicine interventions yielded the highest treatment effects when compared with telemetry and smartphone apps-based services. Although telemedicine was found to be effective in improving several DM related outcomes, the certainty of evidence was downgraded to very low due to substantial heterogeneity, publication bias and risk of bias.

[Start to collaborate with partner patients : an evidence?]

The societal, political and institutional context is today favorable for the establishment of a partnership between patient and healthgivers. Despite the tangible benefits, the perception of partners ambivalent attitudes reinforces the importance of the construction for this collaboration. This article describes this collaborative approach born out of the transformation of a bariatric surgery preparation educational program. In this context, the implementation strategy is the founding stage to explore the needs of partners. This highlights the need to secure the healthgivers regarding power issues, as well as to question the skills required for patient partners. The definition of the partnership model by the partners provides answers.

[Obesity : eat less and move more ? Not so easy]

Obesity is a chronic disease that requires a complex treatment. Establishing a balanced diet and regular physical activity is not always simple, especially in the long term. There are multiple factors (biological and psychological) favoring weight gain, often limiting the effectiveness of lifestyle approaches. Pharmacology offers us another therapeutic option with new molecules effective for weight loss. Bariatric surgery is also effective, but it is not without risks, especially if the patients have not been adequately prepared for this procedure. Furthermore, these approaches should always be proposed as complementary to lifestyle changes. This article summarizes the different treatments for obesity and highlights the importance of a multidisciplinary management and proper patient education.

Cellular circadian period length inversely correlates with HbA1c levels in individuals with type 2 diabetes

AIMS/HYPOTHESIS

The circadian system plays an essential role in regulating the timing of human metabolism. Indeed, circadian misalignment is strongly associated with high rates of metabolic disorders. The properties of the circadian oscillator can be measured in cells cultured in vitro and these cellular rhythms are highly informative of the physiological circadian rhythm in vivo. We aimed to discover whether molecular properties of the circadian oscillator are altered as a result of type 2 diabetes.

METHODS

We assessed molecular clock properties in dermal fibroblasts established from skin biopsies taken from nine obese and eight non-obese individuals with type 2 diabetes and 11 non-diabetic control individuals. Following in vitro synchronisation, primary fibroblast cultures were subjected to continuous assessment of circadian bioluminescence profiles based on lentiviral luciferase reporters.

RESULTS

We observed a significant inverse correlation (ρ = -0.592; p < 0.05) between HbA_1c values and circadian period length within cells from the type 2 diabetes group. RNA sequencing analysis conducted on samples from this group revealed that ICAM1, encoding the endothelial adhesion protein, was differentially expressed in fibroblasts from individuals with poorly controlled vs well-controlled type 2 diabetes and its levels correlated with cellular period length. Consistent with this circadian link, the ICAM1 gene also displayed rhythmic binding of the circadian locomotor output cycles kaput (CLOCK) protein that correlated with gene expression.

CONCLUSIONS/INTERPRETATION

We provide for the first time a potential molecular link between glycaemic control in individuals with type 2 diabetes and circadian clock machinery. This paves the way for further mechanistic understanding of circadian oscillator changes upon type 2 diabetes development in humans.

DATA AVAILABILITY

RNA sequencing data and clinical phenotypic data have been deposited at the European Genome-phenome Archive (EGA), which is hosted by the European Bioinformatics Institute (EBI) and the Centre for Genomic Regulation (CRG), ega-box-1210, under accession no. EGAS00001003622.

Separation of blood microsamples by exploiting sedimentation at the microscale

Microsample analysis is highly beneficial in blood-based testing where cutting-edge bioanalytical technologies enable the analysis of volumes down to a few tens of microliters. Despite the availability of analytical methods, the difficulty in obtaining high-quality and standardized microsamples at the point of collection remains a major limitation of the process. Here, we detail and model a blood separation principle which exploits discrete viscosity differences caused by blood particle sedimentation in a laminar flow. Based on this phenomenon, we developed a portable capillary-driven microfluidic device that separates blood microsamples collected from finger-pricks and delivers 2 µL of metered serum for bench-top analysis. Flow cytometric analysis demonstrated the high purity of generated microsamples. Proteomic and metabolomic analyses of the microsamples of 283 proteins and 1351 metabolite features was consistent with samples generated via a conventional centrifugation method. These results were confirmed by a clinical study scrutinising 8 blood markers in obese patients.

Variable oxytocin levels in humans with different degrees of obesity and impact of gastric bypass surgery

Exogenous oxytocin administration in obese mice, rats, and monkeys was shown to induce sustained weight loss, mostly due to a decrease in fat mass, accompanied by an improvement of glucose metabolism. A pilot study in obese humans confirmed the weight-reducing effect of oxytocin. Knowledge about circulating oxytocin levels in human obesity might help indicating which obese subjects could potentially benefit from an oxytocin treatment. Conclusive results on this topic are missing. The aim of this study was to measure circulating oxytocin levels in lean (n = 37) and obese (n = 72) individuals across a wide range of body mass index (BMI) values (18.5-60 kg/m²) and to determine the impact of pronounced body weight loss following gastric bypass surgery in 12 morbidly obese patients. We observed that oxytocin levels were unchanged in overweight and in class I and II obese subjects and only morbidly obese patients (obesity class III, BMI > 40 kg/m²) exhibited significantly higher levels than lean individuals, with no modification 1 year after gastric bypass surgery, despite substantial body weight loss. In conclusion, morbidly obese subjects present elevated oxytocin levels which were unaltered following pronounced weight loss.

[Food reward circuitry in obese patients]

Besides hormonal regulation of appetite and satiety, food intake depends on the activity of certain brain systems. Functional imaging studies are useful to better understand this central regulation of energy intake. Obesity is associated with increased brain responses to food stimuli at the level of the reward system. More specifically, studies have shown in obese individuals an increased motivation to obtain food reward as well as a decrease in pleasure during its actual consumption. Food consumption may be, in some instances, comparable to addiction, and be reflected by irresistible cravings for certain foods.

Effects of a Weight Loss Program on Metabolic Syndrome, Eating Disorders and Psychological Outcomes: Mediation by Endocannabinoids?

OBJECTIVE

To evaluate the effects of weight loss on endocannabinoids, cardiometabolic and psychological parameters, eating disorders (ED) as well as quality of life (QoL) and to elucidate the role of endocannabinoids in metabolic syndrome (MS).

METHODS

In total, 114 patients with obesity were prospectively included in a 12-month weight loss program. Plasma endocannabinoids were measured by mass spectrometry; ED, psychological and QoL-related parameters were evaluated by self-reported questionnaires; physical activity was measured by accelerometer. Nutritional assessment was done by a 3-day food diary.

RESULTS

Among completers (n = 87), body weight decreased in 35 patients (-9.1 ± 8.6 kg), remained stable in 39 patients, and increased in 13 patients (+5.8 ± 3.4 kg). 75% of patients with MS at baseline were free of MS at follow-up, and their baseline plasma N-palmitoylethanolamide (PEA) values were significantly lower when compared to patients with persisting MS. At baseline, there was a positive relationship between PEA and waist circumference (p = 0.005, R2 = 0.08), fasting glucose (p < 0.0001, R2 = 0.12), total cholesterol (p = 0.001, R2 = 0.11), triglycerides (p = 0.001, R2 = 0.11), LDL-cholesterol (p = 0.03, R2 = 0.05) as well as depression score (p = 0.002, R2 = 0.29).

CONCLUSION

Plasma PEA might play a role in metabolic improvement after weight loss. Even in subjects without weight loss, a multidisciplinary intervention improves psychological outcomes, ED, and QoL.

Gastric bypass in morbid obese patients is associated with reduction in adipose tissue inflammation via N-oleoylethanolamide (OEA)-mediated pathways

Paradoxically, morbid obesity was suggested to protect from cardiovascular co-morbidities as compared to overweight/obese patients. We hypothesise that this paradox could be inferred to modulation ofthe “endocannabinoid” system on systemic and subcutaneous adipose tissue (SAT) inflammation. We designed a translational project including clinical and in vitro studies at Geneva University Hospital. Morbid obese subjects (n=11) were submitted to gastric bypass surgery (GBS) and followed up for one year (post-GBS). Insulin resistance and circulating and SAT levels of endocannabinoids, adipocytokines and CC chemokines were assessed pre- and post-GBS and compared to a control group of normal and overweight subjects (CTL) (n=20). In vitro cultures with 3T3-L1 adipocytes were used to validate findings from clinical results. Morbid obese subjects had baseline lower insulin sensitivity and higher hs-CRP, leptin, CCL5 and anandamide (AEA) levels as compared to CTL. GBS induced a massive weight and fat mass loss, improved insulin sensitivity and lipid profile, decreased C-reactive protein, leptin, and CCL2 levels. In SAT, increased expression of resistin, CCL2, CCL5 and tumour necrosis factor and reduced MGLL were shown in morbid obese patients pre-GBS when compared to CTL. GBS increased all endocannabinoids and reduced adipocytokines and CC chemokines. In morbid obese SAT, inverse correlations independent of body mass index were shown between palmitoylethanolamide (PEA) and N-oleoylethanolamide (OEA) levels and inflammatory molecules. In vitro, OEA inhibited CCL2 secretion from adipocytes via ERK1/2 activation. In conclusion, GBS was associated with relevant clinical, metabolic and inflammatory improvements, increasing endocannabinoid levels in SAT. OEA directly reduced CCL2 secretion via ERK1/2 activation in adipocytes.

Shape of the OGTT glucose curve and risk of impaired glucose metabolism in the EGIR-RISC cohort

OBJECTIVE

To study whether the shape of the oral glucose tolerance test (OGTT)-glucose curve is a stable trait over time; it is associated with differences in insulin sensitivity, ß-cell function and risk of impaired fasting glucose (IFG) and glucose tolerance (IGT) in the Relationship between Insulin Sensitivity and Cardiovascular Disease (RISC) cohort.

METHODS

OGTT-glucose curve shape was classified as monophasic, biphasic, triphasic and anomalous in 915 individuals. Oral glucose insulin sensitivity (OGIS), Matsuda insulin sensitivity index (ISI) and ß-cell function were assessed at baseline and 3years apart.

RESULTS

The OGTT-glucose curve had the same baseline shape after 3years in 540 people (59%; κ=0.115; p<0.0001). Seventy percent of the participants presented with monophasic OGTT-glucose curve shape at baseline and after 3years (percent positive agreement 0.74). Baseline monophasic shape was associated with significant increased risk of IFG (OR 1.514; 95% CI 1.084-2.116; p=0.015); biphasic shape with reduced risk of IGT (OR 0.539; 95% CI 0.310-0.936) and triphasic shape with reduced risk of IFG (OR 0.493; 95% CI 0.228-1.066; P=0.043) after 3years. Increased risks of IFG (OR 1.509; 95% CI 1.008-2.260; p=0.05) and IGT (OR 1.947; 95% CI 1.085-3.494; p=0.02) were found in people who kept stable monophasic morphology over time and in switchers from biphasic to monophasic shape (OR of IGT=3.085; 95% CI 1.377-6.912; p=0.001).

CONCLUSION

After 3years follow-up, the OGTT-glucose shape was stable in 59% of the RISC cohort. Shapes were associated with different OGIS and ß-cell function; persistence over time of the monophasic shape and switch from biphasic to monophasic shape with increased risk of impaired glucose metabolism.

[When weight influences mental health… and reciprocally]

Obesity and mental disorders are frequent diseases in our society and do not always receive the appropriate care. Moreover, it has been proved that obese people suffer more from mental disorders than the general population. This article reviews mental illnesses commonly found in obese people to raise awareness about their screening and treatment in order to improve both weight loss and the quality of life of people who are suffering from it.

[Eating disorder and food addiction in a population candidates for a bariatric surgery]

Non stabilized severe eating disorder is a contra-indication for bariatric surgery. Specific cares can stabilize this disorder, and therefore a surgery can be undertaken. In this respect, more and more attention is paid to the concept of food addiction even if its definition is still debated. Some authors, according to neurobiological data, consider food addiction as independent from eating disorder, but others see food addiction as a severe sub-type of eating disorder. To contribute to this debate, we performed a study in our department including 23 subjects candidates for a bariatric surgery and found a significant association between food addiction and eating disorder, independently of the body mass index. Clarification of the food addiction concept should permit to reconsider the specific cares needed by these obese patients.

Impact of Hypocaloric Hyperproteic Diet on Gut Microbiota in Overweight or Obese Patients with Nonalcoholic Fatty Liver Disease: A Pilot Study

BACKGROUND

NAFLD is likely to become the most common cause of chronic liver disease. The first-line treatment includes weight loss.

AIMS

To analyze the impact of a hypocaloric hyperproteic diet (HHD) on gut microbiota in NAFLD patients.

METHODS

Fifteen overweight/obese patients with NAFLD were included. At baseline and after a 3-week HHD (Eurodiets(®), ~1000 kcal/day, ~125 g protein/day), we measured gut microbiota composition and function by shotgun metagenomics; body weight; body composition by bioelectrical impedance analysis; liver and visceral fat by magnetic resonance imaging; plasma C-reactive protein (CRP); and liver tests. Results between both time points, expressed as median (first and third quartile), were compared by Wilcoxon signed-rank tests.

RESULTS

At baseline, age was 50 (47-55) years and body mass index 34.6 (32.4, 36.7) kg/m(2). HDD decreased body weight by 3.6 % (p < 0.001), percent liver fat by 65 % (p < 0.001), and CRP by 19 % (p = 0.014). HDD was associated with a decrease in Lachnospira (p = 0.019), an increase in Blautia (p = 0.026), Butyricicoccus (p = 0.024), and changes in several operational taxonomic units (OTUs) of Bacteroidales and Clostridiales. The reduced liver fat was negatively correlated with bacteria belonging to the Firmicutes and Bacteroidetes phyla (a Ruminococcaceae OTU, r = -0.83; Bacteroides, r = -0.73). The associated metabolic changes concerned mostly enzymes involved in amino acid and carbohydrate metabolism.

CONCLUSIONS

In this pilot study, HHD changes gut microbiota composition and function in overweight/obese NAFLD patients, in parallel with decreased body weight, liver fat, and systemic inflammation. Future studies should aim to confirm these bacterial changes and understand their mode of action.

TRAIL REGISTRATION

Under clinicaltrials.gov: NCT01477307.

Dance therapy combined with patient education improves quality of life of persons with obesity: A pilot feasibility study for a randomised controlled trial

OBJECTIVE

To assess the effect of dance therapy combined with patient education on quality of life, functional capacity (lower limb power and endurance) and physical activity level in obese individuals.

METHODS

Thirty-three obese patients were randomised to a control group (structured patient education ambulatory program), and 34 to an intervention group (structured patient education ambulatory program combined with weekly sessions of dance therapy). Patients' quality of life, physical function and physical activity level were assessed at baseline and after 16 weeks.

RESULTS

Almost only women were willing to enrol in the study. Participants of the intervention group significantly improved their quality of life (p=0.023), and particularly self-esteem (p=0.014). However, dance therapy added to a patient educational program did not produce statistically significant higher effects than a patient education program alone on functional capacities and patients' physical activity level.

CONCLUSION

A 16 week structured patient educational program combined with dance therapy seems to have a positive effect on the quality of life of obese people, but no effect on functional capacities and physical activity.

PRACTICE IMPLICATION

Dance therapy combined with structured patient education is an interesting approach to improve quality of life of obese people.

[How to support obese patients in a long-term process of change?]

It is illusory to think losing weight effectively by acting only on diet or physical activity. To lose weight satisfactorily and to maintain that weight loss, we should move more on lifestyle changes, namely changes in behavior on several axes. Through concrete examples of an obese patient wanting to lose weight, we will see what skills he must acquire to achieve its objective and what tools the therapist can use to help.

[Not all patients might benefit from gastric by-pass]

Obesity is a chronic disease with a need for long-term follow-up. Bariatric surgery is very beneficial for patients who are not able to lose weight by lifestyle modifications alone. However, some patients present a weight regain after surgery. Predictive factors for the evolution of weight loss after bariatric surgery are not available today. For that reason, all preventive and therapeutic facilities should be used in order to reduce the risk of relapse after surgery. A recently introduced multidisciplinary therapeutic program for preparation of patients before bariatric surgery could be very valuable for a sustainable change of their lifestyle in order to minimize the risk of weight regain in the years after surgery.

Diabetes Mellitus Is Associated With Reduced High-Density Lipoprotein Sphingosine-1-Phosphate Content and Impaired High-Density Lipoprotein Cardiac Cell Protection

OBJECTIVE

The dyslipidemia of type 2 diabetes mellitus has multiple etiologies and impairs lipoprotein functionality, thereby increasing risk for cardiovascular disease. High-density lipoproteins (HDLs) have several beneficial effects, notably protecting the heart from myocardial ischemia. We hypothesized that glycation of HDL could compromise this cardioprotective effect.

APPROACH AND RESULTS

We used in vitro (cardiomyocytes) and ex vivo (whole heart) models subjected to oxidative stress together with HDL isolated from diabetic patients and nondiabetic HDL glycated in vitro (methylglyoxal). Diabetic and in vitro glycated HDL were less effective (P<0.05) than control HDL in protecting from oxidative stress. Protection was significantly, inversely correlated with the degree of in vitro glycation (P<0.001) and the levels of hemoglobin A1c in diabetic patients (P<0.007). The ability to activate protective, intracellular survival pathways involving Akt, Stat3, and Erk1/2 was significantly reduced (P<0.05) using glycated HDL. Glycation reduced the sphingosine-1-phosphate (S1P) content of HDL, whereas the S1P concentrations of diabetic HDL were inversely correlated with hemoglobin A1c (P<0.005). The S1P contents of in vitro glycated and diabetic HDL were significantly, positively correlated (both <0.01) with cardiomyocyte survival during oxidative stress. Adding S1P to diabetic HDL increased its S1P content and restored its cardioprotective function.

CONCLUSIONS

Our data demonstrate that glycation can reduce the S1P content of HDL, leading to increased cardiomyocyte cell death because of less effective activation of intracellular survival pathways. It has important implications for the functionality of HDL in diabetes mellitus because HDL-S1P has several beneficial effects on the vasculature.