[Obesity and Eating Disorders. Indications for the different levels of care. An Italian Expert Consensus Document]. / Documento di Consensus. Obesità e Disturbi dell'Alimentazione Indicazioni per i diversi livelli di trattamento.

This paper is an Italian Expert Consensus Document on multidimensional treatment of obesity and eating disorders. The Document is based on a wide survey of expert opinion. It presents, in particular, considerations regarding how clinicians go about choosing the most appropriate site of treatment for a given patient suffering from obesity and/or eating disorders: outpatient, partial hospitalization, residential rehabilitation centre, inpatient hospitalization. In a majority of instances obesity and eating disorders are long-term diseases and require a multiprofessional team-approach. In determining an initial level of care or a change to a different level of care, it is essential to consider together the overall physical condition, medical complications, disabilities, psychiatric comorbidity, psychology, behaviour, family, social resources, environment, and available services. We first created a review manuscript, a skeleton algorithm and two rating scales, based on the published guidelines and the existing research literature. As the second point we highlighted a number of clinical questions that had to be addressed in the specific context of our National Health Service and available specialized care units. Then we submitted eleven progressive revisions of the Document to the experts up to the final synthesis that was approved by the group. Of course, from point to point, some of the individual experts would differ with the consensus view. The document can be viewed as an expert consultation and the clinical judgement must always be tailored to the particular needs of each clinical situation. We will continue to revise the Document periodically based on new research information and on reassessment of expert opinion to keep it up-to-date. The Document was not financially sponsored.

Relational competence and eating disorders.

Eating Disorders are very widespread within the adolescent population. A possible interpretation and the comprehension of such forms of psychopathology may revolve around the failure to develop a well-defined personal identity, an incapacity to achieve a sense of differentiation with respect to others, an incapacity to measure oneself against others, dependence on others, the fear of rejection and a sense of inadequacy. This study explores the relational styles and behaviour of individuals suffering from eating disorders and their influence on the development of the personality, with reference being made in particular to self-valuation, dependence on others and levels of differentiation. A sample population of 90 women with eating disorders was studied. The subjects were subdivided into 3 groups (30 with restricting anorexia nervosa, 30 with binge-eating/purging anorexia nervosa and 30 with bulimia nervosa), overlapping in terms of age, duration of disorders and interrelation style, using the Relational Competence Test. The most significant results of this study concern the question of the definition of an autonomous personal identity. This process seems to be in progress in young women suffering from bulimia nervosa who appear to be driven towards a "definition of the self in opposition" with the consequent tendency towards relational experiences outside their own family. In women with binge-eating/purging AN moreover an awareness of the difference between the self and others and of their state of dependence would appear to be present, however behaviour aimed at the determination of an autonomous self is not evident. In women with restricting anorexia nervosa a definition of the identity is totally absent; these women develop an omnipotent self in their 'oneness' with others. These relational aspects lead to the identification of a continuum between restricting anorexia nervosa, binge-eating/purging anorexia nervosa and bulimia nervosa in an evolutionary perspective regarding the self-with-others.

Family functioning in adolescent anorexia nervosa: a comparison of family members' perceptions.

Abnormal patterns of family functioning have often been reported in anorexia nervosa. Moreover, members of families with an adult with eating disorders have different family functioning perspectives. This study investigated whether differences in family members' perspectives, similar to the ones found in families of adults with eating disorders, can be found in families of adolescents with anorexia nervosa. Perceived family functioning, measured with the Family Assessment Device, was compared between 49 control and 34 clinical families, and across family members. Differences were found between the two groups on a number of aspects of family functioning, with the clinical families showing most disturbances. There was a general agreement across family members in their perceptions of family functioning, with one notable exception. Clinical daughters disagreed with both their parents about the family level of communication, whereas control daughters disagreed only with their fathers. Disagreements between clinical adolescents and their mothers about the family communication style appear to be important in anorexia nervosa in this age group, although it is not possible to reach conclusions about the direction of causality. These findings support the use of family-oriented therapies that aim to identify and work with difficulties in communication within the family.

One-year weight follow-up in anorexia nervosa after inpatient psycho-nutritional rehabilitative treatment.

Many inpatient treatments have been proposed for anorexia nervosa (AN) in the past, but few weight outcomes are available today. The criteria for outcome evaluation have always considered body weight. The fifty-three women with AN [26 restrictive (ANR) and 27 bulimic (ANB), studied in this paper were all those discharged in 1996 after an inpatient psycho-nutritional rehabilitation programme. Body weight and BMI were significantly increased between admission and discharge and this increase was maintained at the one-year follow-up. Mean weight in ANR and ANB were similar both at admission and on discharge, but showed significant differences at the follow-up. Follow-up weight was stable (+/- 5%) in 31%, decreased in 15% and increased in 54% of ANR, compared with 44%, 33% and 23% respectively in ANB. There were no differences in age and illness duration. It is very difficult to study presence or absence of menses because many patients were on estro-progestins. Furthermore, only 28% of patients with menses presented BMI higher than 17.5. Only the ANR group showed a significant weight increase at the follow-up. Their BMI was acceptable in 65% compared with 33% in the ANB group. Bulimic behaviour seems to be itself a negative prognostic factor for weight recovery.

Adipose tissue cellularity and weight reduction forecastin.

Seventy-six obese female outpatients underwent controlled 1000 kcal diets (50% carbohydrate, 25% fat, 25% protein). Prior-to-treatment data underwent "step-wise" multiple regression analysis to investigate the possibility of predicting body weight after 6 months of treatment (y), Body weight can be forecast using a linear regression function. This function, based on initial weight (x1) and adipose cell weight (x2), uses the equation y = 9.75 + 0.87x1 - 8.41x2 (F = 696.53; P less than 0.001; R2 = 0.95). Afterwards, patients were subdivided into three groups according to the difference between 6th and 12th month body weights: weight loss, weight stable, and weight increase groups. Weight gaining patients showed a significantly higher mean fat cell number, weight lossers had a higher mean adipose cell weight than the other two groups.

Glucose tolerance and blood lipids in bran-fed patients with impaired glucose tolerance.

Thirty-eight patients (13 men and 25 women) with impaired glucose tolerance, aged 33--70 yr, underwent a dietary program adding 20 g of raw bran to their usual diet without changing their dietary habits. After 1 mo of treatment, the areas under the curves for glucose and insulin were reduced from 26,214 +/- 5618 to 24,529 +/- 5207 g/min (P < 0.001) and from 15,893 +/- 9714 to 12,440 +/- 7377 mU/min (P < 0.001), respectively, cholesterol was reduced from 234 +/- 40 to 212 +/- 29 mg/dl (P < 0.001), and triglycerides were reduced from 108 +/- 56 to 97 +/- 50 mg/dl (P < 0.05). Body weight (initially 128.44% relative body weight) decrease 0.8% (P < 0.02). After the first month, 14 subjects were studied for a further 2 mo. Six patients continued bran feeding, and eight, who stopped bran, were used as controls. Patients who took bran maintained metabolic improvement over the 3-mo treatment period, while those who stopped bran did not.

[Carbohydrate metabolism in gross obesity]. / Il metabolismo glicidico nella grande obesità.

Results obtained in an investigation of two groups of obese and grossly obese subjects are presented. Poorer carbohydrate tolerance was noted in the latter. Blood insulin patterns after oral glucose loading, however, were less easy to interpret. Overall, the values were much the same in the two groups. Nevertheless, analysis of the curves showed that the grossly obese displayed a later peak.

[Behavior of adipose tissue cellularity in gross obesity]. / Comportamento della cellularità adiposa nella grande obesità.

Adipose tissue cellularity was studied in relation to the degree of obesity. It was found that mild obesity is essentially linked to a simple increase in adipocyte size, whereas gross obesity involves considerable hyperplasia of adipose tissue with at least twice the normal number of adipocytes. Prognostic and therapeutic conclusions are drawn from these personal data.

Glucose tolerance in jejunoileal bypass for morbid obesity: a fifteen month follow-up.

Twelve patients with body weight varying from 106 to 163 Kg, underwent jejunoileal bypass operations; their oral glucose tolerance tests (oGTT) were evaluated before the operation and one, five, and fifteen months afterwards. The lowering of the glycemic curve and the decrease of the insulinemia values during oGTT have been studied in relation to intestinal absorption deficit and weight loss. It is concluded that weight loss was the main factor determining the improvement of glucose metabolism.

[Physiopathological correlations between carbohydrate and lipid metabolicm and obesity]. / Contributo allo studio delle correlazioni fisiopatologiche tra metabolismo glucidico e lipidico nell'obesità.

Sugar and fat metabolism were studied in a group of obese women without diabetes. Blood triglicerides and cholesterol were, on average, within normal limits, though endogenous hypertriglyceridaemia was noted in a few cases. Triglycerides were significantly related to blood sugar (baseline and after glucose loading), whereas there was no significant connection with blood insulin. The meaning of these results is discussed.