Obesity treatment: results after 4 years of a Nutritional and Psycho-Physical Rehabilitation Program in an outpatient setting

Recruitment of emergency department patients to a prospective observational study

BACKGROUND

The dynamic environment of the emergency department (ED) poses unique challenges to the execution of well-designed research. There is limited investigation into the viability of studies conducted in the ED. This paper offers a systematic evaluation of our recruitment of emergency patients for a prospective observational research study, shedding light on the intricate landscape of research feasibility within the ED setting.

RESULTS

Research coordinators dedicated 2816.83 h to screening, recruiting, and enrolling patients between June 2018 and September 2023, having to stop recruitment twice due to financial constraints and the COVID-19 pandemic. 485 patients were approached and 84 of them were enrolled, resulting in a 31.94% enrollment rate, with approximately 2.8 participants recruited per month. Of those enrolled, 77 completed all study endpoints. Most participants were Hispanic (n = 44; 52.3%) and/or Black (n = 37; 44%), middle-aged (µ = 51.7 years), and female (n = 48; 57.1%). Participant recruitment was challenged by competing mindsets, the COVID-19 pandemic, and high staff turnover.

CONCLUSIONS

Recruiting emergency patients for a prospective observational study is feasible given adequate staffing and financial resources. Standardizing feasibility assessments for the recruitment of patients in the emergency department is important to the success of future study.

The Unrestrained Overeating Behavior and Clinical Perspective

Obesity-related co-morbidities decrease life quality, reduce working ability, and lead to early death. In the adult population, eating addiction manifests with excessive food consumption and the unrestrained overeating behavior, which is associated with increased risk of morbidity and mortality and defined as the binge eating disorder (BED). This hedonic intake is correlated with fat preference and the total amount of dietary fat consumption is the most potent risk factor for weight gain. Long-term BED leads to greater sensitivity to the rewarding effects of palatable foods and results in obesity fatefully. Increased plasma concentrations of non-esterified free fatty acids and lipid-overloaded hypertrophic adipocytes may cause insulin resistance. In addition to dietary intake of high-fat diet, sedentary lifestyle leads to increased storage of triglycerides not only in adipose tissue but also ectopically in other tissues. Lipid-induced apoptosis, ceramide accumulation, reactive oxygen species overproduction, endoplasmic reticulum stress, and mitochondrial dysfunction play role in the pathogenesis of lipotoxicity. Food addiction and BED originate from complex action of dopaminergic, opioid, and cannabinoid systems. BED may also be associated with both obesity and major depressive disorder. For preventing morbidity and mortality, as well as decreasing the impact of obesity-related comorbidities in appropriately selected patients, opiate receptor antagonists and antidepressant combination are recommended. Pharmacotherapy alongside behavioral management improves quality of life and reduces the obesity risk; however, the number of licensed drugs is very few. Thus, stereotactic treatment is recommended to break down the refractory obesity and binge eating in obese patient. As recent applications in the field of non-invasive neuromodulation, transcranial magnetic stimulation and transcranial direct current stimulation are thought to be important in image-guided deep brain stimulation in humans. Chronic overnutrition most likely provides repetitive and persistent signals that up-regulate inhibitor of nuclear factor kappa B (NF-κB) kinase beta subunit/NF-κB (IKKβ/NF-κB) in the hypothalamus before the onset of obesity. However, how the mechanisms of high-fat diet-induced peripheral signals affect the hypothalamic arcuate nucleus remain largely unknown.

Multidisciplinary residential program for the treatment of obesity: how body composition assessed by DXA and blood chemistry parameters change during hospitalization and which variations in body composition occur from discharge up to 1-year follow-up

PURPOSE

Obesity is a chronic disease characterized by a complex variable clinical presentation with comorbidities. A multidisciplinary residential program (MRP) represents one of the best options for treating obesity. The purpose of this study was to evaluate the effectiveness of 8-week MRP on weight loss, body composition assessed by DXA, and metabolic blood parameters between entry (T0) and discharge (T1). The secondary endpoint was the evaluation of the patients' adherence to diet during the check-up outpatient visits, at 2 (T2), 6 (T3), and 12 (T4) months after discharge.

METHODS

168 subjects were enrolled (61 males and 117 females, aged 58.5 ± 13 years, BMI 41.3 ± 6 kg/m²) in the study. The difference in values ​​(end of hospitalization compared to baseline) was calculated through the univariate analysis procedure, which provides regression analysis and analysis of variance for a variable dependent on one or more variables.

RESULTS

There was a statistically significant improvement of all parameters investigated: total mass (- 5.68 kg), fat mass (- 4416.85 g), fat mass index (- 1724.56), visceral adipose tissue (- 332.76 g), arm circumference (- 1.63 cm) and calf circumference (- 1.16 cm). As it is reasonable to expect, even the fat free mass has been reduced (- 1236.03 g); however, the skeletal muscle index was not affected. Statistically significant improvement in glycaemic and lipid profile were reported. The BMI average reduction continued from discharge until T4. No statistically significant changes in fat free mass and visceral adipose tissue (VAT) were reported during a year of follow-up.

CONCLUSIONS

The present study demonstrated the clinical benefits of 8-week MRP, which includes hypocaloric diet, physical exercise, and psychological support.

LEVEL OF EVIDENCE

III, evidence obtained from cohort or case-control analytic studies.

Therapeutic educational robot enhancing social interactions in the management of obesity

Obesity is a chronic multifactorial pathology determined by many factors, including incorrect eating habits and a low level of physical activity. There is an urgent need to promote a persistent change in lifestyle in obese subjects, but very few individuals maintain long-term results achieved after diet therapies. Therapeutic Education (TE) has taken over an important role as a multidisciplinary intervention aimed at improving lifestyle and at acquiring new skills for the management of the disease. However, only a small portion of patients can maintain participation in such programs and fully benefit from them. Assistive technologies, and in particular assistive social robots, are powerful tools to boost independence and improve participation in educational activities. The aim of the research work described in this article is to evaluate the effect of employing a social robot as a therapeutic educational robot helping the expert therapist in the education activity. This article describes the implementation, deployment, and evaluation of a social educational robot used as a TE assistant. Although we cannot provide statistically significant results due to the limited number of people involved in the experimental protocol, all experimental results show a positive trend, indicating that the robot can enhance the social interactions between the patients and the therapist and among the patients, thus bringing to better overall results of the TE sessions, measured with standard tests for obesity management.

Successful telehealth transformation of a pediatric outpatient obesity teaching program due to the COVID-19 pandemic - the "Video KiCK" program

OBJECTIVES

To investigate if digital approaches can ameliorate the known consequences of social-distancing restrictions in the context of the global COVID-19 pandemic for adolescent participants originally registered for a face-to-face outpatient weight regulation program and whether video-based multiprofessional outpatient obesity therapy is successful for a group of adolescents with preexisting obesity.

METHODS

The certified KiCK outpatient training program for children and adolescents with overweight and obesity was remodeled as a consequence of the lockdown traditional face-to-face program to a completely digital and video-based format on short notice. The virtual approach was compared with the results of the conventional program regarding metabolic parameters, body mass index standard deviation score (BMI SDS), well-being, and physical fitness.

RESULTS

Sixty-nine of 77 enrolled participants for KiCK (age 8 to 17 years, BMI z score >2.0) were able and willing to participate virtually. After the first lockdown significant improvements of BMI SDS (mean 0.18; p=0.02), homeostasis model assessment (HOMA) index (mean 1.4; p=0.016), triglycerides (mean 0.18 mmol/dL; p=0.021), 6 minute-walk-test (mean 97.0 m; p=0.030, and well-being according to the World Health Organization 5 (WHO-5) questionnaire (mean 2.5; p=0.002) were found after the virtual intervention, which was comparable to the results observed previously in matched pairs data from the program during the pre-COVID period. After the end of the second lockdown weight SDS, BMI SDS, HOMA INDEX, and cholesterol were also measured reduced compared to baseline parameters measured before program initiation. Walking distance in the 6 MWT and improvement in general well-being in the WHO-5 questionnaire also persisted.

CONCLUSIONS

These results indicate good acceptance and efficacy of the video-intervention for youth with overweight and obesity during the lockdown, supporting the use of virtual modules in future programs after the pandemic.

Reduction of Cardio-Metabolic Risk and Body Weight through a Multiphasic Very-Low Calorie Ketogenic Diet Program in Women with Overweight/Obesity: A Study in a Real-World Setting

BACKGROUND

The prevention and treatment of obesity and its cardio-metabolic complications are relevant issues worldwide. Among lifestyle approaches, very low-calorie ketogenic diets (VLCKD) have been shown to lead to rapid initial weight loss, resulting in better long-term weight loss maintenance. As no information on VLCKD studies carried on in a real-world setting are available, we conducted this multi-centre study in a real-world setting, aiming at assessing the efficacy and the safety of a specific multiphasic VLCKD program in women with overweight or obesity.

METHODS

A multi-center, prospective, uncontrolled trial was conducted in 33 outpatient women (age range 27-60 y) with overweight or obesity (BMI: 30.9 ± 2.7 kg/m²; waist circumference: 96.0 ± 9.4 cm) who started a VLCKD dietary program (duration: 24 weeks), divided into four phases. The efficacy of VLCKD was assessed by evaluating anthropometric measures and cardiometabolic markers; liver and kidney function biomarkers were assessed as safety parameters.

RESULTS

The VLCKD program resulted in a significant decrease of body weight and BMI (-14.6%) and waist circumference (-12.4%). At the end of the protocol, 33.3% of the participants reached a normal weight and the subjects in the obesity range were reduced from 70% to 16.7%. HOMA-IR was markedly reduced from 3.17 ± 2.67 to 1.73 ± 1.23 already after phase 2 and was unchanged thereafter. Systolic blood pressure decreased after phase 1 (-3.5 mmHg) and remained unchanged until the end of the program. Total and LDL cholesterol and triglycerides were significantly reduced by VLCKD along with a significant HDL cholesterol increase. Liver, kidney and thyroid function markers did not change and remained within the reference range.

CONCLUSIONS

The findings of a multi-center VLCKD program conducted in a real-world setting in a cohort of overweight/obese women indicate that it is safe and effective, as it results in a major improvement of cardiometabolic parameters, thus leading to benefits that span well beyond the mere body weight/adiposity reduction.

Aerobic Exercise and Metabolic Syndrome: The Role of Sympathetic Activity and the Redox System

BACKGROUND

Aerobic exercise can greatly assist in reducing collateral effects of metabolic syndrome (MetS). Moreover, aerobic exercise is associated with sympathetic activation and adaptive responses to sustain muscle engagement, changes in the release of Orexin A, a pleiotropic neuropeptide.

AIM

The aim of this study was to analyze the beneficial effects of aerobic exercise without dietary changes, in a cohort of MetS subjects, focusing on the role of sympathetic and orexinergic activity. Several blood parameters linked to MetS ROS production, heart rate, galvanic skin response, d-ROM test, and Orexin A serum levels were evaluated in ten males with MetS (BMI 30-34.9) before and after a period of 6 months of aerobic exercise compared to ten healthy subjects.

METHODS

Ten male subjects (aged 54 ± 4.16) with MetS (MetS group) and ten healthy males (aged 49.7 ± 2.79, Healthy group) were told about the study protocol and possible risks, signed the informed consent, and voluntarily participated in the study. Several blood parameters were evaluated in the two tested groups and were re-evaluated in the MetS group after 6 months of training (MetS6M group). The training protocol consisted of more than 30 min/day of walking (average speed of 4.5 km/h) and 3 days/week of aerobic activities (jogging under heart rate control - 120-140 bpm for 45 min).

RESULTS

The results showed that exercise induced a significant increase in GSR and plasma Orexin A but no significant increase in d-ROM values. Significant decreases in the serum ALT enzyme, triglycerides, and total cholesterol were found, while the HDL levels were significantly higher. Finally, a significant reduction of BMI and resting HR were reported.

CONCLUSION

The results of this study confirm that physical activity is associated with sympathetic activation, having a pivotal role against adverse effects linked to MetS. Moreover, this study demonstrates that, in patients with MetS, Orexin A is involved in hormonal adaptations to exercise.

Identifying Predictors of the Visceral Fat Index in the Obese and Overweight Population to Manage Obesity: A Randomized Intervention Study

INTRODUCTION

Nowadays, obesity is one of the main causes of death and disability. In recent years, it has been shown that the excess and distribution of body fat increases morbidity, with excess visceral fat being the most important factor that triggers pathologies. Thus, estimation of visceral fat makes it possible to identify patients with a higher cardiovascular risk, aiding the management of obesity. The main objective of the study was to identify predictors of the visceral fat index through a lifestyle intervention and to observe the effect of the intervention on dietary habits and functional capacity.

METHODS

A randomized intervention, parallel-group study was made. This study included 97 obese and overweight people (control group, n = 48; experimental group, n = 49) with a low socioeconomic status in an 8-month lifestyle intervention. Anthropometric, fitness and nutritional tests were assessed.

RESULTS

It was found that being female, eating the recommended daily portions of fruit, gaining strength in the legs and gaining flexibility are factors predictive of a lower visceral fat index. Age over 45 years and eating the recommended weekly portions of cereals and meats, fat and processed meats increases the visceral fat index after a lifestyle intervention. There were changes in the visceral fat index and in the different physical condition variables, but not in eating habits.

CONCLUSION

A multicomponent lifestyle intervention reduces the visceral fat index; age over 45 and consuming cereals and meat increases the visceral fat index.

Overweight and obesity: effectiveness of interventions in adults

OBJECTIVE

To identify the most effective interventions in overweight and obese adults.

METHOD

A narrative review through a search of the literature in databases PubMed, Cochrane, Joanna Briggs Institute, EMBASE, Cuiden y Cinahl with free and controlled language (MeSH terms) using Boolean operators AND and NOT. The research was limited to articles published between 2007 and 2015. Eighteen articles were selected based on the established inclusion and exclusion criteria.

RESULTS

Different types of interventions were identified based on the modification of lifestyles, mainly diet, physical activity and behavior. Major differences were found in specific content, degree of intensity of interventions, time tracking and elements evaluated. Most of studies found statistically significant weight loss but this was limited in terms of weight and number of people. Web-based interventions have no uniform effect on weight loss but achieve similar levels to face-to-face interventions in maintaining weight loss.

CONCLUSIONS

The combination of personalised diet, exercise and cognitive behavioural therapy is the most effective form of intervention in overweight and obesity. There is insufficient data to indicate whether group or individual interventions are more effective. Online intervention allows greater accessibility and lower cost.

High-Intensity Interval Training for Overweight Adolescents: Program Acceptance of a Media Supported Intervention and Changes in Body Composition

High-intensity interval training (HIIT) consists of short intervals of exercise at high intensity intermitted by intervals of lower intensity and is associated with improvement of body composition and metabolic health in adults. Studies in overweight adolescents are scarce. We conducted a randomized controlled trial in overweight adolescents to compare acceptance and attendance of HIIT with or without weekly motivational encouragement through text messages and access to a study website. HIIT was offered for six months (including summer vacation) twice a week (60 min/session). Participation rates were continuously assessed and acceptance was measured. Clinical parameters were assessed at baseline and after six months. Twenty-eight adolescents participated in this study (age 15.5 ± 1.4; 54% female). The standard deviation score for body mass index over all participants was 2.33 at baseline and decreased by 0.026 (95% CI -0.048 to 0.10) units, p = 0.49. Waist to height ratio was 0.596 at baseline and decreased by 0.013 (95% CI 0.0025 to 0.024), p = 0.023. Participation within the first two months ranged from 65% to 75%, but fell to 15% within the last three months. Attendance in the intervention group was 14% (95% CI -8 to 37), p = 0.18, higher than the control group. Overall program content was rated as "good" by participants, although high drop-out rates were observed. Summer months constitute a serious problem regarding attendance. The use of media support has to be assessed further in appropriately powered trials.

Normocaloric Diet Restores Weight Gain and Insulin Sensitivity in Obese Mice

An increased incidence of obesity is registered worldwide, and its association with insulin resistance and type 2 diabetes is closely related with increased morbidity and mortality for cardiovascular diseases. A major clinical problem in the management of obesity is the non-adherence or low adherence of patients to a hypocaloric dietetic restriction. In this study, we evaluated in obese mice the effects of shifting from high-calorie foods to normal diet on insulin sensitivity. Male C57BL/6JOlaHsd mice (n = 20) were fed with high fat diet (HFD) for a 24-week period. Afterward, body weight, energy, and food intake were measured in all animals, together with parameters of insulin sensitivity by homeostatic model assessment of insulin resistance and plasma glucose levels in response to insulin administration. Moreover, in half of these mice, Glut4 mRNA levels were measured in muscle at the end of the high fat treatment, whereas the rest of the animals (n = 10) were shifted to normocaloric diet (NCD) for 10 weeks, after which the same analyses were carried out. A significant reduction of body weight was found after the transition from high to normal fat diet, and this decrease correlated well with an improvement in insulin sensitivity. In fact, we found a reduction in serum insulin levels and the recovery of insulin responsiveness in terms of glucose disposal measured by insulin tolerance test and Glut4 mRNA and protein expression. These results indicate that obesity-related insulin resistance may be rescued by shifting from HFD to NCD.

Obesity Education Strategies for Cancer Prevention in Women's Health

Obesity is the cause of up to one-third of all cancers affecting women today, most notably endometrial, colon and breast cancer. Women's health providers are poised to advise women on obesity's link to cancer development, but often lack resources or training to provide appropriate counseling. Here, we review obesity's role in increasing the risk of several common reproductive system conditions faced by women, including polycystic ovarian syndrome, infertility, gynecologic surgical complications, and pregnancy complications. These events can be used as teachable moments to help frame the discussion of weight management and promote cancer prevention. We also review national guidelines and existing tangible weight-loss strategies that can be employed within the outpatient women's health setting to help women achieve weight loss goals and affect cancer prevention.

Safety and efficacy of a multiphase dietetic protocol with meal replacements including a step with very low calorie diet

To investigate safety, compliance, and efficacy, on weight loss and cardiovascular risk factors of a multiphasic dietary intervention based on meal replacements, including a period of very low calorie diet (VLCD) in a population of obese patients. Anthropometric parameters, blood tests (including insulin), dual-energy-X-ray absorptiometry (DXA), and questionnaires for the assessment of safety and compliance before and after (phase I) a 30-day VLCD, 700 kcal/day, normoproteic, 50 g/day carbohydrate, four meal replacements; (phase II) a 30-day low calorie diet (LCD), 820 kcal/day, three meal replacements plus a protein plate; (phase III) 60-day LCD, 1,100 kcal/day, two meal replacements plus two protein plates and reintroduction of small amounts of carbohydrates; (phase IV) 60-day hypocaloric balanced diet (HBD), 1,200 kcal/day, one meal replacement, two protein plates and the reintroduction of carbohydrates. 24 patients (17 females, 7 males, mean BMI 33.8±3.2 kg/m2, mean age 35.1±10.2 years) completed the study. The average weight loss was 15.4±6.7%, with a significant reduction of fat mass (from 32.8±4.7 to 26.1±6.3% p<0.05) and a relative increase of lean mass (from 61.9±4.8 to 67.1±5.9% p<0.05). An improvement of metabolic parameters and no variations of the liver and kidney functions were found. A high safety profile and an excellent dietary compliance were seen. The VLCD dietary program and the replacement dietary system described here is an effective, safe, and well-tolerated treatment for weight control.