Evaluación integral del paciente con obesidad candidato a cirugía bariátrica­endócrino metabólica / Comprehensive evaluation of the patient with obesity who is a candidate for metabolic bariatric-endocrine surgery

En la actualidad, la obesidad es conside-rada una pandemia, cuya incidencia se ha triplicado en los últimos 30 años, y ha ge-nerado problemas de salud pública cada vez mayores. Tomando como base las guías de la Asociación Americana de Endocrinólogos (AACE), la Sociedad para la Obesidad, la Sociedad Americana de Cirugía Bariátrica y Metabólica (ASMBS), la Asociación para Medicina de la Obe-sidad y la Asociación Americana de Anes-tesiólogos, se realiza el presente docu-mento, con el fin de que se constituya en la hoja de ruta que guíe el procedimiento a seguir en los pacientes que padecen de esta enfermedad crónica y que acuden al Hospital General San Francisco (HGSF)1. La obesidad se caracteriza por el uso de varios medicamentos debido a las co-morbilidades relacionadas: enfermedad cardiovascular, diabetes mellitus tipo 2, enfermedad renal crónica, hígado graso no alcohólico, síndrome metabólico y varios tipos de cánceres2. Este protocolo contiene el más alto nivel de evidencia disponible hasta la fecha, en relación al manejo quirúrgico y no quirúrgico del paciente con diagnóstico de obesidad, incluyendo temas como la identificación de los pacientes candidatos para los pro-cedimientos bariátricos, tipo de proce-dimientos que deberían ser ofertados, el manejo preoperatorio, transoperatorio y el cuidado post operatorio de seguimiento2-4.Desde la publicación por parte de la Ame-rican Society for Metabolic and Bariatric Surgery (ASMBS) en el año 2013 de las guías de manejo del paciente con obe-sidad, se ha evidenciado un incremento significativo en las publicaciones que avalan excelentes resultados para el tra-tamiento de los pacientes con obesidad y con diabetes mellitus tipo 2 mediante la cirugía bariátrica y metabólica 2,5,6. En el año 2016 la publicación del Diabetes Sur-gery Summit (DSS2)7 marca diferencia en el manejo de los pacientes con diabetes mellitus tipo 2, es así que las mismas han crecido sustancialmente y la evidencia demuestra que el manejo metabólico ba-riátrico de estos pacientes es superior al manejo médico y cambios de estilo de vida cuando se evalúa el control glucémico y remisión de las comorbilidades. Con la evaluación previa del equipo mul-tidisciplinario, tendremos información científica del más alto nivel que nos per-mita tener un paciente con recuperación óptima aplicando los criterios de En-hanced Recovery after Bariatric Surgery (ERASB)8. En el Ecuador, la obesidad se ha conver-tido en un problema de salud pública, es así que en la población pediátrica ha au-mentado desde el año 1986 pasando del 8,0% al 26,0% para el año 2012 en el grupo de 11 a 19 años. La prevalencia de sobrepeso y obesidad en población adulta en el Ecuador es del 62,8%, según el sexo es 5,5% mayor en las mujeres (65,5%) que en los hombres (60,0%), y el mayor índice de obesidad y sobrepeso se pre-senta entre la cuarta y quinta décadas de vida, con prevalencias superiores a 73,0%9,10.

Currently, obesity is considered a pan-demic, the incidence of which has tripled in the last 30 years, and has generated in-creasing public health problems. Based on the guidelines of the American As-sociation of Endocrinologists (AACE), the Obesity Society, the American So-ciety for Metabolic and Bariatric Surgery (ASMBS), the Association for Obesity Medicine and the American Association of Anesthesiologists, this document is intended to serve as a roadmap to guide the procedure to be followed in patients suffering from this chronic disease who come to San Francisco General Hospital (HGSF)1.Obesity is characterized by the use of se-veral medications due to related comor-bidities: cardiovascular disease, type 2 diabetes mellitus, chronic kidney disease, non-alcoholic fatty liver disease, meta-bolic syndrome and several types of can-cers2. This protocol contains the highest level of evidence available to date, in relation to the surgical and non-surgical management of the patient with a diag-nosis of obesity, including issues such as the identification of candidate patients for bariatric procedures, type of proce-dures that should be offered, preopera-tive, trans-operative management and fo-llow-up post-operative care2-4.Since the publication by the American So-ciety for Metabolic and Bariatric Surgery (ASMBS) in 2013 of the guidelines for the management of patients with obesity, there has been a significant increase in publications that support excellent results for the treatment of patients with obesity and type 2 diabetes mellitus through bariatric and metabolic surgery2,5,6. In 2016 the pu-blication of the Diabetes Surgery Summit (DSS2)7 makes a difference in the mana-gement of patients with type 2 diabetes mellitus, it is so that the same have grown substantially and the evidence shows that bariatric metabolic management of these patients is superior to medical manage-ment and lifestyle changes when glycemic control and remission of comor-bidities are evaluated. With the previous evaluation of the multidisciplinary team, we will have scientific information of the highest level that will allow us to have a patient with optimal recovery applying the criteria of Enhanced Recovery after Bariatric Surgery (ERASB)8.In Ecuador, obesity has become a public health problem; thus, in the pediatric population it has increased since 1986 from 8,0% to 26,0% in 2012 in the 11 to 19 years age group. The prevalence of overweight and obesity in the adult po-pulation in Ecuador is 62,8%, according to sex is 5,5% higher in women (65,5%) than in men (60,0%), and the highest rate of obesity and overweight occurs between the fourth and fifth decades of life, with prevalences higher than 73,0%9,10.

Intervenciones psicoeducativas para reducir factores psicosociales y controlar el peso en mujeres embarazadas s / Psychoeducational interventions to control weight gain in pregnant women / Intervenções psicoeducativas para reduzir fatores psicossociais e controle de peso em mulheres grávida

Objetivo: identificar las intervenciones psicoeducativas (IP) dirigidas a reducir factores psicosociales (ansiedad, depresión, estrés, imagen corporal, autoestima y apoyo social) y controlar el aumento de peso en mujeres embarazadas. Método: revisión sistemática de ensayos clínicos aleatorizados y estudios cuasi-experimentales consultado en las bases de datos de PubMed, Academic Search Complete, Medline, Web of Science, Ovid, ScienceDirect, Wiley Online Library y Scopus. Resultados: se incluyeron 4 estudios publicados entre el 2000 y 2016. Las IP que incluyen algún componente psicoeducativo como: psicoterapia, entrevista motivacional, establecimiento de objetivos y resolución de problemas junto con asesoramiento en conductas como alimentación saludable y actividad física, tienen un efecto significativo en disminuir la depresión y ansiedad, y a la vez mejoran el control del peso gestacional. Las IP dirigidas al estrés, autoestima, imagen corporal y apoyo social no mostraron efecto significativo para mejorar estas condiciones ni para el control de peso gestacional. Conclusión: se debe considerar componentes psicoeducativos, aunado con terapias complementarias para reducir los factores psicológicos y GPG. Se necesitan más investigaciones para identificar la detección de estos síntomas.

Objective: Identify psychoeducational interventions (PI) aimed at reducing psychosocial factors (anxiety, depression, stress, body image, self-esteem and social support) and controlling weight gain in pregnant women. Method: Systematic review of randomized clinical trials and quasi-experimental studies consulted in the databases of PubMed, Academic Search Complete, Medline, Web of Science, Ovid, ScienceDirect, Wiley Online Library and Scopus. Results: We include four studies published between el 2000 y 2016. The PIs that include some psychoeducational component such as: psychotherapy, motivational interview, goal setting and problem solving together with counseling on behaviors such as healthy eating and physical activity, have a significant effect in reducing depression and anxiety, and at the same time improve the control of gestational weight. The PIs aimed at stress, self-esteem, body image and social support showed no significant effect to improve these conditions or for the control of gestational weight. Conclusion: psychoeducational components should be considered, combined with complementary therapies to reduce psychological factors and GPG. More research is needed to identify the detection of these symptoms.

Objetivo: Identificar intervenções psicoeducativas (IP) voltadas à redução de fatores psicossociais (ansiedade, depressão, estresse, imagem corporal, autoestima e suporte social) e controle do ganho de peso em gestantes. Método: Revisão sistemática de ensaios clínicos randomizados e estudos quase-experimentais consultados nas bases de datos de PubMed, Academic Search Complete, Medline, Web of Science, Ovid, ScienceDirect, Wiley Online Library e Scopus. Resultados: Quatro estudos publicados entre 2000 e 2016. IP incluindo um componente psicoeducacional como incluído: psicoterapia, entrevista motivacional, estabelecimento de metas e resolução de problemas, juntamente com conselhos sobre comportamentos, como alimentação saudável e atividade física, têm um efeito significativo na diminuição depressão e ansiedade e, ao mesmo tempo, melhorar o controle do peso gestacional. Os IPs voltados ao estresse, autoestima, imagem corporal e suporte social não apresentaram efeito significativo para melhorar essas condições ou para o controle do peso gestacional. Conclusão: os componentes psicoeducacionais devem ser considerados, combinados com terapias complementares para reduzir fatores psicológicos e GPG. Mais pesquisas são necessárias para identificar a detecção desses sintomas.

Body weight perception and body weight control behaviors in adolescents / Percepção do peso corporal e comportamentos para controle de peso em adolescentes

Abstract Objective: To investigate the association between the perception of body weight (as above or below the desired) and behaviors for body weight control in adolescents. Methods: This was a cross-sectional study that included 1051 adolescents (aged 15-19 years) who were high school students attending public schools. The authors collected information on the perception of body weight (dependent variable), weight control behaviors (initiative to change the weight, physical exercise, eating less or cutting calories, fasting for 24 h, taking medications, vomiting, or taking laxatives), and measured body weight and height to calculate the body mass index and then classify the weight status. Associations were tested by multinomial logistic regression analysis. Results: Adolescents of both sexes who perceived their body weight as below the expected weight took more initiatives to gain weight, and those who perceived themselves as overweight made more efforts to lose weight. In adolescents who perceived themselves as overweight, the behavior of not taking medication was associated with the outcome only in boys (Odds Ratio = 8.12), whereas in girls, an association was observed with the variables eating less, cutting calories, or avoiding fatty foods aiming to lose or avoid increasing body weight (Odds Ratio = 3.39). Adolescents of both sexes who practiced exercises were more likely to perceive themselves as overweight (male Odds Ratio = 2.00; Odds Ratio = 1.93 female). Conclusion: The perception of the body weight as above and below one's expected weight was associated with weight control behaviors, which were more likely to result in initiatives to lose and gain weight, respectively.

Resumo Objetivo: Verificar a associação da percepção (acima ou abaixo) do peso corporal esperado com os comportamentos para controle de peso em adolescentes. Métodos: Estudo transversal, feito com 1.051 adolescentes (15 a 19 anos) do ensino médio de escolas públicas estaduais. Foram coletadas informações sobre a percepção do peso corporal (variável dependente), comportamentos de controle de peso (iniciativa para mudar o peso, prática de exercícios físicos, comer menos ou cortar calorias, ficar 24 h sem comer, tomar medicamentos, vomitar ou tomar laxantes) e aferidas as medidas de massa corporal e estatura para cálculo do índice de massa corporal e classificação do status do peso. As associações foram testadas por meio da regressão logística multinomial. Resultados: Adolescentes de ambos os sexos com percepção do peso corporal abaixo do peso esperado apresentaram mais iniciativas para ganhar peso e aqueles que se percebiam acima do peso tiveram mais iniciativas para perder peso. Nos adolescentes que se percebiam acima do peso, o comportamento de não tomar medicamento esteve associado ao desfecho apenas nos rapazes (OR = 8,12), enquanto nas moças observou-se associação com comer menos, cortar calorias ou evitar alimentos gordurosos para perder ou para não aumentar o peso corporal (OR = 3,39). Adolescentes de ambos os sexos que faziam exercício físico tiveram maior chance de se perceber acima do peso (masculino OR = 2,00; feminino OR = 1,93). Conclusão: A percepção do peso acima e abaixo do peso esperado esteve associada aos comportamentos de controle de peso, nos quais, respectivamente, tinham mais chances de tomar iniciativas para perder e para ganhar peso.

Beating Obesity: Factors Associated with Interest in Workplace Weight Management Assistance in the Mining Industry

BACKGROUND: Rates of overweight and obese Australians are high and continue to rise, putting a large proportion of the population at risk of chronic illness. Examining characteristics associated with preference for a work-based weight-loss program will enable employers to better target programs to increase enrolment and benefit employees' health and fitness for work. METHODS: A cross-sectional survey was undertaken at two Australian mining sites. The survey collected information on employee demographics, health characteristics, work characteristics, stages of behavior change, and preference for workplace assistance with reaching a healthy weight. RESULTS: A total of 897 employees participated; 73.7% were male, and 68% had a body mass index in the overweight or obese range. Employees at risk of developing obesity-related chronic illnesses (based on high body mass index) were more likely to report preference for weight management assistance than lower risk employees. This indicates that, even in the absence of workplace promotion for weight management, some at risk employees want workplace assistance. Employees who were not aware of a need to change their current nutrition or physical activity behaviors were less likely to seek assistance. This indicates that practitioners need to communicate the negative effects of excess weight and promote the benefits of a healthy lifestyle to increase the likelihood of weight management. CONCLUSION: Weight management programs should provide information, motivation. and trouble-shooting assistance to meet the needs of at-risk mining employees, including those who are attempting to change and maintain behaviors to achieve a healthy weight and be suitably fit for work.

Psychiatric symptoms, substance use, and other medical conditions in patients with obesity who seek treatment for weight loss / Síntomas psiquiátricos, consumo de sustancias y otras condiciones médicas en pacientes con obesidad que buscan tratamiento para reducir peso

Abstract: INTRODUCTION: Scaling in obesity classes increases its effect on medical comorbidities and psychiatric symptoms. Anxiety and depression have a significant effect on treatment adherence and weight loss. OBJECTIVE: This study had three aims: a) to evaluate the prevalence of psychiatric symptoms; b) to evaluate the interactions between obesity classes and demographic variables in relation to psychiatric symptoms; and c) to analyze the interactions between obesity classes, demographic variables, and psychiatric symptoms in association with medical comorbidities in a sample of obese individuals seeking treatment for weight loss. METHOD: Medical record review of 22 weight loss clinics during January-December 2014. Binomial logistic regression was carried to assess univariate associations, second- and third-order interactions. RESULTS: Total sample was composed of 13,305 patients, mostly women (82.04%), married (53.66%), with elementary education (38.6%), mean body max index was 34.94 (SD = 4.39). The most prevalent psychiatric symptoms were anxiety (45.21%) and depression (16.36%). When analyzing interactions, it was found that men with class II obesity had higher odds for alcohol use (OR 1.56, IC 95% 1.10-2.22), and participants with obesity class III and married had more probability of diabetes II (OR 1.53, IC 95% 1.06-2.19). DISCUSSION AND CONCLUSION: Results show the complexity of the relation between demographic variables, psychiatric symptoms, medical comorbidities and obesity, underscoring the need to tailor treatments based in such variables, to promote adherence and weight loss.

Resumen: INTRODUCCIÓN: El incremento en el grado de obesidad se asocia con comorbilidades médicas y los síntomas psiquiátricos. La ansiedad y la depresión afectan la adherencia al tratamiento de la obesidad y la reducción de peso corporal. OBJETIVO: El estudio tuvo tres objetivos principales: a) Evaluar la prevalencia de síntomas psiquiátricos; b) evaluar las interacciones entre grados de obesidad, variables demográficas y síntomas psiquiátricos; c) analizar las interacciones entre grados de obesidad, síntomas psiquiátricos y comorbilidades médicas. MÉTODO: A través de revisión de expedientes médicos de 22 clínicas de reducción de peso entre enero-diciembre de 2014. Se analizó a través de regresión logística univariada y evaluando interacciones de segundo y tercer orden. RESULTADOS: La muestra total fue de 13305, mayormente mujeres (82.04%) la mayoría son casados (53.66%) con escolaridad de secundaria (38.6%) y preparatoria (36.7%), el IMC promedio fue de 34.94 (SD = 4.39). Las comorbilidades más prevalentes fueron síntomas de ansiedad (45.21%) y depresión (16.36%). Al analizar las interacciones los hombres con obesidad tipo II tuvieron mayor probabilidad de consumo de alcohol (OR 1.56 IC 95% 1.10-2.22), y los participantes con obesidad tipo III y casados tuvieron mayor probabilidad de diabetes (OR 1.53 IC 95% 1.06-2.19). DISCUSIÓN Y CONCLUSIÓN: Los resultados muestran la compleja relación entre variables demográficas, obesidad, síntomas psiquiátricos y comorbilidades, implicando la necesidad de desarrollar programas de tratamiento que tomen en cuenta dichas variables para promover la adherencia al tratamiento y la reducción de peso.