Obesity as a chronic disease: current approach

En 1926 Don Gregorio Marañón publicaba en su libro Gordos y flacos la siguiente reflexión: “la palabra gordo resume multitud de conceptos de herencia, de costumbres, de carácter, de modalidades de la sensibilidad y de la inteligencia”1. Años antes, en 1760, el fisiólogo Malcom Flemyng había escrito: “no todas las personas corpulentas son grandes comedoras, ni todas las delgadas comen poco. Con frecuencia es al contrario. Un voraz apetito es causa de corpulencia, no como única causa y no es condición sine qua non de llegar a serlo”2. Siguiendo esta línea de pensamiento, que reconoce la multiplicidad de factores responsables de la obesidad, no cabe mantener una visión simplista entendiéndola como resultado de la glotonería y la falta de voluntad, ya que esta forma de percibirla, supone una barrera importante para su tratamiento. La obesidad debe ser entendida como una enfermedad crónica, igual que la diabetes o la hipertensión; es más, una enfermedad responsable de muchas otras enfermedades, pues es difícil encontrar una patología que no sea más prevalente en el paciente obeso, ni una patología cuya condición no empeore con la aparición de una obesidad3. De hecho, en 2013 la American Medical Association (AMA), reconoció la obesidad como una enfermedad4. La AMA defendió su acción como una forma de legitimar la obesidad, mejorar su tratamiento y facilitar su cobertura sanitaria. Con esta visión de la enfermedad, se revisa el concepto y clasificación de la obesidad, su epidemiología, sus causas y consecuencias y, finalmente, las posibilidades de tratamiento.In 1926, Gregorio Marañón published in his book “Gordos y Flacos” the following reflection: “the word fatso summarizes many concepts of inheritance, customs, character, modalities of sensitivity and intelligence”1. Many years ago, in 1760, the physiologist Malcolm Flemyng had written: “Not that all corpulent persons are great eaters; or all thin persons spare feeders. We daily see instances of the contrary. Tho’ a voracious appetite be one cause of Corpulency, it is not the only cause; and very often not even the conditio sine qua non thereof”2. Following this way of thinking, which recognizes the multiplicity of factors responsible for obesity, it is not possible to maintain a simplistic vision, understanding it as a result of gluttony and lack of will, since this way of perceiving it represents an important barrier to its treatment. Obesity should be understood as a chronic disease, just like diabetes or hypertension; furthermore, a disease responsible for many other diseases, because it is difficult to find a pathology that is not more prevalent in the obese patient, nor a pathology whose condition does not get worse with the appearance of obesity3. In fact, in 2013 the American Medical Association (AMA) recognized obesity as a disease4. The AMA defended its action as a way to legitimize obesity, improve its treatment and facilitate its health coverage. With this approach as a disease, we review the concept and classification of obesity, its epidemiology, its causes and consequences and, finally, the possibilities of treatment

Characteristics of patients with type 2 diabetes mellitus newly treated with GLP-1 receptor agonists (CHADIG Study): a cross-sectional multicentre study in Spain

Objective: Several glucagon-like peptide-1 (GLP-1) receptor agonists (GLP-1Ra) have been made recently available in Spain for type 2 diabetes mellitus (DM2) treatment. There are no published data on the clinical and sociodemographic profile of patients initiating treatment with GLP-1Ra in Spain. Our objective was to understand these patients' characteristics in a real-world clinical practice setting. Design: Cross-sectional observational study. Setting: Spanish specialist outpatient clinics. Participants: 403 adults with DM2 initiating GLP-1Ra treatment were included. Primary and secondary outcome measures: Sociodemographic and DM2-related clinical data, including treatment at and after GLP-1Ra initiation and comorbidities, were collected. Results: Evaluable patients (n=403; 50.9% female) were included ( July 2013 to March 2014) at 24 centres by 53 specialists (47 endocrinology, 6 internal medicine), with the following profile (value±SD): age (58.3±10.4 years), diabetes duration (9.9±7 years), body mass index (BMI; 36.2±5.5) and glycated haemoglobin (HbA1c; 8.4±1.4%); 14% had HbA1c≤7%. Previous antidiabetic treatment: 53.8% only oral antidiabetic drugs (OADs), 5.2% insulin and 40% insulin and OAD; of those receiving OAD, 35% single drug, 38.2% 2 drugs and 24% 3 drugs. Concomitant to GLP-1Ra, 55.3% were only on OAD, 36.2% on insulin and OAD, and 7.2% only on insulin. Of those receiving OAD, the GLP-1Ra was mainly associated with 1 drug (65%) or 2 drugs (31.8%). GLP-1Ra are frequently added to existing antidiabetic drugs, with dipeptidyl peptidase-4 inhibitors being the OAD most frequently switched (45% receiving 1 before starting GLP-1Ra, only 2.7% receiving it concomitantly). Conclusions: In Spain, GLP-1Ra therapy is usually started in combination with OADs or OADs and insulin. These drugs are used in relatively young patients often not reaching therapeutic goals with other treatment combinations, roughly a decade after diagnosis and with a relatively high BMI. The latter could be explaine

Bariatric surgery: evidence-based practical recommendations

[Resumen] La obesidad mórbida es, habitualmente, refractaria a los tratamientos convencionales, por lo que la modificación de hábitos dietéticos y de actividad física y/o el uso de fármacos consiguen pérdidas de peso parciales con habitual recuperación posterior. La cirugía bariátrica constituye una opción terapéutica para los casos de obesidad con elevado índice de masa corporal (IMC) asociada a comorbilidades, con buenos resultados a corto y largo plazo. El Grupo de Trabajo sobre Obesidad de la Sociedad Española de Endocrinología y Nutrición (GOSEEN) ha elaborado un documento con recomendaciones prácticas basadas en la evidencia para el tratamiento quirúrgico de la obesidad. La revisión se estructura en 3 partes. En la primera se definen los conceptos de obesidad y comorbilidades asociadas, los tratamientos médicos y sus resultados, las indicaciones y contraindicaciones para el tratamiento quirúrgico con los criterios de selección de los pacientes, el manejo pre y perioperatorio y la valoración de grupos especiales, como adolescentes y personas de edad avanzada. En la segunda parte se describen las distintas técnicas quirúrgicas, las vías de acceso y los resultados comparativos, las complicaciones tanto a corto como a largo plazo, la repercusión de la pérdida ponderal sobre las comorbilidades y los criterios para evaluar la efectividad de la cirugía. En la tercera parte se desarrolla el seguimiento postoperatorio, el control dietético en fases tempranas y más tardías tras la cirugía, y el calendario de control médico y analítico con la suplementación de los distintos macro y micronutrientes en función de la técnica quirúrgica empleada. Se incluye un apartado final sobre gestación y cirugía bariátrica, así como tablas y gráficos complementarios al texto desarrollado. La cirugía bariátrica sigue siendo un tratamiento discutido para la obesidad, pero los resultados en la corrección del exceso ponderal con mejoría en las patologías asociadas y en la calidad de vida confirman que puede ser el tratamiento de elección en pacientes seleccionados, con la técnica quirúrgica apropiada y con un correcto control pre y postoperatorio.[Abstract] Morbid obesity is usually refractory to conventional treatments. Consequently, weight that is lost by modifying diet and exercise and/or the use of drugs is usually later regained. Bariatric surgery constitutes a therapeutic option in obese patients with a high body mass index associated with comorbidities and achieves good results in both the short and the long term. The Obesity Working Group of the Spanish Society of Endocrinology and Nutrition has produced a document with practical, evidencebased recommendations for the surgical treatment of obesity. The review is structured in three parts. The first part defines the concepts of obesity and associated comorbidities, medical treatments, their results, and the indications and contraindications for surgical treatment, as well as the criteria for patient selection, pre- and perisurgical management, and assessment of special groups such as adolescents and the elderly. The second part discusses the different surgical techniques, approaches and comparative results, short- and long-term complications, the repercussions of weight loss on comorbidities, and the criteria for assessing the effectiveness of surgery. The third part discusses postsurgical follow-up, dietary control in the early and subsequent stages after surgery and the schedule for medical and laboratory follow-up, together with the different macro- and micronutrient supplements that should be used depending on the surgical technique employed. A final section is included on pregnancy and bariatric surgery, as well as tables and figures that complement the text. Although bariatric surgery continues to be a questionable treatment for obesity, the results correcting excess weight, with improvements in associated comorbidities and in quality of life, confirm that this option could be the treatment of choice in selected patients when the appropriate surgical technique and correct preand postoperative follow-up are employed