Bishay Ramy H, Kormas Nic
Concord Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
Metabolic Rehabilitation Program, Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Concord, NSW, Australia.
Curr Diabetes Rev. 2018;14(3):246-256. doi: 10.2174/1573399813666170329154902.
The global epidemic of obesity will see normal weight adults constituting a mere one-third of the global population by 2025. Although appetite and weight are regulated by a complex integration of neurological, endocrine and gastrointestinal feedback mechanisms, there is a constant interaction between psychological state, physical impairment, presence of comorbid chronic disease and medications.
We discuss two cases and reveal a practical approach to investigating and managing patients with obesity and diabetes in the 'real world'. Within this scope, the aetiology, associated disease burden, and pharmacological therapies for the treatment of the obese patient with type 2 diabetes are reviewed. An insight into non-surgical metabolic rehabilitation is also provided.
Lifestyle, including diet, exercise, medications, as well as genetic predisposition, and rarely, endocrinopathies should be considered in the assessment of the obese patient. Investigations are not complex and include cardiometabolic and nutritional screens and an assessment for institution of graded, safe levels of exercise. In more complicated patients, referral to a multidisciplinary outpatient program may be necessary and it is not uncommon for patients to lose between 10-20% of their initial weight. Despite this, metabolic surgery may be necessary as further weight loss with long-term weight maintenance may be medically indicated. The type of surgery is tailored to the patient's medical risk and co-morbidities as well as likelihood of compliance with the required follow-up.
It is the opinion of the authors that metabolic rehabilitation should be intensive, multidisciplinary, and have a supervised exercise program, as the gold standard of care. These suggestions are based on the clinical pearls gained over two decades of clinical experience working in one of Australia's most innovative multidisciplinary metabolic rehabilitation programs caring for patients with severe obesity.
全球肥胖流行趋势表明，到2025年，正常体重的成年人将仅占全球人口的三分之一。尽管食欲和体重受神经、内分泌及胃肠道反馈机制的复杂综合调节，但心理状态、身体损伤、慢性合并症的存在及药物之间存在持续的相互作用。
我们讨论两个病例，并揭示在“现实世界”中调查和管理肥胖及糖尿病患者的实用方法。在此范围内，对肥胖的2型糖尿病患者的病因、相关疾病负担及药物治疗进行综述。还提供了对非手术代谢康复的见解。
在评估肥胖患者时，应考虑生活方式，包括饮食、运动、药物，以及遗传易感性，很少情况下还应考虑内分泌疾病。检查并不复杂，包括心脏代谢和营养筛查以及对分级、安全运动水平的评估。对于更复杂的患者，可能需要转诊至多学科门诊项目，患者体重减轻初始体重的10%-20%并不罕见。尽管如此，代谢手术可能是必要的，因为从医学角度看可能需要进一步减重并长期维持体重。手术类型根据患者的医疗风险、合并症以及遵守所需随访的可能性进行调整。
作者认为，代谢康复应强化、多学科，并设有监督运动项目，作为护理的金标准。这些建议基于在澳大利亚最具创新性的多学科代谢康复项目之一中，二十多年来照顾严重肥胖患者所积累的临床经验。
