Bariatric surgery is emerging as a powerful weapon against severe obesity and type 2 diabetes mellitus (T2DM). Given its role in metabolic regulation, the gastrointestinal tract constitutes a ...meaningful target to treat T2DM, especially in light of accumulating evidence that surgery with gastrointestinal manipulations may result in T2DM remission (metabolic surgery). The major mechanisms mediating the weight loss-independent effects of bariatric surgery comprise effects on tissue-specific insulin sensitivity, β-cell function and incretin responses, changes in bile acid composition and flow, modifications of gut microbiota, intestinal glucose metabolism and increased brown adipose tissue metabolic activity. Shorter T2DM duration, better preoperative glycemic control and profound weight loss, have been associated with higher rates of T2DM remission and lower risk of relapse. In the short and medium term, a significant amount of weight is lost, T2DM may completely regress, and cardiometabolic risk factors are dramatically improved. In the long term, metabolic surgery may achieve durable weight loss, prevent T2DM and cancer, improve overall glycemic control while leading to significant rates of T2DM remission, and reduce total and cause-specific mortality. The gradient of efficacy for weight loss and T2DM remission comparing the four established surgical procedures is biliopancreatic diversion >Roux-en-Y gastric bypass >sleeve gastrectomy >laparoscopic adjustable gastric banding. According to recently released guidelines, bariatric surgery should be recommended in diabetic patients with class III obesity, regardless of their level of glycemic control, and patients with class II obesity with inadequately controlled T2DM despite lifestyle and optimal medical therapy. Surgery should also be considered in patients with class I obesity and inadequately controlled hyperglycemia despite optimal medical treatment.
To describe the design of the Feel4Diabetes-intervention and the baseline characteristics of the study sample.
School- and community-based intervention with cluster-randomized design, aiming to ...promote healthy lifestyle and tackle obesity and obesity-related metabolic risk factors for the prevention of type 2 diabetes among families from vulnerable population groups. The intervention was implemented in 2016-2018 and included: (i) the 'all-families' component, provided to all children and their families via a school- and community-based intervention; and (ii) an additional component, the 'high-risk families' component, provided to high-risk families for diabetes as identified with a discrete manner by the FINDRISC questionnaire, which comprised seven counselling sessions (2016-2017) and a text-messaging intervention (2017-2018) delivered by trained health professionals in out-of-school settings. Although the intervention was adjusted to local needs and contextual circumstances, standardized protocols and procedures were used across all countries for the process, impact, outcome and cost-effectiveness evaluation of the intervention.
Primary schools and municipalities in six European countries.
Families (primary-school children, their parents and grandparents) were recruited from the overall population in low/middle-income countries (Bulgaria, Hungary), from low socio-economic areas in high-income countries (Belgium, Finland) and from countries under austerity measures (Greece, Spain).
The Feel4Diabetes-intervention reached 30 309 families from 236 primary schools. In total, 20 442 families were screened and 12 193 'all families' and 2230 'high-risk families' were measured at baseline.
The Feel4Diabetes-intervention is expected to provide evidence-based results and key learnings that could guide the design and scaling-up of affordable and potentially cost-effective population-based interventions for the prevention of type 2 diabetes.
Feel4Diabetes (standing for: Families across Europe following a hEalthy Lifestyle for Diabetes prevention, http://feel4diabetes-study.eu/) is a school and community based intervention program, aiming ...to prevent type 2 diabetes (T2D) among families from vulnerable population groups, in six European countries, by promoting healthy lifestyle. In the current issue of BMC Endocrine Disorders, three reviews and three papers providing a detailed description of the methodology used to obtain measurements related to the trial conduction, as well as two papers using original data collected in the Feel4Diabetes-study are presented.
The aim of this study was to develop and examine the predictive accuracy of an index that estimates obesity risk in childhood based on perinatal factors and maternal sociodemographic characteristics. ...Analysis was conducted by using cross-sectional and retrospective data collected from a European cohort of 2775 schoolchildren and their families participating in the Feel4Diabetes-study. The cohort was randomly divided by using two-thirds of the sample for the development of the index and the remaining one third for assessing its predictive accuracy. Logistic regression analyses determined a prediction model for childhood obesity. The area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated. Cut-off analysis was applied to identify the optimal value of the index score that predicts obesity with the highest possible sensitivity and specificity. Eight factors were found to be significantly associated with obesity and were included as components in the European “Childhood Obesity Risk Evaluation” (CORE) index: region of residence, maternal education, maternal pre-pregnancy weight status, gestational weight gain, maternal smoking during pregnancy, birth weight for gestational age, infant growth velocity, and exclusive breastfeeding during the first 6 months. Risk score ranged from 0 to 22 corresponding to a risk from 0.9 to 54.6%. The AUC-ROC was 0.725 with optimal cut-off ≥9 (sensitivity = 74.1%, specificity = 61.0%, PPV = 11.3%, NPV = 97.2%).
Conclusion:
The European CORE index can be used as a screening tool for the identification of infants at high-risk for becoming obese at 6–9 years. This tool could assist healthcare professionals in initiating preventive measures from the early life.
Trial registration:
The Feel4Diabetes-intervention is registered at
https://clinicaltrials.gov/
; number, CT02393872; date, March 20, 2015.
What is Known:
• As prevention of obesity should start early in life, there is a compelling rationale for the early identification of high-risk children to facilitate targeted intervention.
What is New:
• This study developed and assessed the predictive accuracy of an index for the Childhood Obesity Risk Evaluation (CORE), combining certain perinatal factors and maternal sociodemographic characteristics in a large European cohort.
• The European CORE index can be used as a screening tool for identifying infants at high-risk for becoming obese at 6–9 years and assist health professionals in initiating early prevention strategies.
It is known that Cardiovascular (CV) disease is the leading cause of morbidity and mortality in individuals with type 2 diabetes. Over the last years, one of the most discussed topics is the CV ...safety of anti-diabetic medications. Regarding CV safety of older antidiabetic agents the data are less clear and conclusions about their CV safety are mostly based on randomized controlled trials designed to assess their glucose lowering efficacy. In this review, we summarize the current knowledge about the CV safety of older and newer antidiabetic medications. According to the published literature metformin is the first line agent for the treatment of type 2 diabetes and seems to have cardio-protective effects. The choice of the second line agent when metformin monotherapy fails to achieve HbA1c targets is less clear. In the light of the findings of the EMPA-REG OUTCOME trial and the recently published LEADER and SUSTAIN 6 trials, empagliflozin, liraglutide and semaglutide seem reasonable options as second line agents for patients with CV disease. Sulfonylureas on the other hand, with the exception of gliclazide, should be avoided in those patients, although CV safety trials are still lacking. In individuals without CV disease any of the other classes of anti-diabetic medication can be selected on a patient-centered approach. Saxagliptin, alogliptin, sitagliptin and lixisenatide have been evaluated in CV safety trials and have neutral effects on CV outcomes, while pioglitazone may have some CV benefits. Saxagliptin and alogliptin, however, should be avoided in patients with heart failure, while pioglitazone is contraindicated in this population.
In health care systems in need of additional intensive care unit (ICU) beds, the decision to mechanically ventilate critically ill patients in Internal Medicine (IM) Department wards needs to balance ...patients' health outcomes, possible futility, and logistics. We aimed to examine the survival rates and predictors in these patients. We prospectively enrolled consecutive patients receiving mechanical ventilation during their care in the IM wards of a tertiary University hospital between April 2016 and December 2018. Primary outcome was 90-day mortality and secondary outcomes were in-hospital mortality and ICU transfer. Our cohort consisted of 151 unique patient intubations, of whom 74 (49%) patients were transferred to ICU within a median of 0 days (range 0-7). Compared to patients who remained in the wards, patients transferred to ICU had lower in-hospital and 90-day mortality (65% vs. 97%, and 70% vs. 99%, respectively, p8 who were transferred to ICUs received futile care. Mortality for patients receiving mechanical ventilation in IM wards is almost inevitable when ICU availability is lacking. Therefore, applying additional transfer criteria beyond the SOFA score is imperative.
A wealth of clinical and epidemiological evidence has linked obesity to a broad spectrum of cardiovascular diseases (CVD) including coronary heart disease, heart failure, hypertension, stroke, atrial ...fibrillation and sudden cardiac death. Obesity can increase CVD morbidity and mortality directly and indirectly. Direct effects are mediated by obesity-induced structural and functional adaptations of the cardiovascular system to accommodate excess body weight, as well as by adipokine effects on inflammation and vascular homeostasis. Indirect effects are mediated by co-existing CVD risk factors such as insulin resistance, hyperglycemia, hypertension and dyslipidemia. Adipose tissue (AT) quality and functionality are more relevant aspects for cardiometabolic risk than its total amount. The consequences of maladaptive AT expansion in obesity are local and systemic: the local include inflammation, hypoxia, dysregulated adipokine secretion and impaired mitochondrial function; the systemic comprise insulin resistance, abnormal glucose/lipid metabolism, hypertension, a pro-inflammatory and pro-thrombotic state and endothelial dysfunction, all of which provide linking mechanisms for the association between obesity and CVD. The present narrative review summarizes the major pathophysiological links between obesity and CVD (traditional and novel concepts), analyses the heterogeneity of obesity-related cardiometabolic consequences, and provides an overview of the cardiovascular impact of weight loss interventions.
•Obesity is closely linked to CVD•This relationship is direct and indirect•Adipose tissue localization and metabolism play a crucial role•Weight loss confers important risk reduction
Diabetes mellitus is associated with an increased risk of coronary heart disease (CHD) morbidity and mortality. Although it frequently coexists with other cardiovascular disease (CVD) risk factors, ...it confers an increased risk for CVD events on its own. Coronary atherosclerosis is generally more aggressive and widespread in people with diabetes (PWD) and is frequently asymptomatic. Screening for silent myocardial ischaemia can be applied in a wide variety of ways. In nearly all asymptomatic PWD, however, the results of screening will generally not change medical therapy, since aggressive preventive measures, such as control of blood pressure and lipids, would have been already indicated, and above all, invasive revascularization procedures (either with percutaneous coronary intervention or coronary artery bypass grafting) have not been shown in randomized clinical trials to confer any benefit on morbidity and mortality. Still, unresolved issues remain regarding the extent of the underlying ischaemia that might affect the risk and the benefit of revascularization (on top of optimal medical therapy) in ameliorating this risk in patients with moderate to severe ischaemia. The issues related to the detection of coronary atherosclerosis and ischaemia, as well as the studies related to management of CHD in asymptomatic PWD, will be reviewed here.
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