CENTRO DE INVESTIGACION
EN NUTRICION, ALIMENTOS Y SALUD

LA INFORMACION ES EL PRIMER PASO HACIA LA PREVENCION

ABSTRACTS DE TRABAJOS PRESENTADOS POR EL DR. ALBERTO CORMILLOT Y COL. EN CONGRESOS INTERNACIONALES

IMPLANTE DE BALON INTRAGASTRICO COMO MEDIO DE REDUCCION DEL PESO EN UNA RED ESPECIALIZADA Y MULTIDISCIPLINARIA PARA EL TRATAMIENTO DE LOS PACIENTES OBESOS.

OBESITY SURGERY, 12, 2002. POSTER ABSTRACTS.

7MO. CONGRESO DE LA FEDERACION INTERNACIONAL PARA LA CIRUGIA DE LA OBESIDAD. 4TO. SIMPOSIO INTERNATIONAL ON LAPAROSCOPIC OBESITY SURGERY. 16TO. INTERNATIONAL SYMPOSIUM ON OBESITY SURGERY. SAO PABLO, BRASIL. AUGUST 21-31, 2002.

P123. Pagina 515. /p144. Pagina 521.

Alberto Cormillot, Rosana La Regina, Carlos Pozzoni, Alejandro Diz, Julio Argonz, Analia Fuchs. Clínica de Nutricion y Salud, Bs.As. Argentina.

Antecedentes: Los implantes del balon intragástrico comenzaron, en Argentina, cerca de octubre del 2002. El propósito de esta presentación es describir y evaluar este mecanismo (balón) como apoyo temporario de los pacientes obesos, teniendo en cuenta la importancia de la motivación para cambiar hábitos del comer y del estilo de vida, y la de ser cuidadosamente seleccionados y guiados por un equipo experimentado y multidisciplinario.

Métodos: 76 pacientes, 32 hombres y 43 mujeres recibieron el balón intragástrico desde octubre del año 2000 hasta marzo del año 2002.

La edad media fue de 43 y 37 (hombres, mujeres), el peso promedio 143 y 116,43. El IMC promedio fue de 42 kg/m2 y 43 kg/m2.

Todos los participantes habían probado diversos intentos de rebajar de peso.

Fueron seleccionados según afecciones clínicas, bioquímicas, y psiquiátricas. Despues de agosto del 2001, los pacientes fueron entrevistados por un psicólogo para determinar con más profundidad cuáles eran las expectativas de los pacientes, y para preparalos para el evento. Siguen un programa clínico y psico-educacional.

Resultados: Los balones se mantuvieron colocados durante 6 meses. La pérdida de peso % promedio fue de 14,06 en hombres y de 11,19 en mujeres. La reducción del sobrepeso fue de 26.41% (55,9%-10%) en hombres y 11.19 (67%1.66%) en mujeres. Después de extraerlo, sólo el 26% de los pacientes cumplieron con las visitas de tratamiento. A los dos meses, el 86% mantenían su peso, a diferencia del 11% de 'no cumplidores'.

Conclusiones: La colocación del balón intragastrico fue un procedimiento seguro y confiable para bajar de peso, cuando los pacientes fueron seleccionados con mucho cuidado y motivados.

TÉCNICA DEL BALÓN INTRAGÁSTRICO (BI) PARA EL TRATAMIENTO DE LA OBESIDAD SEVERA: SEGUIMIENTO A CORTO Y MEDIANO PLAZO DE LOS PRIMEROS 52 PACIENTES EN ARGENTINA.

Resumen del trabajo presentado en el 6º Congreso de la Federación Internacional para la Cirugía de la Obesidad, 15th International Symposium on Obesity Surgery, 3erd International Symposium on Laparoscopic Surgery, Septiembre 5-8 Chania, Creta, Grecia.

Autores:
Dr. Alberto Cormillot, Dra. Rosana La Regina, Dra. Analía Fuchs.

Antecedentes:
La obesidad severa es una enfermedad crónica muy difícil de tratar. La cirugía como recurso para bajar de peso restringiendo la ingesta de alimentos es una opción para los pacientes que tienen un IMC >35 o que presentan comorbilidades importantes. Entre las intervenciones bariátricas, el Tratamiento con Balón Intragástrico constituye una alternativa mínimamente invasiva que no requiere anestesia general ni inactividad prolongada. La colocación, inyección de volumen y la extracción de BI se realizan por endoscopía. La acción del BI es llenar el estómago de manera parcial, induciendo saciedad.

Métodos:
Desde octubre del 2000 a marzo del 2001, se realizaron las primeras 52 implantaciones de BI en Argentina. Los candidatos (29 mujeres y 23 hombres) obesos se reclutaron en la Red Cormillot para el Tratamiento de la Obesidad, siguiendo las indicaciones y restricciones de Bioenterics Corporation después de haber realizado exhaustiva evaluación clínica, bioquímica y pisquiátrica. Todos los pacientes habían intentado bajar de peso con distintos tratamientos sin éxito y presentaban condiciones que mejorarían con una reducción del peso corporal. Los pacientes recibieron información pormenorizada sobre el procedimiento y firmaron un formulario de consentimiento. Las expectativas y el plan de seguimiento (dieta, actividad física y consultas) se discutieron por adelantado.

Características del procedimiento:
El dispositivo se colocó mediante visualización endoscópica directa. Se llenó el balón con volúmenes variables de salina y azul de metileno para detectar pérdidas, a fin de personalizar el tratamiento (450 a 600 cc). Posee una válvula autosellante y una tapa de válvula radiopaca.

Resultados:
El tiempo de intervención fue de 8 a 20 min. bajo una leve sedación con Medazolan. El IMC preoperatorio fue de 35 a 53 en mujeres y 38 a 67 en hombres. Los hallazgos gastroscópicos fueron: 4 gastritis grado 1 (2 diagnosticadas como Helychobacter Pilory más tarde) y 1 polipo (benigno). Los pacientes estuvieron en condiciones de trasladarse a su habitación por sus propios medios y la estada media en el hospital fue de 2+/- días. Las complicaciones inmediatas fueron: vómitos (80%), nausea (90%) en las mujeres y 20% en los hombres, dolor epigástrico (55%), acidez de estómago (40%), meteorismo (15%). Cinco pacientes decidieron que se les extrajera el BI. De acuerdo a la fecha del implante, el cambio de IMC medio para mujeres y hombres fue de -6 y -4 en 6 meses, -3.3 y 3.2 en 4 meses y 3 y 2.4 en 2 meses. En la última visita, los pacientes fueron asintomáticos y continuaban bajando de peso. Alrededor de un 40% cumplió con los contactos postquirúrgicos.

Conclusiones:
Aunque las expectativas de los pacientes habían sido ampliamente conversadas previamente al implante del balón, excedieron la reducción de peso realmente lograda. Debe ponerse más énfasis en el cumplimiento con las consultas y los grupos de apoyo durante el seguimiento. Los resultados preliminares fueron satisfactorios y alientan a continuar con la colocación de BI. Otra posibilidad para estos pacientes es un segundo implante de balón.

HABITOS DE ACTIVIDAD FISICA EN OBESOS EN MANTENIMIENTO
Autores:
Dr. Alberto Cormillot, Dra. Analía Fuchs

Presentado en el IV Congreso Latinoamericano, IV Congreso Argentino, VI Jornadas Rioplateses de Obesidad y Trastornos Alimentarios. Septiembre 1999, Buenos Aires, Argentina.

El estilo de vida sedentario, sostenido en el tiempo, que produce menor gasto energético relativo, constituye la explicación más aceptable del incremento de sobrepeso y obesidad en poblaciones occidentales.

En los planes para bajar de peso y mantenerlo a largo plazo, la actividad física parece cumplir un rol esencial. Con el objetivo de conocer su importancia en el mantenimiento del descenso alcanzado, se estudiaron obesos que hubieran descendido 10 ó más kilos y mantenido ese descenso por lo menos durante los anteriores 12 meses.

A tal efecto se utilizó la reunión anual de obesos en grupos de mantenimiento y se encuestó, por medio de un cuestionario de autollenado, a los sujetos que cumplieran las condiciones del estudio. El hecho de pesarse y medirse semanalmente en los grupos hace más confiables los datos obtenidos.

Resultados:
Se procesaron 120 encuestas, que permitieron caracterizar a la muestra de la siguiente manera: edad promedio, 49 años; 84%, mujeres; 63% casados; 55% amas de casa; 86% no fumadores. El IMC promedio de estos sujetos al comienzo del programa fue de 33 kg/altura2, el 27% de ellos presentaba obesidad grado 3. El 37% varió entre los 11 y los 187 kg, mantenidos por un mínimo de 12 meses y un máximo de 24 años. En el 86% de las encuestas se mencionan intentos anteriores de adelgazar. La misma proporción de sujetos halló que bajar es más fácil que mantenerse (33%), más difícil (34%) o igual (34%). El 72% de los sujetos mencionaron un episodio de la vida que determinó, en este intento, la decisión de bajar de peso y mantenerse.

En cuanto a la actividad física, mediante el análisis cualitativo de las encuestas se observó, en primer lugar, que estos obesos habían incorporado la actividad física a su estilo de vida. El 49% manifestó disfrutar siempre de realizarla y el 32% extrañar si algún día no puede hacerla (contra el 3% que en los dos casos contestaron "nunca"). Sólo el 15% la considera "un mal necesario" siempre, mientras que el 36% respondió "nunca". La mayoría hace caminatas, entre 10 y 45 cuadras por día. Una tercera parte de ellos hacen además otro tipo de actividad física organizada. Para ir a trabajar, hacer compras, pasear, solo el 8% usa siempre el auto; el 18% a veces y el 32% nunca. El 13% usa siempre transporte público y el 29% siempre camina.

Conclusión:
Mantener el descenso de peso es posible cuando se realizan cambios permanentes en el estilo de vida. La actividad física es un indicador confiable de la adherencia a un programa de mantenimiento.

OBESITY AS HOMEOSTATIC BIOPSYCHOSOCIAL SYSTEM.

Cormillot, J. Luxardo, R. Zukerfeld, Instituto Argentino de Nutrición, Buenos Aires. Argentina.

8th International Congress on Obesity, Paris, France. 29 August- 3 Sept., 1998

Obesity is a chronic disease of considerable comorbidity and its outcomes have been greatly frustrating over the past decades. The aim of this study is to introduce two concepts we have considered useful to understand and approach the problem: planned crisis (PC) and reverse assertivity (RA). PC is defined as the cognitive-behavior style by which the subject generates explicative or justificative situations of his/her eating behavior and RA as the cognitive behavior style by which the subject induces behaviors in other people in order to explain or justify his/her own eating beahvior. Our hypothesis is that there is internal homeostasis in obese people that is not only biological but also, psychosocial in nature. Such homeostasis would tend to maintain itself by PC and RA mechanisms which are independent of the psychopathological conditions, expressed as “I-cannot-comply”. Otherwise, PC- and RA-dependent mechanisms are of the “I-do-not-want-to-comply” type. More than 30 years of clinical observations of different types of obesity provide paradigmatic examples of PC ("I went shopping, found no size for me, I got anxious and set myself to eat”) and of RA (“my husband told me not to eat. I went mad and ate”) both typically involving relapses. Conclusions: It is important to diagnose these mechanisms properly and design treatment programs that will focus on the development of new homeostatic conditions compatible with the reduction of risk factors by means of: (a) a psychoeducational approach and realistic goals; (b) developing strategies in which the concept of compliance is replaced by that of empowerment as done in modern treatment programs for chronic diseases.

Acknowledgments: M.Argüello.

QUALITY OF LIFE ASSESSMENT IN 54 MEMBERS FROM A WEIGHT MAINTENANCE GROUP

E. Barinaga, A. Cormillot, R.Zukerfeld, G. Piatti, C. Sharry, R. Hilu. Fundación ALCO; Buenos Aires, Argentina. 8th International Congress on Obesity, Paris, France, September 1998.

The purpose of this study was to examine the quality of life and presence of eating disorders and anxiety in obese patients who had lost at least 20 Kg and kept their weight loss during the 4 years they attended a maintenance group.

Method: 40 women and 14 men (X age 48.2, X BMI: 25:32) completed the EAT-26, STAI, quality of life scales (Nottingham Health Profile, EuroQoL), Duke Social Support and Stress Scale and structured interviews in order to obtain a Wellbeing and Health Index (WHI) to measure health and quality of life variables.

Results:According to the established cut-off values, 14,8% exhibited some disturbance in their eating behavior and 5.5% some anxiety feature. Neither problems in energy nor mobility were found in this sample. Total quality of life assessed either by questionnaire or structured interview (WHI: 0=worst, 100=optimum) scored higher than global self-perception (82.5 vs 73.4, p<0.05). Perception of support did not differ significantly from that of obese subjects under treatment but perception of social stress was lower (12.1 vs 24,8, p<0.05).

Conclusions:Patients who had lost weight and maintained their weight loss in a group, improved mood and quality of life. While a percentage of dieting behavior seemed to persist, there was a significant improvement in their interpersonal relationships. Furthermore, demands for appreciation of their health status and quality of life seemed to increase probably because they had denied their initial quality of life. It is important to develop a continuing maintenance system where achievements are recognized and responsible self-care encouraged.

A SIMPLE FORMULA TO DETERMINE ABDOMINAL FAT RELATED METABOLIC RISK FACTORS

Cormillot A., Debeza A., Panzica M.P., Karagenzian O. Clinica Cormillot, Buenos Aires, Argentina.

8th International Congress on Obesity, Paris, France. 29August-3Sept. 1998.

There is a tight relationship between metabolic risk factors (RF) and abdominal fat distribution. Waist perimeter ()WP) and Sagital Diameter (SD) are usually taken as a measure of abdominal fat. In order to discriminate between subcutaneous and visceral fat, the latter being more related to RF, expensive techniques such as tomographies and ecographies are usually employed. The aim of our studies was to find a simple formula to determine visceral fat and its capacity to predict RF in the medical office. Several formulas were tried out and cross-validated with other anthropometric parameters. The one presented here is (Sagital Diameter) / (Transversal Diameter) x WP = IGIA. The rational for the formula used here is given by the fact that, when a person lays down, visceral fat stays in place, while subcutaneous fat distributes at sides, enlarging the transverse diameter. One hundred and nine subjects, mean age 39, BMI between 21 and 49 were tested for Total Cholesterol, HDL-Col, LDL-Col, Tg, Uric Acid, Fibrinogen, Insulin, Glucose and Hypertension. These 9RF were rated according to the clinical and epidemiological experience and each ptient was given a “score” from 1 to 16. This “score” was tested for its relationship to the index formula SD and Transverse Diameter measures were performed by means of an enlarge caliper specially designed by Maria Pia Panzica and Oscar Karagenzian.

Spearman Rank correlation performed between the parameters IGIA and the score was r = 0.76 (p <<0.0001) (for DS and WF alone were r = 0.71 and r = 0.70 respectively in the same sample). These results did not improve when heigth, BMI or other measures were considered. Besides low IGIA was related to absence of familiar antecedents of early cardiovascular disease. This is a simple formula to be utilized in the medical practice. In order to be widely useful, it must be tested in a random free-living population and in a prospective study.

MORBID OBESITY: QUALITY OF LIFE AND PSYCHOPATHOLOGY.

A. Cormillot, R. Zukerfeld, E.Barinaga, R. Medina, W. Leitner, M.A. Erut.

Fundación ALCO, Buenos Aires, Argentina.

8th International Congress on Obesity, Aug-Sept 1998, Paris, France.

The purpose of this study was to examine the quality of life and various psychopathological characteristics in subjects with BMI >40, who attended self-help groups in Buenos Aires. Method: 83 subjects, 80,7% female, X age: 42,5, completed the EAT-26, STAI, BDI (abbrev.), quality of life scale (Nottingham Health Profile, EuroQoL), the Duke Social Support and Stress Scale and were interviewed as per the DSM-IV. Results: According to the established cut-off values (EAT>21, STAI>50, BDI>8), 30.7% of the sample exhibited some kind of eating disorder, 49,4% had anxiety features and 30.1% depressive symptoms. Furthermore, 66% reported lack of energy and 40% social isolation. Total quality of life measured either by questionnaire or structured interview (0 = worst, 100=optimum) was significantly poorer than global self-assessment (44.5 vs 57.7, p< 0.05). No difference was observed on subjective feelings of stress as compared with other chronic disease patients, but perception of support was higher. We detected 30 DSM-IV diagnostic categories, no usually mentioned in the literature, with an increased prevalence of Affective, Anxiety and Eating Disorders and Non-Compliance (Z91.1) on axis I and Borderline Personality Disorder on axis II. Conclusions Morbid obese patients may exhibit more anxiety, depression and eating behavior disorders than other obese patients. Objectively assessed, their quality of life is clearly poorer, but subjects often deny their condition. While feelings of more support may be attributable to their integration into self-help groups, some of them still need psychiatric intervention. This is a differentiated population requiring a psycho-educational approach in order to address obestiy and comorbidity simultaneously, which if overlooked, may hinder the treatment.

Acknowledgements. A.M.Martinez.

PSYCHOLOGICAL ASPECTS AND QUALITY OF LIFE OF OBESE SUBJECTS ATTENDING GROUPS. ONE YEAR OUTCOME.

S.Gugliotta, R. Zukerfeld, A.Cormillot, E. Barinaga, M.Ventura, L.Dorin. Fundación ALCO, Buenos Aires, Argentina.

8th International Congress on Obesity, Paris, France. September 1998.

The purpose of this study was to compare anxiety, eating disorders and quality of life features in compliers and non-compliers in an obesity self-helpgroup system.

Method: During the first month of group intervention 40 patients (X age 42.2, X BMI 32.6) were administered the STAI-T, EAT-26 and structured interviews (0 = worst 100 = optimum) in order to obtain a Wellbeing and Health Index (WHI) measuring ten health and quality of life variables. Procedures were repeated one year later with patients localized.

Results: One year later 10 patients (25%) still attended groups regularly. Of the total dropout number (30 patients) we could get information from 14.

Conclusions: No significant modification was found in anxiety features one year later. Changes were observed in the baseline magnitude of the eating disorder and dropout seemed to be associated with a worsening of this disorder. Quality of life seemed to improve in the patients who remained within the system. To reduce dropout it is, therefore, desirable to: 1) strenghten anxiety management strategies, 2) improve methods for early detection and treatment of eating disorders, 3) use wellbeing and quality of life indexes as confrontation and motivation, 4) develop patient empowerment as done in chronic disease treatments.

POSSIBLE WEIGHT IN OBESE PATIENTS

Karagenzian O, Romero A, Cormillot A. Clínica Cormillot, Buenos Aires, Argentina.

8th International Congress on Obesity, Paris, France. September 1998.

We studied 286 patients, 250 women and 36 men and registered the variables Sex, Age, Hight, Weight, Ideal Weight (IW), Maximum Weight (MW), Years of Obesity (YO) (AO), Actual Weight (AW); and Time Maintained (TM) in Possible Weight (PW).

The definition of possible weight was provided by A. Cormillot and A. Fuchs in "A Possible weight. Progress in obesity research" 1990 (pp. 663-664) London; John Libbey.

PW = PI + 0.1 (ED - 20) + 0.1 AO (ED >20) + 0.1(PM - P Y) (1)

		Mean	SD	Min	Max	Median
Age	in years	52	12	18	79	54
Height	in mts	1.61	0.08	1.38	1.87	1.60
IW	in kgs	60	7.6	44	86	59
MW	in kgs	86.0	17.3	56	170	84
YO	in years	21	12.6	1	60	20
AW	in kgs	70.05	11.7	38	115	69
TM	in years	4.4	3	1.5	16	4
PW	in kgs	67	8.6	51	94	66

Fitting a multilinear regression we obtain:

AW= 1.21 IW + 0.79 0.1 (MW-IW) + 1.13 0.1 YO - 6.65 (2)

Multiple correlation coeficient R2 = 0.7122

This means that 71.22% of the Actual Weights are all explained by the formula proposed by Cormillot et al.

Correlation between predicted values of PW and AW (this one calculated by (2) is r=0.8523 (p << 0.005).

PROFESSIONAL AND GROUP LEADER TRAINNING FOR THE TREATMENT OF OBESITY.

A. Cormillot, R. Zukerfeld, E. Barinaga, A. Olkies. Clínica Cormillot. Buenos Aires, Argentina

6th International Congress on Obesity

Education and trainning in obesity appears either as an unresolved problem or resolved with special dispersed efforts. In the last 20 years we have worked in this sense, both at a professional and community level.

Objectives: permanent education, diagnosis and treatment methodology, positive attitude for team integration, skills development or a better care delivery. Trainning includes programs for physicians, dietists, psychologists, physical activity instructors, and recovered obese. Personal and professional abilities are important. The first are: respect, authenticity, warmth, simpathy, flexibility, honesty, humility, involvement in study and research, discipline and perseverance. Professional educational program is divided into seniors and juniors. Seniors are individual or group instructors/supervisors of juniors. Plan consists in discussion meetings, medical auditory, educational videos, research work, rol-playing, activities with patients, update in obesity, nutrition, psychology, groups, medical care, physical activity, other addictions. Dedication: 8 hours/week. The program with group leaders include information, clarification, rol-playing for a better understanding of the group dynamics and ability to share all attitudes and tecniques possible. Dedication: 3 h/wee. Education methods involve levels of statistical significance and it incorporates teaching staff and evaluates all of them (also teachers) as another stage of learning.

EATING DISORDERS IN OBESE WOMEN BEFORE LOOSING WEIGHT AND ON MAINTENANCE.

R. Zukefeld, E. Barinaga, L. Girard, A. Cormillot. Centro de Investigación sobre Nutrición y Obesidad (CINO). Buenos Aires, Argentina

The 6th International Congress on Obesity

The purpose of this study was to determine the presence of eating disorders in obese patients and its progress under outpatient group treatment with two models: a) self-helpgroup, b) professional group.

102 obese women from Buenos Aires and Montevideo distributed in 2 groups were considered: I) n=49, 37.1 + 11 yr, first month of treatment, 22.6+9% Ow., BMI 30.5+4.

II) n=53, 39.2+8yr, body weight maintenance for over one year; 2.9%Ow., BMI 23.2+2.9.

The Eating Disorders Inventory (Garner, 1983) was used.

Group I: All scores were higher than those for the general population except for Perfectionism. Drive to Thinness (DT), Body Dissatisfaction (BD) and Maturity Fear (MF) scores were similar to Bulimia Nervosa. 25% had scores > 10 in Bulimia.

Subgroup (b) had higher scores than subgroup (a), especially on interpersonal Distrust (ID).

Group II: All scores were significantly lower than Group I, similar to the general population except for DT and MF which remained high. Only 1% of Group II had score >10 in Bulimia.

Subgroup (a) presented higher scores than subgroup (b), particularly in DT, Bul. and Inefficacy.

Eating Disorders are present in obese women, especially in those seeking professional help who seem to have greater bulimic tendency, more dissatisfaction with their body and greater difficulty to trust in other people. These characteristics improve with self-help or professional systems, with greater improvement under the latter.

THE POSSIBLE WEIGHT

A. Cormillot, A. Fuchs, CINO. Buenos Aires, Argentina.

The 6th International Congress on Obesity, Kobe Japan, Octobre 1990.

For many obese people it is difficult to maintain the body weight listed in current tales. To obtain a more realistic weight, we developed the following formula considering the age of the patient, time elapsed since the beginning of obesity and the maximum overweight.

Possible Weight (PW) = Ideal Weight (IW) + 0.1 (age-20) + (0.1 x years of obesity) + (0.1 x Maximum Overweight (MOW) in Kg).

This formula was applied to 176 group leaders (all women, 20 to 60 yr old.) who maintained their weight loss for more than 12 months (up to 10 years). Many of them had lost weight beyond the PW, but usually they regained a few kg after some time, and finally they stabilized closer to the PW.

Mean values were.

	Mean	SD	Min	Max
Present Weight	62.97	6.49	48.50	79.00
IW (min)	53.90	5.68	43.50	72.01
IW (max)	58.59	4.91	47.50	78.00
PW	62.90	5.85	52.00	78.02

At the same time, the effect of potential predictor variables was assessed by stepwise multiplelinear regresion.

One of the models that fits data best is:

PW = IW + 21.62 x (MOW/IW)

The possibility of predicting a realistic weight as an end-point of treatment, and long-term achievement can reduce the frustrations caused by unattainable goals and may help improve adherence.