Management of obesity in the times of climate change and COVID-19: an interdisciplinary expert consensus report.

Obesity is a chronic disease associated with increased metabolic and cardiovascular risk, excessive morbidity and mortality worldwide. The authors of the present consensus, clinicians representing medical specialties related to the treatment of obesity and its complications, reviewed a number of European and American guidelines, published mostly in 2019-2021, and summarized the principles of obesity management to provide a practical guidance considering the impact that increased adiposity poses to health. From a clinical perspective, the primary goal of obesity treatment is to prevent or slow down the progression of diseases associated with obesity, reduce metabolic and cardiovascular risk, and improve the quality of life by achieving adequate and stable weight reduction. However, obesity should be not only considered a disease requiring treatment in an individual patient, but also a civilization disease requiring preventive measures at the populational level. Despite the evident benefits, obesity management within the health care system-whether through pharmacotherapy or bariatric surgery-is only a symptomatic treatment, with all its limitations, and will not ultimately solve the problem of obesity. The important message is that available treatment options fail to correct the true drivers of the obesity pandemic. To this end, new solutions and efforts to prevent obesity in the populations are needed.

Cardiovascular risk management in type 2 diabetes of more than 10-year duration: Results of Polish ARETAEUS2-Grupa Study.

BACKGROUND: ARETAEUS 1 study showed that a great majority of patients with type 2 diabetes mellitus (T2DM) of short duration did not meet all of the treatment goals. Since then the treatment goals in T2DM have been changed. The aim of the ARETAEUS 2-Grupa Study was to assess cardiovascular (CV) risk management and meeting treatment goals in the population of T2DM of more than 10-year duration. METHODS: ARETAEUS2-Grupa was a cross-sectional questionnaire-based study conducted in Poland in 2012. Randomly selected physicians recruited 1,740 patients with T2DM diagnosed more than 10 years before the study. RESULTS: Lipid treatment goals were met respectively: for total cholesterol in 34.5% of all patients, triglycerides in 53.8%, low density lipoprotein cholesterol (LDL-C) in 26.5% and high density lipoprotein cholesterol (HDL-C) in 38.2%. Most of patients with and without coronary artery disease were receiving aspirin (90.3% and 60%, respectively) and statins (84.4% and 67.7%, respectively). The current blood pressure (BP) goal (140/90 mm Hg) was met in 43.5% of patients and the previous goal (< 130/80 mm Hg) in 12.4%. The patients were mainly treated with ≥ 3 antihypertensive drugs. All treatment goals (for HbA1c, BP and LDL-C) were reached only by 8.2% of patients, any two goals by 26.3% of patients, one goal by 39.8% of patients, none by 25.6% of patients. CONCLUSIONS: The new less restrictive treatment goals are reached more frequently but still much is to be done in the field of clinical practice guidelines implementation and CV prevention in T2DM population.

Management and treatment goals in Polish patients with type 2 diabetes of more than ten years' duration - results of ARETAEUS2-Grupa Study.

INTRODUCTION: Previous studies have shown insufficient diabetes control in patients with type 2 diabetes (T2DM). Diabetes Poland changed the target HbA1c and blood pressure (BP) values in diabetic patients in their practice guidelines in 2011, that were further sustained. To assess the management and treatment choices in T2DM of more than ten years' duration and the degree to which diabetic control criteria recommended by the Diabetes Poland clinical practice guidelines 2012 are being met. MATERIAL AND METHODS: ARETAEUS2-Grupa was a cross-sectional questionnaire-based study conducted in Poland in 2012 (April-June). It involved 1,740 patients of any age and both genders, with T2DM diagnosed more than ten years before the study, and recruited by randomly selected physicians. RESULTS: All patients received pharmacological treatment, most of them combination therapy or insulin in monotherapy. 40% of patients met the goal for HbA1c control (≤ 7%) and the median value of HbA1c was above the recommended threshold (7.2%). Only 8% of thetotal population met all three goals (HbA1c, BP and lipid levels), 26% - two goals, and 40% - only one goal. Over 25% of patients did not meet any of the treatment goals. CONCLUSIONS: We observed considerable deviations from treatment targets recommended by current clinical practice guidelines for patients with T2DM of more than ten years' duration. The frequency of cardiovascular risk factors and late diabetes complications was high, while a relatively high percentage of patients was not examined for late diabetes complications.

Prothrombotic alterations in plasma fibrin clot properties in thyroid disorders and their post-treatment modifications.

INTRODUCTION: Available data on fibrin clot properties and fibrinolysis in hyperthyroidism and hypothyroidism are inconsistent. Our objective was to assess the impact of effective treatment of hyper- and hypothyroidism on fibrin clot characteristics. MATERIAL AND METHODS: In a case-control study, ex vivo plasma fibrin clot permeability (Ks) and efficiency of fibrinolysis were assessed in 35 consecutive hyperthyroid and 35 hypothyroid subjects versus 30 controls. All measurements were performed before and after 3months of thyroid function normalizing therapy. RESULTS: At baseline, hyperthyroid, but not hypothyroid, patients had lower Ks than controls (p<0.0001). Hyperthyroid and hypothyroid groups compared with controls had prolonged clot lysis time (CLT), and lower rate of D-dimer release from clots (D-Drate) (all p<0.05). The regression analysis adjusted for fibrinogen showed that in hyperthyroid patients, pre-treatment thyroid stimulating hormone (TSH) independently predicted Ks, while thrombin activatable fibrinolysis inhibitor (TAFI) antigen predicted CLT. In hypothyroid individuals a similar regression model showed that TSH independently predicts CLT. After 3months of thyroid function normalizing therapy, 32 (91.4%) hyperthyroid and 30 (85.7%) hypothyroid subjects achieved euthyroidism and had improved fibrin clot properties (all p<0.05), with normalization of Ks in hyperthyroid and lysability in hypothyroid patients. CONCLUSIONS: Both hyper- and mild-to-moderate hypothyroidism are associated with prothrombotic plasma fibrin clot phenotype and restoration of euthyroidism improves clot phenotype. Abnormal fibrin clot phenotype might contribute to thromboembolic risk in thyroid disease.

Management and treatment goals in Polish patients with type 2 diabetes of short duration: results of the ARETAEUS2-Grupa study.

INTRODUCTION:  In 2011, the Diabetes Poland updated its recommended goals in diabetes treatment, including hemoglobin A1c (HbA1c) and blood pressure (BP) levels. Adherence to the updated guidelines has not been systematically assessed so far. OBJECTIVES:  The aim of the study was to assess which methods are most commonly used in the treatment of recently diagnosed type 2 diabetes and to what extent the new criteria for diabetes control are met in these patients. PATIENTS AND METHODS:  The ARETAEUS2­Grupa study was a cross­sectional questionnaire­based study conducted in Poland in 2012 (April-June). It involved 1636 patients of any age and sex, with type 2 diabetes diagnosed within the previous 2 years, recruited by randomly selected physicians. RESULTS:  Of all patients, 37.5% met the goal of an HbA1c level of ≤6.5% (recommended in type 2 diabetes of short duration), while 62% met the goal of an HbA1c level of ≤7% (general recommendation). Only 6.7% of the patients met all 3 goals (HbA1c ≤6.5%, BP <140/90 mmHg, and low­density lipoprotein cholesterol <100 mg/dl or <70 mg/dl in coronary heart disease), 29.7% met 2 goals, 36.8% met only 1 goal, while 26.7% did not meet any of the treatment goals. With the use of the HbA1c level recommended for the overall population, the proportions of patients meeting 3, 2, and 1 goals increased to 11%, 34.5%, and 35.5%, respectively, while the percentage of the patients not meeting any goals decreased to 18%. Metformin in monotherapy or in combination was the most commonly used drug in the study population (80%).  CONCLUSIONS:  The majority of the patients with type 2 diabetes of short duration did not meet any of the treatment goals as recommended in the current practice guidelines. When the treatment goals were used for the overall population (HbA1c ≤7%), a slightly higher, but still unsatisfactory, proportion of the patients met all the treatment goals. Metformin alone or in combination was the most commonly used drug in the study population.

Specialty outpatient care of diabetic patients in Poland--are we far from treatment targets? Rationale, design, and preliminary results of the OPTIMO study.

INTRODUCTION: While clinical practice guidelines reflect the best known evidence-based approach to patient care, it is individual clinicians and patients who make decisions and treatment choices, and individual patients who actually achieve (or not) the treatment goals. OBJECTIVES: The aim of the study was to describe the population of diabetic patients attending specialty outpatient clinics, to characterize the management of patients with different types of diabetes, and to assess the accordance of management with the recommendations developed by Diabetes Poland. PATIENTS AND METHODS: The OPTIMO observational study was conducted from 2006 to 2009 and included patients with diabetes diagnosed according to the 1999 World Health Organization criteria who were observed for 1 to 3 years, with control visits at least every 6 months. Participating physicians used pocket PCs equipped with specially developed software to collect patients' data and to provide educational reminders to clinicians. RESULTS: The final analysis involved 9600 patients for whom valid baseline questionnaires were available. Type 2 diabetes was observed in 92% and type 1 diabetes in 6% of the patients. Mean age was 60.5 years. Women constituted 54% of the population. Coronary heart disease was observed in 32% and arterial hypertension in 76% of the patients. At baseline, 23% of the patients had hemoglobin A1c level below 6.5% and 44% below 7.0. Total cholesterol and triglycerides treatment goals were met at baseline by slightly more than half of the patients, while low-density lipoprotein cholesterol treatment goal was met only by 33% of the patients. Baseline blood pressure below 130/80 mmHg was reported for 11% of the patients. CONCLUSIONS: At the beginning of the OPTIMO study, we have observed considerable deviations from treatment targets recommended by current clinical practice guidelines for diabetic patients, which leaves significant room for improvement in the care of diabetic patients.

Is newly diagnosed type 2 diabetes treated according to the guidelines? Results of the Polish ARETAEUS1 study.

INTRODUCTION: There is a paucity of data on meeting treatment goals in patients with newly diagnosed type 2 diabetes (DM2). OBJECTIVES: The aim of the study was to characterize Polish patients with newly diagnosed DM2, to assess management of hyperglycemia, and to estimate the proportion of patients achieving the criteria of disease control recommended by the national clinical practice guidelines published in 2008. PATIENTS AND METHODS: ARETAEUS1 was a cross-sectional questionnaire-based study conducted in several regions of Poland in 2009 (January-April). It involved 1714 patients with DM2 of any age and sex, treated for less than 24 months, and recruited by randomly selected physicians. RESULTS: Only 28.9% of patients with DM2 met the goal for glycated hemoglobin (HbA1c) control (<6.5%). In the total population, only 1.4% of all patients met all 3 goals (HbA1c, blood pressure, and lipid levels), 12.5%--2 goals, and 35.3%--only 1 goal; 50.7% did not meet any of the treatment goals. Achieving all of the treatment goals varied between the patient subgroups (in relation to the current diabetes treatment, age, sex, body mass index, and diabetes duration). CONCLUSIONS: Most patients with newly diagnosed DM2 do not meet all their major treatment goals, which indicates relatively low adherence to the national guideline recommendations for diabetes control and primary cardiovascular prevention in DM2. Metformin seems to be underused and titration of other glucose lowering medications may be insufficiently target-driven. Assuming that adherence to the current clinical practice guidelines is beneficial for patients, we recommend that both practitioners and patients have increased awareness of these guidelines and of the ways to achieve and maintain treatment goals.

Cardiovascular risk factors control in Polish patients with type 2 diabetes within the first two years of diagnosis: results of the ARETAEUS1 study.

BACKGROUND: The practice guidelines of cardiological and diabetological societies emphasise that cardiovascular (CV) risk control in diabetic patients is especially important and should be stricter than in subjects without diabetes. There are little data on the frequency of meeting treatment goals in patients with newly diagnosed diabetes mellitus type 2 (DM2). AIM: To characterise Polish patients with DM2 diagnosed within the previous two years and to assess if the treatment targets from the current (2008) guidelines of Diabetes Poland regarding control of CV risk factors are met. METHODS: ARETAEUS1 was a cross-sectional questionnaire-based study conducted in various regions of Poland in 2009 (January-April). It involved 1,714 patients of all ages and both genders, who had DM2 treated for less than 24 months. They were recruited by randomly selected physicians. RESULTS: Total cholesterol treatment goal (< 4.5 mmol/L) was met in 22% of all patients, triglycerides treatment goal (< 1.7 mmol/L) in 44%, LDL cholesterol treatment goal (< 2.6 mmol/L) in 20% and HDL cholesterol treatment goal (> 1.0 mmol/L in men and > 1.3 mmol/L in women) in 55%. Only 13% of the overall population met the goal of blood pressure (BP) below 130/80 mm Hg. When a less restrictive BP control threshold (< 140/90 mm Hg) was applied, 48% of patients had their BP below the threshold. In the analysis of subgroups (patients with and without previous CV events; receiving 1-5 or not receiving antihypertensive drugs; receiving and not receiving statins and fibrates) we observed from 0% to 3.3% of patients meeting three (HbA1c, BP and cholesterol) treatment goals. The percentages of patients meeting two out of three treatment goals were between 8% and 33% in different subgroups. The percentages of patients meeting only one out of three treatment goals ranged from 27.8% to 46.7% or at least one - from 39% to 69%. CONCLUSIONS: Most patients with newly diagnosed diabetes are not meeting their treatment goals regarding control of CV risk factors, which indicates relatively low adherence to national guideline recommendations for diabetes control and primary CV prevention in DM2. Difficulties in achieving CV treatment targets in the diabetic population indicate the need for a great deal of effort on the part of clinicians and patients. Practice guidelines developers should consider what treatment targets are achievable at a reasonable expense of effort.

Characteristics of patients with type 2 diabetes of short duration in Poland: Rationale, design and preliminary results of the ARETAEUS1 study.

INTRODUCTION: There is a paucity of Polish data describing the characteristics of and assessing treatment goals in patients with relatively newly diagnosed type 2 diabetes. OBJECTIVES: The aim of the study was to describe the baseline characteristics of patients with newly diagnosed type 2 diabetes, who participated in the ARETAEUS1 study, and to assess to what degree diabetic control criteria recommended by the Polish Diabetes Association clinical practice guidelines are met. PATIENTS AND METHODS: This cross-sectional questionnaire-based study was conducted from January to April 2009. It involved patients of any age and gender, diagnosed with type 2 diabetes after January 1, 2007, and recruited by randomly selected physicians, both diabetologists and non-diabetologists. RESULTS: We analyzed 1714 valid questionnaires from 333 physicians: 1150 from non-diabetologists and 564 from diabetologists. Mean age of patients was 60 years, mean body mass index -- 30.6 kg/m2, proportion of females -- 50%. The levels of median glycated hemoglobin (HbA1c), total cholesterol and triglycerides, mean low-density lipoprotein (LDL) cholesterol, as well as blood pressure were above the thresholds recommended in the guidelines (i.e., <6.5% for HbA1c, <4.5 mmol/l for total cholesterol, <2.6 mmol/l [or <1.8 mmol/l in patients with coronary heart disease (CHD)] for LDL cholesterol, <1.7 mmol/l for triglycerides, and <130/80 mmHg for blood pressure). Cardiovascular disease risk factors were common: hypertension was reported in over 75% of patients, lipid disorders in nearly 75%, CHD in 27% (previous acute coronary syndrome or stable CHD), previous stroke in 4%, and previous transient ischemic attack in 5.5%. Diabetic foot was reported in 1.7% of patients, nephropathy in 7%, retinopathy in 9% (in the group of diabetologists) and in 21% of patients (in the group of non-diabetologists). CONCLUSIONS: We observed a relatively high prevalence of cardiovascular disease risk factors and late diabetes complications in patients with diabetes diagnosed within the previous 2 years.

International Diabetes Federation document concerning postmeal glycemic control: assessment of quality of clinical practice guidelines using AGREE instrument.

Clinical practice guidelines constitute one of the most important sources of information and education for physicians. Therefore, establishing rules to develop and appraise such guidelines properly is of increasing importance. This task is served by the AGREE (Appraisal of Guidelines Research and Evaluation) instrument, a questionnaire, which, according to its authors, allows reproducible assessment of guideline quality. The aim of this paper is to allow readers familiarize themselves with such rules of guidelines appraisal. In order to achieve this purpose, we present the actual application of the AGREE instrument using as an example recently published document on postmeal hyperglycemia issued by the International Diabetes Federation.

[Environmental factors in the development of type 1 diabetes -- a new insight]. / Rola czynników srodowiskowych w rozwoju cukrzycy typu 1 -- nowe spojrzenie.

According to the traditional model of pathogenesis of type 1 diabetes - it develops in genetically susceptible individuals in whom environmental factors trigger an autoimmune process of beta-cell destruction. Although susceptibility may be inherited, there is a growing body of evidence showing the role of environmental factors that might not only trigger but also perpetuate the chronic autoimmune process. These factors may exert their action long before the disease manifests itself clinically, which significantly hampers their identification. Three groups of environmental factors that were most widely studied include of viral infections, feeding patterns in infancy and toxic compounds (especially nitrites). Other factors possibly playing a role in modifying the development of the disease are vaccinations, psychological stress and climatological factors. The authors summarize the data supporting the role of environmental factors in the development of the disease and show a more recent model of type 1 diabetes pathogenesis. It may partly explain why the disease incidence increased has so much in the last three decades despite markedly improved hygiene and health care standards.

Autoantibodies against N-homocysteinylated proteins in patients on long-term haemodialysis.

BACKGROUND: Autoantibodies against N(epsilon)-homocysteinylated (N(epsilon)-Hcy) proteins at high titres have been demonstrated in patients with premature coronary artery disease (CAD) and stroke. Since recently, elevated N(epsilon)-Hcy-proteins levels have been reported in haemodialysis patients, we sought to investigate whether anti-N(epsilon)-Hcy-protein antibodies occur in such subjects and if they are associated with cardiovascular risk. METHODS: We studied 43 patients, aged 27-89 (mean 58.8) years, dialysed for, on average, 50 months and 31 age- and sex-matched healthy controls. IgG antibodies against N(epsilon)-Hcy-albumin and -haemoglobin were determined using an in-house enzyme-linked immunosorbent assay. RESULTS: Haemodialysis patients had higher plasma tHcy (23.18 +/- 1.37 vs 13.51 +/- 0.64; P < 0.0001), serum folate (29.7 +/- 6.9 vs 9.9 +/- 3.8 nmol/l; P < 0.0001) and anti-N(epsilon)-Hcy-albumin and -haemoglobin antibodies (absorbancy at 490 nm: 0.39 +/- 0.22 vs 0.34 +/- 0.12; P = 0.03 and 0.60 +/- 0.31 vs 0.42 +/- 0.09; P < 0.0001, respectively) than controls. Levels of anti-N(epsilon)-Hcy-albumin antibodies, but not those against haemoglobin, correlated negatively with the duration of haemodialysis (r = -0.39; P = 0.01). This correlation disappeared after a 6-month follow-up. Haemodialysis patients treated with folic acid on a long-term basis had similar levels of anti-N(epsilon)-Hcy-albumin and -haemoglobin antibodies compared with the minority which denied taking this vitamin (absorbancy A490: 0.35 +/- 0.22 vs 0.38 +/- 0.05; P = 0.5 and 0.63 +/- 0.30 vs 0.51 +/- 0.11; P = 0.4, respectively). CONCLUSIONS: Our study shows that an autoimmune response to anti-N(epsilon)-Hcy-proteins occurs in patients on maintenance haemodialysis and is more pronounced than in healthy subjects.

[Higher incidence of type 1 diabetes in males--a study in teenagers and young adults in Krakow region in 1987-1999]. / Wieksza zapadalnosc na cukrzyce typu 1 u plci meskiej--badania u nastolatków i mlodych doroslych w Krakowie i okolicy w latach 1987-1999.

Numerous reports of increasing incidence of type 1 diabetes worldwide, and similar tendency in children population in Poland prompted the study aiming at evaluating the incidence of type 1 diabetes in a population aged 15-29 years in Krakow area (voivodeship) in 1987-1999. The type 1 diabetes registry established in Chair and Department of Endocrinology CMUJ in 1986 was continued. To improve ascertainment two independent data sources were used: hospital departments and outpatient diabetic clinics. Definite inclusion criteria were assigned and data verified. Incidence rates and trends of incidence were calculated for gender and age groups, differences between the groups were analyzed. Incidence rates were standardized for the European population. The seasonality of disease occurrence was calculated. Registry ascertainment was assessed using "capture-recapture" method. Incidence of type 1 diabetes showed a significant increase in the whole group (0.32 new cases/100,000/year), mainly due to marked incidence increase observed in males (0.53). The oldest age group (25-29 years) showed the most rapid increase in diabetes type 1 incidence (1.07). Seasonality of disease occurrence was found in females. Mean ascertainment was 81%, with the lowest values in 1996-1999. The results obtained indicate that the increase of type 1 diabetes incidence in the age group 15-29 years in Krakow region was due to rapidly increasing incidence in males, especially those aged 25-29 years. Lack of disease occurrence seasonality in this group may indicate a role of other factors (associated with lifestyle or hormonal) responsible for such marked increase in young males, not seen in females. The study was terminated in 1999 due to new administrative division of the country and problems with data collection from the area of non-longer existing Krakow voivodeship.

Screening for acute myocarditis--is scintigraphy with (99m)Tc-Anti-Granulocyte BW 250/183 an answer?

BACKGROUND: Myocarditis is most often caused by Coxackie B virus, influenza viruses, and echoviruses. It is usually self-restricting and ending in full recovery, but in some patients the infection leads to congestive cardiomyopathy. It is difficult to identify patients with myocarditis using clinical criteria, laboratory tests, ECG and ultrasonography, and currently a myocardial biopsy is required to establish the diagnosis. The risk of complications, sampling error and costs of this procedure underline the need of non-invasive but sensitive methods of imaging. Several radiopharmaceuticals have been used so far to confirm inflammation: 67Ga, (99m)Tc-nanocolloids and 111In-leucocytes. Scintigraphy with radiolabeled autologous white blood cells (WBCs) is considered a very useful method in identifying sources of inflammation but is difficult to perform and time-consuming. AIMS: The aim of our study was to investigate whether scintigraphy with (99m)Tc-Anti-Granulocyte BW 250/183 antibody is a valuable diagnostic method in evaluating focal and diffuse inflammation of the heart and could therefore be suggested for use in screening for acute myocarditis. MATERIAL AND METHODS: A two dimensional scintigraphy and SPECT mode of heart imaging with the use of (99m)Tc-Anti-Granulocyte antibody (740 MBq) was performed on 14 subjects (11 males and 3 females) aged 25-60 years with a positive myocardial biopsy confirming an inflammatory process in the myocardium. After i.v. administration of the tracer a 1 minute series of planar scans was performed within the first 60 minutes. Delayed static scans were performed at 1, 2, 4 and 24 hours. RESULTS: The scintigraphic scans revealed the uptake of the tracer in the heart area in 13 patients, confirming active inflammatory process. Follow-up scintigraphy was performed 3-5 months after the first study, when the control myocardial biopsy was negative. The results of the study showed the concordance between myocardial biopsy and scintigraphy results in patients with an inflammatory process in the heart. CONCLUSIONS: Scintigraphy with the use of (99m)Tc-Anti-Granulocyte seems to be a useful diagnostic method in evaluating patients with suspected myocarditis, but further studies are needed to establish its sensitivity and specificity.