A controlled, class-based multicomponent intervention to promote healthy lifestyle and to reduce the burden of childhood obesity.

BACKGROUND: Overweight and obesity prevention in childhood and adolescence represent a priority for public health; school is a privileged place for health promotion interventions. OBJECTIVES: The study aimed to test the effectiveness of a multicomponent 5-month intervention on the habits of primary school children, making the families aware of the importance of healthy choices. METHODS: Two hundred nine children attending the fourth class of primary school, divided into interventional (n = 103) and control arm (n = 106) were included in the study. In the intervention group, parents and teachers received more intense lifestyle counseling, associated with weekly motivational telephone calls to families to motivate further their lifestyle changes. Standard deviation score (SDS) body mass index (BMI) was the primary outcome measure; on open-air games and TV watching were secondary outcomes. RESULTS: At baseline, no differences were observed between groups. At 8-month follow-up, mean SDS BMI had decreased by 0.06 units in the intervention arm and increased by 0.12 in controls (time × treatment anova, P < 0.002). Outdoor activities increased from 6.23 h week(-1) to 9.93 in the intervention group (P < 0.001), not in controls. This change was associated differences in TV watching from baseline (intervention, -0.96 h week(-1); P = 0.037; controls, +1.33 h week(-1); P = 0.031). CONCLUSION: A multicomponent school-based intervention addressing the needs of children, teachers and families produced a significant and favourable short-term effect on overweight/obese schoolchildren.

Venesection for non-alcoholic fatty liver disease unresponsive to lifestyle counselling--a propensity score-adjusted observational study.

BACKGROUND/AIM: To test the short-term clinical usefulness of venesection associated with lifestyle counselling as against counselling alone on insulin resistance and liver enzymes in subjects with non-alcoholic fatty liver disease (NAFLD), using a propensity score approach. METHODS: We carried out a 6- to 8-month observational analysis of 198 NAFLD patients in three Italian referral centres (79 venesection and 119 counselling alone). Insulin resistance was measured by the homeostasis model assessment (HOMA) method. Logistic regression was used to identify factors associated with normal HOMA and normal alanine aminotransferase (ALT) at the end of observation. The results were adjusted for the propensity score to be enrolled in the venesection programme, based on clinical and laboratory data, including common HFE polymorphisms and liver biopsy (available in 161 cases). RESULTS: After adjustment for propensity and changes in BMI, venesection was significantly associated with normal HOMA [all cases: odds ratio (OR) 3.00; 95% confidence interval (CI) 1.51-5.97; cases with histology: OR 2.29; 95% CI 1.08-4.87] and ALT within normal limits (all cases: OR 2.56; 95% CI 1.29-5.10; cases with histology: OR 2.81; 95% CI 1.20-5.24). The results were confirmed in an analysis of 57 pairs matched for propensity, where venesection similarly increased the probability of normal HOMA (OR 3.27; 95% CI 1.16-7.84) and normal ALT (OR 5.60; 95% CI 2.09-15.00). Similar data were obtained in the subset of cases with normal basal ferritin (<350 ng/ml). CONCLUSION: Iron depletion by venesection favours the normalization of insulin resistance and raised liver enzymes in non-haemochromatosis patients with NAFLD.

Role of nutrition in gastrointestinal oncological patients.

A paradox exists in the relationship between nutrition and cancer. Excessive dietary intake of nutrients and decreased physical activity represent two modifiable factors responsible for cancer development, namely for cancers of the gastrointestinal (GI) tract, and the present epidemics of obesity and diabetes is likely to increase the incidence of GI and metabolically-derived liver in the next few years. At the same time, in subjects diagnosed with cancer, malnutrition represents a risk factor of poor outcome following surgical resection, as well as of increased toxicity following chemo- and radiotherapy. Any effort should be made to modify the current trend of obesity for cancer prevention, as well as to provide enteral or parenteral nutritional support in cancer patients, to cope with nutritional needs and prevent cancer-related cachexia.

Insulin resistance in nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) refers to a spectrum of liver damage ranging from simple steatosis to nonalcoholic steatohepatitis (NASH), advanced fibrosis and cirrhosis. NAFLD is considered the hepatic component of the metabolic syndrome and insulin resistance represents its pathophysiological hallmark. Insulin resistance in NAFLD is characterized by reduced whole-body, hepatic, and adipose tissue insulin sensitivity. The mechanism(s) underlying the accumulation of fat in the liver may include excess dietary fat, increased delivery of free fatty acids to the liver, inadequate fatty acid oxidation, and increased de novo lipogenesis. Liver fat is highly correlated with all the components of the metabolic syndrome, independent of obesity, and NAFLD may increase the risk of type 2 diabetes and atherosclerosis. Overproduction of glucose, very low-density lipoproteins, C-reactive protein and coagulation factors by the fatty liver could contribute to the excess risk of cardiovascular disease. The reason(s) why some patients will develop NASH are poorly understood. Circulating free fatty acids may be cytotoxic by inducing lipid peroxidation and hepatocyte apoptosis. Insulin resistance is often associated with chronic low-grade inflammation, and numerous mediators released from immune cells and adipocytes may contribute liver damage and liver disease progression. Understanding the molecular mediators of liver injury would promote the development of mechanism-based therapeutic interventions. This article briefly summarizes the recent advances in our understanding of the relationship between NAFLD/NASH, insulin resistance and the metabolic syndrome.

Are behavioural approaches feasible and effective in the treatment of type 2 diabetes? A propensity score analysis vs. prescriptive diet.

BACKGROUND AND AIMS: Lifestyle changes are considered first line treatment in type 2 diabetes, but very few data are available in the "real world" of diabetes units. We aimed to measure the effectiveness of moderate and high intensity interventions on weight loss, metabolic control and insulin use. We report a prospective cohort study, carried out in 822 consecutive subjects with type 2 diabetes, first seen in a 4-year period in a diabetes unit of an academy hospital. METHODS AND RESULTS: Subjects were treated with either a sole prescriptive diet (Diet), or received an additional short-course Elementary Nutritional Education (4 group sessions-ENE) or an intensive Cognitive Behavioural Therapy (12-15 group sessions-CBT). The results were adjusted for the propensity score to be assigned different treatments, derived from logistic regression on the basis of age, gender, BMI, HbA1c, diabetes duration and insulin use at baseline. Main outcome measures were weight loss and weight loss maintenance, metabolic control, and secondary failure to insulin use. Both structured programmes produced a larger weight loss, and the adjusted probability of achieving the 7% weight loss target was increased. Similarly, both programmes favoured metabolic control, irrespective of insulin use. After adjustment for propensity score, both ENE (hazard ratio, 0.48; 95% CI, 0.27-0.84) and CBT (hazard ratio, 0.36; 95% CI, 0.16-0.83) were associated with a reduced risk of de novo insulin treatment. CONCLUSION: Structured behavioural programmes aimed at lifestyle changes are feasible and effective in the "real world" setting of a diabetes unit for the treatment of type 2 diabetes.

Which treatment for nonalcoholic fatty liver disease?

Subjects with nonalcoholic fatty liver disease are at risk of progressive liver failure. Lifestyle changes including weight-loss strategies and increased physical activity remain the first-line approach, but a few pharmacological treatments have also been successfully tested. Several drugs improve biochemistry, only a few improve histology; in all cases, the results were not sustained after treatment stop. Pharmacological treatment is not so far indicated outside controlled clinical trials with histological outcomes.

The burden of obesity on everyday life: a role for osteoarticular and respiratory diseases.

The burden of obesity on patients' everyday life is high; obese subjects perceive a poor Health-Related Quality of Life (HRQL) in both physical and mental dimensions. We aimed to identify the areas of everyday life limited by health status and factors mainly responsible for perceived problems. The Nottingham Health Profile questionnaire (NHP) was used in 274 obese subjects seeking treatment at a university-based obesity center. Values were compared with normative Italian data, corrected for age and sex. Anthropometric and clinical data were also recorded, and correlated with health status. All domains of NHP were significantly impaired in obesity, the effect size ranging from 0.14 (Emotional Reactions; p = 0.02) to 0.99 (Physical Mobility; p < 0.0001), and varying in relation to gender, age and obesity class. Female subjects reported a higher-than-expected prevalence of problems in most areas of daily life [from 20% (Paid Employment) to 44% (Jobs around the home), compared with 14-26% in controls]. Males reported a high prevalence of problems in Sex life (31%), Holidays (37%) and Hobbies (49%), compared with 14, 14, and 16% in controls, respectively. Logistic regression analysis identified osteoarticular pain (knee and hip pain) and respiratory diseases as major factors predicting a poor HRQL in its physical dimensions, or perceived problems in everyday life. The relative importance of knee pain was higher than that of hip pain. Osteoarticular and respiratory diseases are major determinants of poor HRQL in obesity. Prevention strategies and treatment of somatic diseases are mandatory for a comprehensive approach to obesity.