Insulin release in response to oral glucose in obesity: The effect of reduction of body weight

Summary Measurements of plasma levels of immunoreactive insulin, non-esterified fatty acids and glucose have been made in normal subjects and a group of obese non diabetic patients, before and after a period of dietary restriction. Levels of immuno-reactive insulin, both in the fasted state and after an oral glucose load, were abnormally high in the group of obese patients and were significantly lower after dietary restriction and loss of body weight.

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Insulinfreisetzung unter oraler Glucosebelastung bei Fettsucht: Einfluß der Gewichtsabnahme

Zusammenfassung Es wurden Messungen der Plasma spiegel von immunreaktivem Insulin, unveresterten Fett-säuren und Glucose bei normalen Personen und bei einer Gruppe von fettleibigen Nichtdiabetikern vor sowie nach einer Periode der Diätbeschränkung vorgenommen. Die Konzentration des immunreaktiven Insulins lag bei den fettleibigen Patienten sowohl im Nüchternzustand als auch nach einer oralen Glucosebelastung abnorm hoch und ging nach Diätbeschränkung und Gewichtsverlust wesentlich zurück.

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Libération d'insuline en réponse à l'administration orale de glucose dans l'obésité: Effet de la réduction du poids corporel

Résumé La concentration plasmatique d'insuline immuno-réactive, d'acides gras non estérifiés et de glucose a été déterminée chez des sujets normaux et dans un groupe d'obèses non diabétiques avant et après une période de restriction alimentaire. La concentration d'insuline immuno-réactive à jeun et après administration orale de glucose était anormalement élevée dans le groupe des sujets obèses et montra une diminution significative après une période de restriction alimentaire ayant entraîné une perte de poids.

     

Patient and physician perceptions of timely access to care

BACKGROUND: Timeliness of care is 1 of 6 dimensions of quality identified in Crossing the Quality Chasm. We compared patient and physician perceptions of appropriate timing of visits for common medical problems. METHODS: This study was conducted at 2 internal medicine clinics at the University of Colorado Health Sciences Center. Adult patients and companions, and outpatient General Internists were surveyed. The survey contained 11 clinical scenarios of varying urgency. Respondents indicated how soon the patient in each scenario should be seen. Responses ranged from that day to 1 to 3 months. Responses were analyzed using the Mann-Whitney U test. RESULTS: Two hundred and sixty-two patients and 46 of 61 physicians responded. For 8 of the 11 scenarios patients felt they should be seen significantly earlier than physicians. Scenarios involving chronic knee and stomach pain, routine diabetes care, and hyperlipidemia generated the greatest differences. Patients and physicians agreed on the urgency of scenarios concerning wheezing in an asthmatic, an ankle injury, and acute pharyngitis. CONCLUSIONS: Patients expected to be seen sooner than physicians thought necessary for many common chronic medical conditions, but are in agreement about timeliness for some acute problems. Understanding patient expectations may help physicians respond to requests for urgent evaluation of chronic conditions.     

Greater beneficial effects of visceral fat reduction compared with subcutaneous fat reduction on parameters of the metabolic syndrome: a study of weight reduction programmes in subjects with visceral and subcutaneous obesity.

AIMS: To evaluate the effect of weight reduction on parameters of the metabolic syndrome in obese patients according to their pattern of abdominal fat distribution. METHODS: A longitudinal intervention study, consisting of a 12-week weight reduction programme, including lifestyle modification and adjuvant appetite suppressant, in 38 subjects with visceral obesity and 47 subjects with subcutaneous obesity. Visceral, subcutaneous and total adipose tissue areas were determined by CT scan at the level of L4-L5. Parameters for components of the metabolic syndrome were measured before and after weight reduction. RESULTS: Reductions in body weight, BMI and subcutaneous adipose tissue area were greater in the subcutaneous than in the visceral obesity group. In contrast, changes in fasting plasma glucose, insulin, and HOMA score were higher in the visceral than in the subcutaneous obesity group. Changes in visceral adipose tissue area were significantly related to changes in fasting plasma glucose, triglycerides and HOMA score. CONCLUSIONS: Visceral fat reduction induced greater beneficial effects on parameters of the metabolic syndrome than subcutaneous fat reduction. Evaluation of changes in abdominal fat distribution is necessary when obese subjects enter a weight reduction programme.     

Oral versus written feedback in medical clinic

OBJECTIVE: To determine whether residents perceived oral, face-to-face feedback about their continuity clinic performance as better than a similar, written version. DESIGN: Single-blind, randomized controlled trial. SETTING: Two university-based, internal medicine residency clinics. PARTICIPANTS: All 68 internal medicine and combined program (medicine-pediatrics, medicine-psychiatry, medicine-neurology, and preliminary year) residents and their clinic preceptors. MEASUREMENTS AND MAIN RESULTS: Residents at each program were separately randomized to oral or written feedback sessions with their clinic preceptors. The oral and written sessions followed similar, structured formats. Both groups were later sent questionnaires about aspects of the clinic. Sixty-five (96%) of the residents completed the questionnaire. Eight of the 19 questions dealt with aspects of feedback. A feedback scale was developed from the survey responses to those eight questions (α=.86). There were no significant differences in the responses to individual questions or in scale means (p>.20) between the two feedback groups. When each university was analyzed separately, one had a higher scale mean (3.10 vs 3.57, p=.047), but within each university, there were no differences between the oral and written feedback groups (p>.20). CONCLUSIONS: No differences were observed between the oral and written feedback groups. In attempting to provide better feedback to their residents, medical educators may better apply their efforts to other aspects, such as the frequency of their feedback, rather than the form of its delivery. Supported by the Department of Medicine, West Virginia University. Presented in part at the Society of General Internal Medicine annual meeting, 1995.     

Referral sources to a weight management program: relation to outcome

OBJECTIVE: To examine the characteristics and outcomes of physician-referred weight management patients relative to self-referred patients. DESIGN: Review of clinic records of all individuals contacting a weight control program during a 2-year period with follow-up throughout consecutive levels of treatment (i.e., enrollment, completion, and outcome). SETTING: Medical school weight management center. PARTICIPANTS: A consecutive sample (N = 1,392) of overweight and obese callers was categorized as physician-initiated (n = 345), media (n = 653), or personal (n = 394) referrals. Attendees at initial consultation (n = 571) were age 41.7 +/- 12.8 years, weight 113.9 +/- 36.1 kilograms, and body mass index (BMI) 40.3 +/- 11.3 kg/m(2) (data expressed as mean +/- standard deviation). INTERVENTIONS: Low-calorie-diet and very-low-calorie-diet programs. MAIN OUTCOME MEASURES: Gender comparisons, attendance at initial consultation, body mass index, motivation, comorbidities, enrollment and completion rates, and weight loss. RESULTS: Compared to callers from other referral sources, physician referrals included a larger minority of males (25.2%) and were more likely to attend an initial consultation (63.5%; P < .001). Among consultation attendees, physician referrals were heavier (mean BMI = 44.8), reported more comorbidities, were less likely to join programs (16.9%), and scored as less motivated than other referrals (P < .007). Completion rates for physician referrals were higher than for self-referrals in the very-low-calorie-diet program (85.7%; P < .04) but not in the low-calorie-diet program (P > .05). Among completers, physician referrals did not differ on weight loss in either program (P > .05). CONCLUSIONS: Compared to self-referrals, physician-referred individuals are in greater need of weight loss, less motivated, less likely to enter treatment, but equally likely to profit from it. Therefore, physician referral for weight loss is beneficial for at least some patients and should be encouraged.     

The potential association between fruit intake and body weight – a review

Both national and international bodies recommend an increased intake of fruits and vegetables in order to decrease the risk of overweight and obesity. However, there is a rationale to investigate the separate role of fruits. The aim of this paper was to systematically review and analyse published human intervention, prospective observational and cross-sectional studies on fruit intake and body weight in adults. We identified three intervention, eight prospective observational and five cross-sectional studies that explored this relationship. Two of the intervention studies showed that fruit intake reduced body weight, five of the prospective observational studies showed that fruit consumption reduced the risk of developing overweight and obesity, and four of the cross-sectional studies found an inverse association between fruit intake and body weight. Important methodological differences and limitations in the studies make it difficult to compare results. However, the majority of the evidence points towards a possible inverse association between fruit intake and overweight. Future intervention and prospective observational studies examining the direct and independent role of fruit in body-weight management in free-living individuals are needed. Moreover, important determinants such as energy density, energy content, fruit and vegetable consumption, physical form of fruit and preparation methods need to be included in future studies.     

Patient satisfaction in resident and attending ambulatory care clinics

OBJECTIVE: To measure and compare patient satisfaction with care in resident and attending physician internal medicine ambulatory care clinics. DESIGN: A cross-sectional survey using a questionnaire derived from the Visit-Specific Satisfaction Questionnaire (VSQ) and Patient Satisfaction Index (PSI) distributed from March 1998 to May 1998. SETTING: Four clinics based at a university teaching hospital and the associated Veterans' Affairs (VA) hospital. PARTICIPANTS: Two hundred eighty-eight patients of 76 resident and 25 attending physicians. RESULTS: Patients of resident physicians at the university site were more likely to be African American, male, have lower socioeconomic status and have lower physical and mental health scores on the Short Form-12 than patients of university attendings. Patients of resident and attending physicians at the VA site were similar. In multivariate analyses, patients of university attending physicians were more likely to be highly satisfied than patients of university residents on the VSQ-Physician (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.6 to 7.8) and the PSI-Physician (OR, 10.1; 95% CI, 3.7 to 27.4) summary scores. Differences were not seen on the summary scores at the VA site. Two individual items displayed significant differences between residents and attendings at both sites: "personal manner (courtesy, respect, sensitivity, friendliness) of the doctor" (P 相似文献   

Optimizing management and financial performance of the teaching ambulatory care clinic

OBJECTIVE: To examine how to optimize teaching ambulatory care clinics performance with regard to access to care, access to teaching, and financial viability. DESIGN: Optimization analysis using computer simulation. METHODS: A discrete-event simulation model of the teaching ambulatory clinic setting was developed. This method captures flow time, waiting time, competition for resources, and the interdependency of events, providing insight into system dynamics. Sensitivity analyses were performed on staffing levels, room availability, patient characteristics such as "new" versus "established" status, and clinical complexity and pertinent probabilities. MAIN RESULTS: In the base-case, 4 trainees:preceptor, patient flow time (registration to check out) was 148 minutes (SD 5), wait time was 20.6 minutes (SD 4.4), the wait for precepting was 6.2 minutes (SD 1.2), and average daily net clinic income was $1,413. Utilization rates were preceptors (59%), trainees (61%), medical assistants (64%), and room (68%). Flow time and the wait times remained relatively constant for strategies with trainee:preceptor ratios <4:1 but increased with number of trainees steadily thereafter. Maximum revenue occurred with 3 preceptors and 5 trainees per preceptor. The model was relatively insensitive to the proportion of patients presenting who were new, and relatively sensitive to average evaluation and management (E/M) level. Flow and wait times rose on average by 0.05 minutes and 0.01 minutes per percent new patient, respectively. For each increase in average E/M level, flow time increased 8.4 minutes, wait time 1.2 minutes, wait for precepting 0.8 minutes, and net income increased by $490. CONCLUSION: Teaching ambulatory care clinics appear to operate optimally, minimizing flow time and waiting time while maximizing revenue, with trainee-to-preceptor ratios between 3 and 7 to 1.     

The potential role of soyfoods in weight and adiposity reduction: an evidence-based review

Evidence concerning the relationship between soyfoods and weight loss was reviewed. Detailed searches of PubMed and Web of Science were performed to identify and evaluate evidence for or against four propositions related to soyfoods and weight loss (Data from in vitro, animal, epidemiologic, and clinical studies were evaluated and summarized). (1) Certain soyfoods will improve weight and/or fat loss when fed at isolcaloric levels (similar calories given across experimental conditions, but not necessarily at a level to maintain current body weight); generally supportive evidence in animal studies, but there is no compelling support in human studies. (2) Certain soyfoods will improve weight and fat loss when included as part of a diet by affecting caloric intake; limited supportive evidence in animal and human studies. (3) Certain soyfoods will prevent/improve risk factors related to glucoregulatory function and cardiovascular health during weight loss; some evidence supporting this proposition, but additional evidence is needed before conclusions can be made. (4) Certain soyfoods will minimize the loss of bone mass during weight loss; no data available pertinent to this proposition. Limitations in existing data make it difficult to reach conclusions regarding these four propositions. Overall, the current data suggest that soyfoods are as good as other protein sources for promoting weight loss and there is a suggestive body of evidence that soyfoods may confer additional benefits, but results must be carefully interpreted and additional evidence is needed before making firm conclusions concerning soyfoods and weight loss.     

Trends in professional advice to lose weight among obese adults, 1994 to 2000

CONTEXT: Obesity is a fast-growing threat to public health in the U.S., but information on trends in professional advice to lose weight is limited. OBJECTIVE: We studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults. DESIGN AND PARTICIPANTS: We used the Behavioral Risk Factor Surveillance System, a cross-sectional prevalence study, from 1994 (n = 10,705), 1996 (n = 13,800), 1998 (n = 18,816), and 2000 (n = 26,454) to examine changes in advice reported by obese adults seen for primary care. MEASUREMENTS: Self-reported advice from a health care professional to lose weight. RESULTS: From 1994 to 2000, the proportion of obese persons receiving advice to lose weight fell from 44.0% to 40.0%. Among obese persons not graduating from high school, advice declined from 41.4% to 31.8%; and for those with annual household incomes below 25,000 dollars, advice dropped from 44.3% to 38.1%. In contrast, the prevalence of advice among obese persons with a college degree or in the highest income group remained relatively stable and high (> 45%) over the study period. CONCLUSIONS: Disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. There is a need for mechanisms that allow health care professionals to devote sufficient attention to weight control and to link with evidence-based weight loss interventions, especially those that target groups most at risk for obesity.     

Venous access and care: harnessing pragmatics in harm reduction for people who inject drugs

Aim To explore the facilitators of long‐term hepatitis C avoidance among people who inject drugs. Design We employed a qualitative life history design. Setting Recruitment took place through low‐threshold drug services and drug user networks in South East and North London. Participants were interviewed at the recruitment services or in their homes. Participants The sample comprised 35 people who inject drugs, 20 of whom were hepatitis C antibody‐negative. Participants' average injecting trajectory was 19 years (6–33), with 66% primarily injecting heroin, and 34% a crack and heroin mix. Nine (26%) of the sample were female and the average age was 39 years (23–53). Measurements Two interviews were conducted with each participant, with the second interview incorporating reference to a computer‐constructed life history time‐line. Interview accounts were audiorecorded, transcribed verbatim and analysed thematically. Findings Hepatitis C risk awareness was recent and deprioritized by the majority of participants. The facilitation of venous access and care was an initial and enduring rationale for safe injecting practices. Difficult venous access resulted in increased contamination of injecting environments and transitions to femoral injecting. Participants expressed an unmet desire for non‐judgemental venous access information and advice. Conclusions Harm reduction interventions which attend to the immediate priorities of people who inject drugs, such as venous access and care, have the potential to re‐engage individuals who are jaded or confused by hepatitis C prevention messages.     

Effects of lifestyle interventions and long‐term weight loss on lipid outcomes – a systematic review

Weight and lipids are critical components of the metabolic syndrome, diabetes and cardiovascular disease. Past reviews considering weight loss on lipid profiles have been for ≤1 year follow‐up and/or were for very overweight, obese or morbidly obese participants. This systematic review includes lifestyle interventions for adults (18–65 years), with a mean baseline BMI < 35 kg/m², with weight and lipid differences over 2 years. Between 1990 and 2010, 14 studies were identified. Mean differences for weight and lipids were modest. However, weight loss at 2–3 years follow‐up, produced significant beneficial lipid profile changes. These were similar to previous reviews conducted on heavier target groups and/or over shorter follow‐up periods; cholesterol (1.3% decrease per kg lost) and triglycerides (1.6% fall per kg). Weight loss sustained longer than 3 years was not associated with beneficial lipid changes, suggesting that other lifestyle changes not just weight loss needs maintaining. Evidence linking lifestyle induced sustained weight loss with lipid profile changes in the long‐term for this group is limited. Probable within‐group differences (treatment vs prevention), would make further group separation prudent. Individual patient data analysis would facilitate this, uncover baseline, medication and confounding effects, and may identify successful program components enabling more effective obesity prevention and treatment strategies.     

Incremental weight loss improves cardiometabolic risk in extremely obese adults

Objective

Excessively obese adults often acquire many metabolic disorders that put them at high risk for developing type 2 diabetes mellitus and cardiovascular disease. We investigated the hypothesis that cardiometabolic risk in a primary care cohort of 208 excessively obese adults (body mass index 40-60 kg/m², 48 with type 2 diabetes mellitus) would deteriorate with additional weight gain and improve incrementally beginning with 5% weight reduction.

Methods

Further analysis of the Louisiana Obese Subjects Study of excessively obese patients enrolled and followed during 2005-2008 is reported.

Results

Weight loss correlated significantly with improvements in fasting plasma glucose, triglycerides, high- and low-density lipoprotein cholesterol, uric acid, alanine aminotransferase, lactate dehydrogenase, and high-sensitivity C-reactive protein. Most parameters deteriorated with weight gain and progressively improved with 5% or more weight loss. Except for low-density lipoprotein cholesterol, all risk factors significantly improved with ≥ 20% loss of body weight. Among patients who had not been diagnosed with type 2 diabetes mellitus and had normoglycemia at baseline, median fasting plasma glucose increased significantly (13%) with stable or gained weight at 1 year, but did not change significantly with reduced weight. Although glucose levels did not change significantly in patients with type 2 diabetes mellitus who gained weight, a decline beginning after 5% weight reduction culminated in 25% glucose reduction with ≥ 20% weight loss. Resting blood pressure declined independently of weight change.

Conclusion

Very obese adults can improve their cardiometabolic risk under primary care weight management. Incremental success may help motivate further therapeutic weight reduction.     

How to provide a structured clinical assessment of a patient with overweight or obesity

With the increasing prevalence of overweight and obesity worldwide, there is a reciprocal increase in the global economic burden and ill-health from obesity-related chronic diseases. Primary healthcare services have a role to play in ensuring early detection of weight issues and in directing patients towards evidence-based care to slow this progression. Research shows that many people with obesity are motivated to lose weight and want their clinician to initiate a conversation about weight management and treatment options. However, this conversation rarely occurs and there is a significant delay in treatment, resulting in an increased burden on the individual, healthcare system and society. In this paper, the components and rationale for the clinical assessment of adult patients with overweight or obesity, including anthropometric measurements and pathology tests, are described. Recommendations to ascertain the potential factors influencing the development of obesity in the patient, such as lifestyle factors (diet and physical activity) and mental health, are also provided. The potential sequelae of obesity that may be present and the necessary assessments for diagnosis are also addressed. These assessments are vital to ensure the patient is referred to the appropriate allied health services and/or specialists.     

The longitudinal association between weight change and health‐related quality of life in adults and children: a systematic review

This systematic review examined longitudinal associations between weight change (weight gain and loss) and both physical and mental aspects of health‐related quality of life (HRQOL) compared with stable weight in adults and children of the general population. MEDLINE, EMBASE, PsycINFO and PubMed databases were searched. Longitudinal observational studies measuring HRQOL with six predefined instruments were synthesized according to type of association: weight change and change in HRQOL (change‐on‐change association) and weight change and HRQOL at follow‐up (predictive association). Twenty studies of adults (n = 15) or children (n = 5) were included. Fifteen studies used the SF‐12 or SF‐36. Results of nine studies in adults examining the change‐on‐change association were combined through a tallying of 606 analyses. Weight gain was most often associated with reduced physical, but not mental HRQOL, across all baseline body mass index categories and in both men and women. Weight loss may be associated with improved physical, but not mental HRQOL, among adults with overweight and obesity. Weight gain was more strongly associated with HRQOL than weight loss, implicating a greater need for preventative strategies to tackle obesity. Results in children and for the predictive association generally reflected these findings but require further research.     

Fat intake and food choices during weight reduction with diet, behavioural modification and a lipase inhibitor

OBJECTIVE: To study the composition of fat intake and fat-rich meals consumed during a trial in which obese subjects were treated with a lipase-inhibitor or placebo, with emphasis on food choices and eating hours. DESIGN: Patients were instructed to record all food and drink taken for four days prior to each dietician visit. The food diaries from all scheduled 15 treatment visits were analysed for nutritional content and composition and for temporal distribution. All meals containing 25 g of fat were defined as fat-rich. SUBJECTS: Twenty-eight women and six men, mean age 45.2 +/- 10.9 (SD) years with a mean body mass index of 37.3 +/- 3.3 (SD) kg m-2 at the beginning of the study. RESULTS: Fat intake, both as absolute weight and as energy % was generally higher in the placebo group but no significant trend over time could be seen. Fat rich meals were increased by 59% towards the end of the study. Most fat rich meals were eaten at lunch and dinner. Cooking fat, fatty sauces, meat dishes and cheese contributed to the major proportion of fat, both for placebo and drug treated subjects. No major changes were seen in food choice over time. CONCLUSION: A lipase inhibitor may affect the amount of fat ingested but does not seem to change major sources of fat. The typical fat-rich meal consumed by these subjects was a meat dish, consumed in the evening.