Obesity: a model of complex interactions between genetics and environment

peer reviewe

Recent advances in the management of obesity

peer reviewedThe management of an obese patient aims not only at obtaining a durable weight loss, but also at attenuating various associated risk factors. This latter objective may already be obtained with a rather moderate weight reduction (5-10% of initial body weight). The first step should favour life-style changes (diet and physical exercise), eventually together with a psychological support. In case of insufficient success, a pharmacological approach may be considered, in addition to life-style advices. Pharmacotherapy currently includes drugs that act on the central nervous system to decrease appetite (sibutramine), in the gastrointestinal tract to diminish fat absorption (orlistat) or at both central and peripheral sites (rimonabant). In case of extreme obesity or severe obesity associated with comorbidities, refractory to medical approaches, bariatric surgery may represent the only solution to obtain a major and sustained weight loss, together with a significant improvement of associated risk factors. Gastroplasty, especially laparoscopic gastric banding, has become very popular in our country. However, because of several limitations, it is increasingly replaced by derivative procedures, especially gastric bypass. In all cases, a multidisciplinary, integrated and individualized approach should be recommended, using realistic goals and targeting long-term weight reduction and improved health

DIAGNOSTIC APPROACH OF THE PATHOPHYSIOLOGICAL TRIAD LEADING TO A DIABETIC FOOT

peer reviewedDiabetic foot is a common complication of diabetes mellitus. Its pathophysiology is most often complex with the interconnection of three different components: diabetic neuropathy, arterial disease and infection. The diagnostic approach should specify the respective role of each component, firstly thanks to a thorough medical interview and a careful clinical examination. Afterwards, well selected complementary exams will confirm the hypotheses generated by the initial clinical approach. Consequently, a specific care strategy will be implemented, ideally with the help of a multidisciplinary team. This educational clinical case is devoted to the sequential diagnostic approach of a patient with a foot ulcer in the context of a diabetic foot.Résumé : La problématique dite du «pied diabétique» est devenue une complication fréquente du diabète sucré. Sa physiopathologie est le plus souvent complexe avec une intrication habituelle de trois composantes, neuropathique, artériopathique et infectieuse. L’approche diagnostique doit permettre d’établir le rôle respectif de ces trois composantes, d’abord grâce à une anamnèse minutieuse et un examen clinique rigoureux. Ensuite, des examens complémentaires judicieusement sélectionnés permettront de conforter les hypothèses générées par la clinique et, in fine, d’établir le plan de soins le plus approprié, en favorisant une prise en charge multidisciplinaire. Cette vignette clinique est centrée sur l’approche diagnostique, clinique d’abord, paraclinique ensuite, d’un patient présentant une plaie dans un contexte de «pied diabétique »

Diagnosis of lower limb pain in a diabetic patient

peer reviewedBy presenting this clinical case, we aim at discussing the diagnosis between arteriopathy, neuropathy and osteoarticular pathology in a patient with type 2 diabetes who complains of lower limb pain. We emphasize the role of a global medical approach based upon anamnesis and clinical exam, which should contribute to select the most helpful paraclinical investigations

News in the management of diabetic foot

The management of diabetic foot requires a rapid intervention in front of any type of wound, if possible by a multidisciplinary team. The daily diabetic foot screening is the best prevention. Peripheral neuropathy leads to articular deformations, loss of pain alert and skin dryness. Arteriopathy, which is also frequent, retards cicatrisation of wounds, with a higher risk of infection and amputation. Meticulous local care and foot pressure off-loading are essential, with, if needed, appropriate antimicrobial therapy. Surgery, with curative, preventive or even restorative interventions, occupies an increasing place. The evaluation, treatment and follow-up of the diabetic foot should follow new guidelines established by the IWGDF

News in the management of diabetic foot

The management of diabetic foot requires a rapid intervention in front of any type of wound, if possible by a multidisciplinary team. The daily diabetic foot screening is the best prevention. Peripheral neuropathy leads to articular deformations, loss of pain alert and skin dryness. Arteriopathy, which is also frequent, retards cicatrisation of wounds, with a higher risk of infection and amputation. Meticulous local care and foot pressure off-loading are essential, with, if needed, appropriate antimicrobial therapy. Surgery, with curative, preventive or even restorative interventions, occupies an increasing place. The evaluation, treatment and follow-up of the diabetic foot should follow new guidelines established by the IWGDF

Obesity and type 2 diabetes

peer reviewedObesity is an epidemic disease associated with numerous cardiovascular risk factors as diabetes mellitus, dyslipidemia, hypertension. Insulin resistance seems to be an important promoter for the development of most of these abnormalities. Besides genetic background, obesity, especially abdominal adiposity, is by far the most important factor for the development of type 2 diabetes. The treatment of a diabetic obese subject begins with diet and regular physical activity, eventually with a psychological support. In case of failure of such lifestyle approach alone, addition of drug therapy should be considered. It may include pharmacological agents able to promote weight loss (orlistat, sibutramine, possibly rimonabant) and/or antihyperglycaemic compounds capable of reducing insulin resistance (metformin, glitazones, acarbose). In case of severe/morbid obesity complicated with type 2 diabetes not well controlled with medical means, bariatric surgery is the only treatment that can induce an important and sustained weight loss, associated with marked improvement of metabolic control and amelioration of overall prognosis