Diabetes and Obesity – a Vicious Circle

Posljednjih desetljeća svjedoci smo dramatičnog porasta broja oboljelih od šećerne bolesti na globalnoj razini. Ova pandemija uvjetovana je ponajprije rastućom prevalencijom tipa 2 šećerne bolesti. Činjenica da više od 80% oboljelih ima prekomjernu tjelesnu masu upućuje na čvrstu povezanost debljine i rizika obolijevanja od šećerne bolesti tipa 2. Na razvoj navedenih epidemioloških pokazatelja najviše utječe suvremeni način života karakteriziran prekomjernom konzumacijom rafinirane, industrijski prerađene hrane s velikim udjelom zasićenih masti i jednostavnih ugljikohidrata udružen s niskom razinom tjelesne aktivnosti. Osim ukupne količine masnog tkiva važna odrednica rizika od nastanka šećerne bolesti jest i raspodjela masnog tkiva. Utvrđeno je da upravo promjene u visceralnome masnom tkivu i disregulacija imunosnog odgovora imaju ključnu ulogu u pokretanju i održavanju začaranog kruga inzulinske rezistencije, kronične sistemske upale i endotelne disfunkcije kao temeljnih patofizioloških mehanizama u podlozi šećerne bolesti tipa 2, ali i drugih manifestacija metaboličkog sindroma poput dislipidemije, arterijske hipertenzije, nealkoholne masne bolesti jetre te, na kraju, kardiovaskularne bolesti. Suočavanje s rastućim problemom debljine i poduzimanje svih mjera usmjerenih k prevenciji i liječenju važno je ne samo s aspekta prevencije šećerne bolesti tipa 2 već i drugih pridruženih čimbenika kardiovaskularnog rizika. Trajna promjena načina života usmjerena prema uravnoteženoj prehrani i redovitoj tjelesnoj aktivnosti temelj je terapijskog pristupa osobama sa šećernom bolešću. Pri odabiru medikamentne terapije prednost treba dati lijekovima koji povrh učinka na regulaciju glikemije povoljno djeluju i na tjelesnu masu. Metabolička kirurgija sve se više prepoznaje kao učinkovita metoda liječenja pretilih osoba sa šećernom bolesti tipa 2.Over the last few decades, we have witnessed a dramatic increase in the number of diabetic patients worldwide. This pandemia is primarily due to increasing prevalence of type 2 diabetes. The fact that over 80% of the patients are overweight or obese indicates a strong association between the obesity and the risk of developing type 2 diabetes. These epidemiological indicators are mostly affected by the modern lifestyle characterized by over-consumption of refined, highly processed foods, rich in saturated fats and simple carbohydrates together with a low level of physical activity. In addition to total body fat, the distribution of adipose tissue between visceral and subcutaneous compartments is an important determinant of the risk of developing diabetes. It has been found that changes in visceral adipose tissue and immune response disregulation play a key role in initiating and maintaining a vicious cycle of insulin resistance, chronic systemic inflammation and endothelial dysfunction as the underlying pathophysiological mechanisms of type 2 diabetes, as well as other manifestations of metabolic syndrome such as dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and ultimately cardiovascular disease. Effective weight management is crucial in preventing the onset and progression of type 2 diabetes and associated cardiovascular risk factors. Lifestyle interventions aimed at improving dietary habits and increasing physical activity is a cornerstone of diabetes management. When prescribing antidiabetic medication therapy, preference should be given to those drugs that have a beneficial effect on body weight. Metabolic surgery has become a promising new option for the treatment of obese patients with type 2 diabetes

Diabetes and Obesity – a Vicious Circle

Posljednjih desetljeća svjedoci smo dramatičnog porasta broja oboljelih od šećerne bolesti na globalnoj razini. Ova pandemija uvjetovana je ponajprije rastućom prevalencijom tipa 2 šećerne bolesti. Činjenica da više od 80% oboljelih ima prekomjernu tjelesnu masu upućuje na čvrstu povezanost debljine i rizika obolijevanja od šećerne bolesti tipa 2. Na razvoj navedenih epidemioloških pokazatelja najviše utječe suvremeni način života karakteriziran prekomjernom konzumacijom rafinirane, industrijski prerađene hrane s velikim udjelom zasićenih masti i jednostavnih ugljikohidrata udružen s niskom razinom tjelesne aktivnosti. Osim ukupne količine masnog tkiva važna odrednica rizika od nastanka šećerne bolesti jest i raspodjela masnog tkiva. Utvrđeno je da upravo promjene u visceralnome masnom tkivu i disregulacija imunosnog odgovora imaju ključnu ulogu u pokretanju i održavanju začaranog kruga inzulinske rezistencije, kronične sistemske upale i endotelne disfunkcije kao temeljnih patofizioloških mehanizama u podlozi šećerne bolesti tipa 2, ali i drugih manifestacija metaboličkog sindroma poput dislipidemije, arterijske hipertenzije, nealkoholne masne bolesti jetre te, na kraju, kardiovaskularne bolesti. Suočavanje s rastućim problemom debljine i poduzimanje svih mjera usmjerenih k prevenciji i liječenju važno je ne samo s aspekta prevencije šećerne bolesti tipa 2 već i drugih pridruženih čimbenika kardiovaskularnog rizika. Trajna promjena načina života usmjerena prema uravnoteženoj prehrani i redovitoj tjelesnoj aktivnosti temelj je terapijskog pristupa osobama sa šećernom bolešću. Pri odabiru medikamentne terapije prednost treba dati lijekovima koji povrh učinka na regulaciju glikemije povoljno djeluju i na tjelesnu masu. Metabolička kirurgija sve se više prepoznaje kao učinkovita metoda liječenja pretilih osoba sa šećernom bolesti tipa 2.Over the last few decades, we have witnessed a dramatic increase in the number of diabetic patients worldwide. This pandemia is primarily due to increasing prevalence of type 2 diabetes. The fact that over 80% of the patients are overweight or obese indicates a strong association between the obesity and the risk of developing type 2 diabetes. These epidemiological indicators are mostly affected by the modern lifestyle characterized by over-consumption of refined, highly processed foods, rich in saturated fats and simple carbohydrates together with a low level of physical activity. In addition to total body fat, the distribution of adipose tissue between visceral and subcutaneous compartments is an important determinant of the risk of developing diabetes. It has been found that changes in visceral adipose tissue and immune response disregulation play a key role in initiating and maintaining a vicious cycle of insulin resistance, chronic systemic inflammation and endothelial dysfunction as the underlying pathophysiological mechanisms of type 2 diabetes, as well as other manifestations of metabolic syndrome such as dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and ultimately cardiovascular disease. Effective weight management is crucial in preventing the onset and progression of type 2 diabetes and associated cardiovascular risk factors. Lifestyle interventions aimed at improving dietary habits and increasing physical activity is a cornerstone of diabetes management. When prescribing antidiabetic medication therapy, preference should be given to those drugs that have a beneficial effect on body weight. Metabolic surgery has become a promising new option for the treatment of obese patients with type 2 diabetes

Diabetes and Obesity – a Vicious Circle

Posljednjih desetljeća svjedoci smo dramatičnog porasta broja oboljelih od šećerne bolesti na globalnoj razini. Ova pandemija uvjetovana je ponajprije rastućom prevalencijom tipa 2 šećerne bolesti. Činjenica da više od 80% oboljelih ima prekomjernu tjelesnu masu upućuje na čvrstu povezanost debljine i rizika obolijevanja od šećerne bolesti tipa 2. Na razvoj navedenih epidemioloških pokazatelja najviše utječe suvremeni način života karakteriziran prekomjernom konzumacijom rafinirane, industrijski prerađene hrane s velikim udjelom zasićenih masti i jednostavnih ugljikohidrata udružen s niskom razinom tjelesne aktivnosti. Osim ukupne količine masnog tkiva važna odrednica rizika od nastanka šećerne bolesti jest i raspodjela masnog tkiva. Utvrđeno je da upravo promjene u visceralnome masnom tkivu i disregulacija imunosnog odgovora imaju ključnu ulogu u pokretanju i održavanju začaranog kruga inzulinske rezistencije, kronične sistemske upale i endotelne disfunkcije kao temeljnih patofizioloških mehanizama u podlozi šećerne bolesti tipa 2, ali i drugih manifestacija metaboličkog sindroma poput dislipidemije, arterijske hipertenzije, nealkoholne masne bolesti jetre te, na kraju, kardiovaskularne bolesti. Suočavanje s rastućim problemom debljine i poduzimanje svih mjera usmjerenih k prevenciji i liječenju važno je ne samo s aspekta prevencije šećerne bolesti tipa 2 već i drugih pridruženih čimbenika kardiovaskularnog rizika. Trajna promjena načina života usmjerena prema uravnoteženoj prehrani i redovitoj tjelesnoj aktivnosti temelj je terapijskog pristupa osobama sa šećernom bolešću. Pri odabiru medikamentne terapije prednost treba dati lijekovima koji povrh učinka na regulaciju glikemije povoljno djeluju i na tjelesnu masu. Metabolička kirurgija sve se više prepoznaje kao učinkovita metoda liječenja pretilih osoba sa šećernom bolesti tipa 2.Over the last few decades, we have witnessed a dramatic increase in the number of diabetic patients worldwide. This pandemia is primarily due to increasing prevalence of type 2 diabetes. The fact that over 80% of the patients are overweight or obese indicates a strong association between the obesity and the risk of developing type 2 diabetes. These epidemiological indicators are mostly affected by the modern lifestyle characterized by over-consumption of refined, highly processed foods, rich in saturated fats and simple carbohydrates together with a low level of physical activity. In addition to total body fat, the distribution of adipose tissue between visceral and subcutaneous compartments is an important determinant of the risk of developing diabetes. It has been found that changes in visceral adipose tissue and immune response disregulation play a key role in initiating and maintaining a vicious cycle of insulin resistance, chronic systemic inflammation and endothelial dysfunction as the underlying pathophysiological mechanisms of type 2 diabetes, as well as other manifestations of metabolic syndrome such as dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and ultimately cardiovascular disease. Effective weight management is crucial in preventing the onset and progression of type 2 diabetes and associated cardiovascular risk factors. Lifestyle interventions aimed at improving dietary habits and increasing physical activity is a cornerstone of diabetes management. When prescribing antidiabetic medication therapy, preference should be given to those drugs that have a beneficial effect on body weight. Metabolic surgery has become a promising new option for the treatment of obese patients with type 2 diabetes

ENDOCRINE ASPECTS OF POLYCYSTIC OVARY SYNDROME

Sindrom policističnih jajnika, najčešći endokrinološki poremećaj u žena generativne dobi, rezultat je interakcije genetičkih svojstava jajnika i brojnih kongenitalnih i okolišnih faktora. Najvažniji postnatalni rizični čimbenik jest debljina, no osnovni je poremećaj u intraovarijskoj regulaciji steroidogeneze, obično udružen sa selektivnom inzulinskom rezistencijom. Kliničke su karakteristike sindroma oligo-amenoreja i menstrualna disfunkcija, povezane s neplodnošću, hiperandrogenizam te često prisutni udruženi rizični čimbenici za kardiovaskularne bolesti i šećernu bolest tipa 2, uključujući pretilost, hiperinzulinemiju, intoleranciju glukoze i dislipidemiju. Vrlo je bitno identificirati i redovito pratiti značajke metaboličkog sindroma te rizik od razvoja komplikacija. Prva terapijska opcija kod većine žena jest redukcija tjelesne težine koja je često dovoljna za uspostavu ovulatornih ciklusa uz povoljan utjecaj na metaboličke rizike, no katkad su potrebni i oralni kontraceptivi i antiandrogeni. U pacijentica s izraženom inzulinskom rezistencijom lijekovi koji povećavaju osjetljivost na inzulin poput metformina i tiazolidindiona važna su terapijska opcija.Polycystic ovary syndrome, the most common endocrine disorder among women of reproductive age, is a result of interaction between ovarian genetic traits and many congenital and environmental factors. The most common postnatal contributor is obesity, but the fundamental disorder is in the intraovarian regulation of steroidogenesis, often accompanied by selective insulin resistance. The syndrome is clinically characterized by oligo-amenorrhea, menstrual dysfunction, infertility, hyperandrogenism, as well as the frequent presence of associated risk factors for cardiovascular disease and diabetes, including obesity, glucose intolerance and dyslipidemia. It is very important to identify and monitor the main features of metabolic syndrome and the risk for complications. Weight loss can restore ovulatory cycles and improve metabolic risk, so it is the first-line intervention for most women, but sometimes oral contraceptives and antiandrogens have to be added. In patients with insulin resistance and associated hyperinsulinemia insulin-sensitizing agents like metformin and thiazolidinediones have important role in its treatment

„Olujni” ikterus – neobična klinička prezentacija tireotoksične krize

Aim: The aim was to present jaundice as the first and most remarkable presenting symptom of this extraordinary thyrotoxic crisis (TTC) case. Due to an unusual clinical presentation this case was a diagnostic dilemma and therapeutic challenge. Case report: A 34-year-old male was admitted to the Emergency Department due to fatigue, diarrhea, jaundice and subjective feeling of increased heart rate. Patient had previous history of hyperthyroidism and paroxysmal atrial fibrillation (AF), but he wasn't taking any medication. ECG revealed AF with rapid ventricular response and left ventricular hypertrophy. Laboratory findings spoke in favor of hepatocellular jaundice. Consequently, the patient was hospitalized at the Department of Gastroenterology. Subsequently arrived thyroid function test confirmed the presence of thyrotoxicosis. Thiamazole, bisoprolol, methylprednisolone, enoxaparin and metildigoxin were introduced into therapy. In further course of hospitalization patient was transferred to the Department of Cardiovascular Diseases due to development of global heart failure. The heart failure therapy was introduced. Significant clinical improvement was achieved and the patient was transferred to the Department of Endocrinology. The parameters of the liver function were improving. Doses of thiamazole were gradually decreasing during hospitalization and thyroid hormones were brought to normal values. Conclusions: TTC is extremely rare in clinical practice, but may occur in cases of unrecognized or inadequately treated hyperthyroidism. If left untreated, results with lethal outcome in 80-90% of the cases, but even if treated mortality rate exceeds 20%. Therefore, early recognition and treatment are of the utmost importance.Cilj: Prikazati nesvakidašnji slučaj tireotoksične krize (TTK) čiji je prvi i najupečatljiviji klinički simptom bio ikterus. Zbog neobične kliničke prezentacije ovaj je slučaj bio dijagnostički i terapijski izazov. Prikaz slučaja: 34-godišnji bolesnik primljen je zbog malaksalosti, dijareje, ikterusa i osjećaja ubrzanog rada srca. Bolesnik od ranije boluje od hipertireoze i paroksizmalne fibrilacije atrija (FA), no kroničnu terapiju ne uzima. Snimljen je EKG i utvrđena je FA s brzim odgovorom klijetki te hipertrofija lijeve klijetke. U laboratorijskim nalazima bio je prisutan obrazac hepatocelularnog ikterusa. Posljedično se bolesnika hospitalizira na Zavodu za gastroenterologiju. Novopridošli nalaz hormona štitnjače potvrdio je tireotoksikozu. U terapiju se uvode tiamazol, bisoprolol, metilprednizolon, enoksaparin te metildigoksin. Uslijed pogoršanja općeg stanja i razvoja globalnog srčanog zatajivanja (SZ) bolesnika se premješta na Zavod za kardiovaskularne bolesti. Primjenom standardne terapije SZ postignuto je značajno kliničko poboljšanje. Bolesnika se premješta na Zavod za endokrinologiju u svrhu nastavka liječenja. Parametri jetrene funkcije su u poboljšanju. Doza tireostatika postepeno se smanjuje, a vrijednosti hormona štitnjače dovedene su u normalu. Zaključci: TTK izuzetno je rijetka u kliničkoj praksi, no može se javiti u slučaju neprepoznate ili neadekvatno medikamentozno liječene hipertireoze. Ako se ne liječi, TTK rezultira smrtnim ishodom u 80-90% slučajeva. Kada se i liječi smrtnost svejedno prelazi 20%. Pravovremeno prepoznavanje i liječenje od neizmjerne je važnosti

Update on treatment of gestational diabetes

Gestacijski dijabetes (GDM) najčešći je metabolički poremećaj u trudnica povezan s neželjenim ishodima trudnoće i dugoročnim zdravstvenim rizicima za majke i njihovo potomstvo. Prevalencija GDM-a u svijetu raste zbog epidemije debljine, sve starije dobi trudnica i strožih dijagnostičkih kriterija. Promjena životnog stila temeljena na uravnoteženoj prehrani i prirast tjelesne mase unutar poželjnih okvira imaju vodeću ulogu u liječenju GDM-a. Ako glikemijske ciljeve nije moguće ostvariti samo dijetom, indicirana je terapija inzulinom s obzirom na to da za oralne antihiperglikemike još nema dovoljno podataka o dugoročnoj sigurnosti. Budući da žene s GDM-om imaju doživotni rizik za razvoj šećerne bolesti tipa 2, potrebno je redovito praćenje i probir na šećernu bolest 4 do 12 tjedana nakon poroda te potom svake 1 do 3 godine. Cilj ovog članka je prikazati novosti u liječenju gestacijskog dijabetesa.Gestational diabetes (GDM) is the most common metabolic disorder in pregnant women associated with adverse pregnancy outcomes and long-term maternal and offspring health risks. Worldwide GDM prevalence is increasing in the setting of the obesity epidemic, advanced maternal age, and tighter diagnostic criteria. Lifestyle interventions that promote healthy eating behaviours and healthy weight gain play a key role in the management of GDM. If glycemic targets are not achieved with diet alone, insulin therapy is recommended since oral antihyperglycemic agents lack long-term safety data. Because GDM is associated with an increased lifetime maternal risk for type 2 diabetes women should be followed up regularly and screened for diabetes 4- to 12-weeks postpartum and every 1–3 years thereafter. The aim of this article is to present an update on treatment of gestational diabetes

ENDOCRINE ASPECTS OF POLYCYSTIC OVARY SYNDROME

Sindrom policističnih jajnika, najčešći endokrinološki poremećaj u žena generativne dobi, rezultat je interakcije genetičkih svojstava jajnika i brojnih kongenitalnih i okolišnih faktora. Najvažniji postnatalni rizični čimbenik jest debljina, no osnovni je poremećaj u intraovarijskoj regulaciji steroidogeneze, obično udružen sa selektivnom inzulinskom rezistencijom. Kliničke su karakteristike sindroma oligo-amenoreja i menstrualna disfunkcija, povezane s neplodnošću, hiperandrogenizam te često prisutni udruženi rizični čimbenici za kardiovaskularne bolesti i šećernu bolest tipa 2, uključujući pretilost, hiperinzulinemiju, intoleranciju glukoze i dislipidemiju. Vrlo je bitno identificirati i redovito pratiti značajke metaboličkog sindroma te rizik od razvoja komplikacija. Prva terapijska opcija kod većine žena jest redukcija tjelesne težine koja je često dovoljna za uspostavu ovulatornih ciklusa uz povoljan utjecaj na metaboličke rizike, no katkad su potrebni i oralni kontraceptivi i antiandrogeni. U pacijentica s izraženom inzulinskom rezistencijom lijekovi koji povećavaju osjetljivost na inzulin poput metformina i tiazolidindiona važna su terapijska opcija.Polycystic ovary syndrome, the most common endocrine disorder among women of reproductive age, is a result of interaction between ovarian genetic traits and many congenital and environmental factors. The most common postnatal contributor is obesity, but the fundamental disorder is in the intraovarian regulation of steroidogenesis, often accompanied by selective insulin resistance. The syndrome is clinically characterized by oligo-amenorrhea, menstrual dysfunction, infertility, hyperandrogenism, as well as the frequent presence of associated risk factors for cardiovascular disease and diabetes, including obesity, glucose intolerance and dyslipidemia. It is very important to identify and monitor the main features of metabolic syndrome and the risk for complications. Weight loss can restore ovulatory cycles and improve metabolic risk, so it is the first-line intervention for most women, but sometimes oral contraceptives and antiandrogens have to be added. In patients with insulin resistance and associated hyperinsulinemia insulin-sensitizing agents like metformin and thiazolidinediones have important role in its treatment

Croatian Experience with Sibutramine in the Treatment of Obesity – Multicenter Prospective Study

Obesity is a chronic disease with a marked impact on health and the prevalence of obesity in Croatia is rapidly rising. Since obesity plays a significant role in the etiology of cardiovascular diseases, diabetes mellitus type 2 and of some cancers, it is an obvious target of public health activities. Weight-reducing drugs, like sibutramine, in combination with diet, exercise and behavioral changes have a role in the management of obesity. Sibutramine acts centrally as a serotonergic and noradrenergic reuptake inhibitor. It reduces body weight by enhancing satiety and stimulating thermogenesis. The aim of this multicenter prospective study was to evaluate the efficacy, tolerability and safety profile of sibutramine in the treatment of overweight patients in Croatia. Patients received 10 mg of sibutramine daily for 12 weeks. The main outcome measures were changes in body weight, BMI, waist and hip circumferences, laboratory assessments (serum triglicerida, cholesterol, glucose, HbA1c), blood pressure and heart rate profile. Of 461 patients included (mean BMI = 35.81+/-6.48 kg/m2, mean age = 43.65+/-10.90 years), 392 completed the study. Three months of sibutramine treatment lead to a significant reduction in body weight, BMI, waist and hip circumferences and improvement in metabolic parameters. Loss of over 5% of their initial body weight was found in 359 patients (91.58%), while 179 patients (45.66%) achieved weight loss over 10%. A decrease of both systolic (–3.39%) and diastolic (–3.75%) blood pressure was noted, while the pulse rate rose slightly (+0.13%). Adverse events were reported by 124 (26.90%) patients, but they precipitated only 17 (3.69%) withdrawals. Results of our study confirmed that sibutramine is an effective and safe weight-reducing drug

Current trends in the pharmacotherapy for obesity

Obesity represents a major global challenge from both healthcare and economic perspectives. Although lifestyle modifications aimed at reducing calorie intake and increasing energy expenditure remain the cornerstone of obesity management, pharmacotherapy can serve as a useful adjunct. Until recently, orlistat was the only medication registered for the treatment of obesity in the European Union (EU). A deeper understanding of the complexity of energy homeostasis has resulted in new pharmacological options for weight reduction. In 2015, two new antiobesity drugs were approved in the EU. These are a fixed combination of naltrexone/bupropion (Mysimba®) and liraglutide at a dose of 3.0 mg (Saxenda®). In addition, lorcaserin (Belviq®) and a fixed combination of phentermine/topiramate (Qsymia®) were introduced into the US market in 2012. However, the European Medicines Agency did not approve their use in the EU. The burden of previous weight loss agents that have been withdrawn due to safety concerns underlines the need for caution and close follow-up of patients undergoing pharmacological interventions for obesity treatment. This article provides an overview of the efficacy and safety of currently available weight loss pharmacotherapies

CONTROVERSIES IN DIAGNOSING DIABETES IN EARLY PREGNANCY

Cilj ovog osvrta je skrenuti pozornost na dijagnostičke nedoumice i neusklađenost dijagnostičkih kriterija za šećernu bolest u ranoj trudnoći koje u svakodnevnom radu koriste dijabetolozi odnosno ginekolozi. Neusaglašenost navedenih kriterija zbunjuje pacijentice i zdravstvene djelatnike. Nije jasno rezultira li primjena strožih kriterija nepotrebnim trošenjem zdravstvenih resursa i opterećenjem žena u osjetljivom razdoblju života ili s druge strane, ako se ne primjenjuju, podcjenjivanjem rizika povezanih s hiperglikemijom, izostankom pravodobne intervencije i posljedično većom incidencijom neželjenih ishoda trudnoće.The aim of this review is to draw attention to the diagnostic dilemma and inconsistency of the diagnostic criteria for diabetes in early pregnancy, used by diabetologists and gynecologists in everyday clinical practice. The lack of consistency of diagnostic criteria confuses patients and health-care providers. It is unclear whether the use of more stringent criteria results in unnecessary health-care costs and putting much pressure on women in the sensitive period of their life or, on the other hand, if not applied, underestimate hyperglycemia-related risks and results in the absence of timely intervention and consequently in a higher incidence of adverse pregnancy outcomes