BACKGROUND: Previous studies have shown that there are racial disparities in type 2 diabetes (T2DM) remission following bariatric surgery, with African-Americans (AA) in particular experiencing a subsequent relapse. In recent years, some have attributed these findings to racial differences in fasting insulin levels, with AA having higher levels, as increasing evidence for an alternate model of T2DM pathophysiology gains support. In this model, basal hyperinsulinemia is considered a primary event in T2DM disease development, rather than a compensatory response to increased insulin resistance. This study aimed to compare glycemic outcomes after bariatric surgery in different races, namely African-Americans (AA), Hispanic-Americans (HA), and Caucasian-Americans (CA), and to determine whether there were any associated changes in insulin levels and insulin resistance that may lend support to this revised model of T2DM pathophysiology. METHODS: A retrospective medical record review of 1,326 patients (389 AA, 179 HA, and 758 CA) who underwent bariatric surgery at Boston Medical Center (BMC) from 2004 to 2015 was conducted. Baseline characteristics and maximum percent weight loss were compared using one-way ANOVA and Chi-square tests of independence. Changes in mean glycated hemoglobin (HbA1c), insulin levels, insulin resistance (HOMA-IR), and blood glucose levels were analyzed using linear mixed models, overall and by racial group. The same procedures were conducted in both the overall patient population and a T2DM subpopulation. RESULTS: Over an 11-year postoperative observation period, all racial groups underwent a significant decrease in HbA1c (P<0.001) within the first two years following surgery. While HbA1c levels remained stable in CA and HA, they began to rise at 2 years in AA only (P=0.043). Additionally, analyses of covariates, including age at surgery (P=0.005), initial BMI (P<0.001), and maximum weight loss (P=0.049), revealed that all three were significant factors affecting mean HbA1c levels. However, when included in the mixed model, the race x time interaction effect on mean HbA1c remained significant. There was also a significant overall decrease in both insulin and HOMA-IR. When stratified by race, analysis of the T2DM population showed that insulin levels began to increase again by the 2nd year after surgery in AA, while in CA and HA they continued to decrease and subsequently stabilize. Analysis of the total patient population showed that HOMA-IR levels in AA, as well as in CA and HA, continued to decrease at this 2-year time point. Decreases in blood glucose levels after surgery were significant overall (P<0.001), but not significant when stratified by race. CONCLUSIONS: After the initial “metabolic reset” that occurs within the first 2 years after bariatric surgery, during which HbA1c levels normalize in the vast majority of patients, it was observed only in the AA population that there was a steady increase in HbA1c to levels near those recorded at baseline. This coincided with an observation of increasing insulin levels despite decreasing insulin resistance seen in AA only. Our results suggest that current discussions regarding a revised model of T2DM pathophysiology, in which hyperinsulinemia precedes insulin resistance, may help explain the racial disparities in glycemic control observed in both post-surgical and non-surgical contexts of T2DM outcome. However, future prospective studies are needed to further the preliminary results of this study.

At the 2nd Diabetes Surgical Summit in 2015, the world’s leading researchers and professionals in the field of diabetes, surgery, and public health gathered to develop new surgical treatment guidelines for diabetes. This summit led to the recommendation of bariatric surgery as an official treatment for type II diabetes, outlining that the surgery be considered for diabetic patients with a Body Mass Index (BMI) of 30, a much lower threshold BMI than that of typical bariatric surgery patients. Despite incontrovertible evidence that bariatric surgery can reverse the progression of diabetes and even cause remission, the physiological mechanisms chiefly responsible for these effects remain controversial. Peer-reviewed published literature was collected to examine the evidence for mechanisms responsible for metabolic improvements following bariatric surgery, especially Roux-en-Y gastric bypass. This review considered the effects of calorie restriction, appetite modulators, incretins, intestinal adaptations, adipose tissue, gut microbiota, bile acid circulation and composition, and psychosocial and behavioral changes on surgery-induced metabolic improvements and sustained type II diabetes remission. Clinical considerations, such as the surgical risks and improved indicators for bariatric surgery were also explored to contextualize the physiological mechanisms under study. The “hind gut hypothesis” emerged as an important overarching mechanism potentially responsible for many of the observed improvements. The more rapid delivery of food to the distal intestine, as well as the delayed mixing of pancreatic, gastric and bile secretions with food, likely contributes to increased nutrient-stimulation of enteroendocrine cells and greater binding of bile acids with their receptors, farnesoid X receptor and TGR5. These changes in food and secretion delivery also appear to positively affect the gut microbiota to support a non-obese microbiota profile. Calorie restriction may be responsible for the early effects of bariatric surgery, including not just a reduction in fat mass but also epigenetic changes to induce β-cell proliferation and increased insulin secretion. However, long-term benefits of bariatric surgery appear to be more closely correlated to enteroendocrine changes, including the surgery-induced changes to levels of appetite modulators that, unlike pure calorie restriction, promote feelings of satiation and reduce rates of diet failure and weight regain. Fat distribution and adipocyte function are also important contributors to both the pathophysiology of obesity-related diabetes and improvements following bariatric surgery. While reductions in BMI and subcutaneous adipose tissue area were not correlated to diabetes remission, reductions in visceral adipose tissue area and enhanced adiponectin secretions were both independent factors associated with diabetes remission. The important role of adipocytes as endocrine organs has emerged as an important field of inquiry. Adipokines, adipocyte hormones, may either promote a pro-inflammatory profile or an anti-inflammatory profile, impacting the development of obesity-related diabetes or diabetes remission, respectively. The findings of this review support the 2nd Diabetes Surgical Summit’s recommendations of proactive bariatric surgery as a treatment for diabetes. The risks of complications and mortality following bariatric surgery are low, whereas the long-term survival after bariatric surgery is improved relative to non-surgical, matched controls. Single-nucleotide polymorphisms associated with obesity and diabetes may serve as early indicators for surgery, and inform both surgical method and follow-up protocols. Despite the benefits of bariatric surgery, only a small number of eligible candidates undergo treatment. In the United States, barriers such as physician and patient perceptions and cost may limit access to surgery. In places that experience a health workforce shortage, there may be no health care professionals or facilities available to perform bariatric surgery. Therefore, while the surgery amazingly causes diabetes remission, one of its greatest benefits may be to continue to inform the mechanisms responsible for metabolic improvements toward developing new pharmacological treatments. In the future, less invasive drug treatments that seek to replicate the effects of bariatric surgery may be more successful in tackling the global obesity and diabetes crisis.

The incidence of obesity is on the rise globally and is associated with many comorbidities, especially type 2 diabetes mellitus (T2DM). Bariatric surgery is the most effective intervention for weight loss and reducing obesity-associated morbidity. The most common bariatric surgeries are roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). RYGB and SG are equally efficacious at long-term reduction of weight in obese individuals and amelioriation of T2DM. Interestingly, the improvement of glucose regulation is noted before weight loss is observed. The most likely mechanism underlying glucose homeostasis after bariatric surgery is hormonal changes in the intestine. Enteroendrocrine changes favorable of an anti-diabetic profile are noted after only a few days of receiving either RYGB or SG surgery. Most consistently, elevated postprandial GLP-1, a potent regulator of appetite and glucose control, is observed in post-bariatric surgery patients. However, data is limited regarding post-prandial GLP-1 levels beyond two years after surgery. This study will address the gap in literature by assessing postprandial elevations of GLP-1 following RYGB or SG for up to five years. We will recruit obese type-2 diabetics from an outpatient bariatric surgery clinic at Boston Medical Center scheduled to receive RYGB or SG and periodically assess postprandial GLP-1 levels to determine if they remain elevated after 5 years. Additionally, we will provide evidence if there is a correlation among changes in postprandial GLP-1, weight loss, and hemoglobin A1c at five years. Our proposed study will help direct researchers to develop safer and more efficacious interventions for obesity and T2DM.

Submitted by Oliveira Santos Dilzaná (dilznana@yahoo.com.br) on 2016-05-09T14:21:39Z No. of bitstreams: 1 DISSERTAÇÃO - NATALIA LIMA FIGUEIROA.pdf: 1675224 bytes, checksum: 9ff174085dd6581bd010e3ccf59e0f9a (MD5) / Approved for entry into archive by Hozana Azevedo (hazevedo@ufba.br) on 2016-05-09T19:24:05Z (GMT) No. of bitstreams: 1 DISSERTAÇÃO - NATALIA LIMA FIGUEIROA.pdf: 1675224 bytes, checksum: 9ff174085dd6581bd010e3ccf59e0f9a (MD5) / Made available in DSpace on 2016-05-09T19:24:05Z (GMT). No. of bitstreams: 1 DISSERTAÇÃO - NATALIA LIMA FIGUEIROA.pdf: 1675224 bytes, checksum: 9ff174085dd6581bd010e3ccf59e0f9a (MD5) / Esta pesquisa procura examinar a obesidade e modo como ela é experienciada através do seu tratamento na forma da cirurgia bariátrica. No primeiro momento etnográfico alguns eventos ocorridos num ambulatório de saúde na cidade de Salvador são narrados para compreender como a obesidade é atuada de formas múltiplas, a despeito das posições teóricas que visam encerrar a controvérsia em torno da obesidade através de uma noção uniforme da mesma. Em seguida são apresentadas as realidades de dois sujeitos em seu processo de preparação para a cirurgia bariátrica, de modo a discutir as atuações das diferentes especialidades médicas envolvidas no tratamento bariátrico e evocar a noção de processo. Por fim discute-se as mudanças decorrentes da cirurgia a partir do modo como os sujeitos aprendem a lidar com a alimentação pós-cirúrgica através do desenvolvimento de habilidades, o que envolve também relativizar o que se considera sucesso neste tratamento. This research aims to examine obesity and the way it is experienced through its treatment by bariatric surgery. At its first ethnographic moment, some events that occurred at a health clinic in the city of Salvador are narrated to understand how obesity is enacted in multiple ways, regardless of theoretical positions that try to end the controversy around obesity through an uniform idea of it. Next, we present the realities of two individuals in their preparation process to bariatric surgery. We do it in a way to discuss the actions of different medical specialties involved in bariatric surgery and to evoke the notion of process. Lastly, we discuss the changes related to the surgery from the way individuals learn how to deal with postsurgical feeding through de development of abilities. This discussion also involves the relativization of the notion of success in this treatment.

abstract: While obesity rates have plateaued within the last decade, two-thirds of the United States population is currently classified as overweight (defined a s a body mass index [BMI] of 25-29.9 kg/m²) or obese (a BMI greater than 30 kg/m²). Bariatric surgical interventions are not only more effective than behavioral treatments in the short term but are the only form of obesity intervention with evidence of consisten t long-term effectiveness. However, even among bariatric surgery patients, weight loss often stabilizes and it is estimated that more than 20% of bariatric surgery patient s will regain a significant amount of weight that was initially lost long-term. Li ttle research to date has been conducted on physical activity in post bariatric surgery pati ents. More specifically, there have been no studies to date examining the effects of Me ditative Movement (MM) programs on body composition in bariatric patients. A s tudy using an 8-week Tai Chi Easy program was conducted in female gastric bypass patient s to explore feasibility of MM in the bariatric population as well as pre- and post-in tervention changes in weight, mindfulness, eating behaviors, body awareness, physical a ctivity patterns, dietary quality and mood. Data analysis revealed that there were no s ignificant changes in weight or physical activity patterns; however, significant changes w ere observed in anxiety, overall body awareness and cognitive restraint in eating. Addit ionally, a significant decrease in processed meat consumption and a weak trend towards increa sed consumption of fruits may suggest an overall improvement in dietary quality. / Dissertation/Thesis / Doctoral Dissertation Physical Activity, Nutrition and Wellness 2014

Submitted by MARINA CRISTINA ZOTESSO null (marina.zotesso@gmail.com) on 2017-05-02T16:37:35Z No. of bitstreams: 1 Dissertação 13.pdf: 1151842 bytes, checksum: 7de43c7e71fde1a200048abf67441b10 (MD5) / Approved for entry into archive by Luiz Galeffi (luizgaleffi@gmail.com) on 2017-05-03T20:28:04Z (GMT) No. of bitstreams: 1 zotesso_mc_me_bauru.pdf: 1151842 bytes, checksum: 7de43c7e71fde1a200048abf67441b10 (MD5) / Made available in DSpace on 2017-05-03T20:28:04Z (GMT). No. of bitstreams: 1 zotesso_mc_me_bauru.pdf: 1151842 bytes, checksum: 7de43c7e71fde1a200048abf67441b10 (MD5) Previous issue date: 2017-03-20 / A obesidade possui alta prevalência no Brasil. É fator de risco para demências, doenças cardiovasculares, cânceres e diabetes, e está associada a transtornos psiquiátricos. A cirurgia bariátrica é uma alternativa para os casos de obesidade mórbida, pois, inibe a progressão de comorbidades. Contudo a literatura é escassa quanto ao funcionamento cognitivo e emocional dos pacientes que vivenciam a rápida redução de peso por meio do processo cirúrgico em contraste com a perda de peso lenta decorrente de reeducação alimentar. O objetivo deste estudo prospectivo foi avaliar o funcionamento emocional e mnemônico de indivíduos obesos, antes e quatro meses depois do emagrecimento. Participaram do estudo 76 voluntários divididos em dois grupos, conforme a fase do tratamento: redução de peso por meio de cirurgia bariátrica (RPCB, N=40) ou redução de peso preparatória para bariátrica (RPPB, N= 36), avaliados por meio de testes cognitivos para memória episódica e operacional, bem como escalas comportamentais. Os instrumentos utilizados para a avalição eram os mesmos em ambas as avaliações. O teste t de Student indicou diferença estatística entre a 1ª avaliação e a 2ª avaliação. Houve mudanças mais robustas para o grupo RPCB, que vivenciou o emagrecimento rápido no âmbito comportamental para os âmbitos de depressão, ansiedade, compulsão e obsessão, resiliência e em especial para cinco categorias da escala que medem a qualidade de vida. O grupo RPCB ainda teve melhor desempenho no seguimento quanto a capacidade de memória operacional, memória verbal e atenção avaliado pelo teste Span de Dígitos. A melhora do grupo RPPB na 2ª avaliação pode estar associada ao acompanhamento multidisciplinar como preparo para CB. O estudo evidencia, dessa forma, que a CB produziu benefícios menmônicos e emocionais aos pacientes. / Obesity has a high prevalence in Brazil. It is a risk factor for dementias, cardiovascular diseases, cancers and diabetes, and is associated with psychiatric disorders. Bariatric surgery is an alternative for cases of morbid obesity, since it inhibits the progression of comorbidities. However, the literature is scarce regarding the cognitive and emotional functioning of patients who experience rapid weight reduction through the surgical process in contrast to the slow weight loss due to dietary reeducation. The aim of this prospective study was to evaluate the emotional and mnemonic functioning of obese individuals, before and four months after their weight loss. Participants were 76 volunteers divided into two groups, according to the treatment phase: weight reduction through bariatric surgery (RPCB, N = 40) or preparatory weight reduction for bariatric (RPPB, N = 36) evaluated by means of Cognitive tests for episodic and operational memory, as well as behavioral scales. The instruments used for the assessment were the same in both evaluations. Student's t test indicated statistical difference between the 1st evaluation and the 2nd evaluation. There were more robust changes for the RPCB group, which experienced rapid weight loss in the behavioral setting for the areas of depression, anxiety, compulsion and obsession, resilience and in particular for five categories of the scale that measure quality of life. The RPCB group still had better performance in the follow-up regarding operational memory capacity, verbal memory and attention assessed by the Span Span test. The improvement of the RPPB group in the 2nd evaluation may be associated to the multidisciplinary follow-up as preparation for CB. The study shows, therefore, that CB produced men- mentic and emotional benefits to the patients.

Submitted by Irene Nascimento (irene.kessia@ufpe.br) on 2017-04-17T19:32:53Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) tese final biblioteca.pdf: 1851580 bytes, checksum: 809baa65e670eaa5609551c9d708e7f8 (MD5) / Made available in DSpace on 2017-04-17T19:32:53Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) tese final biblioteca.pdf: 1851580 bytes, checksum: 809baa65e670eaa5609551c9d708e7f8 (MD5) Previous issue date: 2015-11-11 / Introdução: A obesidade é associada com alterações da estrutura e da função do ventrículo esquerdo (VE). A cirurgia bariátrica tem efeitos favoráveis sobre o remodelamento cardíaco, mas seus efeitos sobre as funções diastólica e sistólica do VE ainda não foram claramente definidas. Objetivo: Avaliar as mudanças na estrutura e nas funções diastólica e sistólica do VE em pacientes submetidos à cirurgia bariátrica. Método: Estudo prospectivo, observacional onde foram avaliados 23 pacientes com índice de massa corpórea superior a 40 submetidos à cirurgia bariátrica. As avaliações clínica e ecocardiográfica foram realizadas no período pré-operatório e 3-7 meses após a cirurgia. Resultados: Após um seguimento médio de 4,7 meses, o peso corporal dos pacientes foi significativamente reduzido de 126,3 ± 25 para 97,7 ± 19 kg (p < 0,001) e o índice de massa corporal de 46,7 ± 5,3 para 36,2 ± 4,7 kg/m2 (p< 0,001). A pressão arterial sistólica foi reduzida de 138,6 ± 14,9 para 118,8 ± 8,9 mmHg (p < 0,001) e a pressão arterial diastólica de 85,8 ± 10,4 para 79,7 ± 6,5 mmHg (p 0,002). A avaliação ecocardiográfica mostrou redução na espessura do septo interventricular e da parede posterior do VE (10,3 ± 1,4 para 8,9 ± 1,2 mm e 9,3 ± 1,3 para 8,4 ± 1,1 mm, respectivamente; p < 0,001). Após a cirurgia, houve redução da massa do VE (valor absoluto: 168,7 ± 35,2 para 149,8 ± 40,7 g, p 0,008; valor indexado pela altura: 45,1 ± 11,3 para 39,7 ± 10,3 g/m2,7, p 0,006) e da espessura relativa do VE de 0,39 ± 0,06 pra 0,34 ± 0,04 (p<0,001). A prevalência de geometria normal do VE aumentou de 60,9% antes da cirurgia para 91,3% no seguimento. As medidas obtidas através de Doppler tecidual detectaram melhorias na função diastólica do VE (velocidade de E’ no anel mitral lateral de 0,16 ± 0,03 m/s no período pré-operatório x 0,17 ± 0,03 m/s no seguimento; p 0,026). Não houve diferença significante na função sistólica de VE mensurada através da fração de ejeção e da fração de encurtamento. Conclusão: Cirurgia bariátrica promove melhorias na estrutura e na função diastólica do VE. Não houve modificações nos parâmetros de função sistólica do VE. / Obesity is associated with changes in left ventricular (LV) structure and function. Bariatric surgery can favorably improve cardiac remodeling. The effects of the procedure in LV diastolic and systolic function have not been clearly defined. The aim of this study was to evaluate the changes in left ventricular structure, systolic and diastolic function in obese patients who have undergone bariatric surgery. We evaluated twenty-three patients (16 women, 7 men; 32,9 ± 8,9 years) with body mass index above 40 submitted to bariatric surgery. Clinical and echocardiographic evaluation were performed preoperatively and 3-7 months after the surgery. After a mean follow-up of 4,7 months, body weight was significantly reduced from 126,3 ± 25 to 97,7 ± 19 kg (p < 0,001) and body mass index from 46,7 ± 5,3 to 36,2 ± 4,7 kg/m2 (p< 0,001). Systolic blood pressure was reduced from 138,6 ± 14,9 to 118,8 ± 8,9 mmHg (p < 0,001) and diastolic blood pressure from 85,8 ± 10,4 to 79,7 ± 6,5 mmHg (p 0,002). Echocardiography showed decrease of the interventricular septum and left ventricular (LV) posterior wall thickness (10,3 ± 1,4 to 8,9 ± 1,2 mm and 9,3 ± 1,3 to 8,4 ± 1,1 mm, respectively; p < 0,001). After surgery, there was a reduction in left ventricular mass (LVM) (absolute value: 168,7 ± 35,2 to 149,8 ± 40,7 g, p 0,008; value indexed by height: 45,1 ± 11,3 to 39,7 ± 10,3, p 0,006) and in LV relative wall thickness (RWT) from 0,39 ± 0,06 to 0,34 ± 0,04 (p<0,001). The prevalence of normal left ventricular geometry improved from 60,9% before surgery to 91,3% at follow-up. Tissue Doppler imaging detected improvement in the LV diastolic function (mitral E’ lateral 0,16 ± 0,03 m/s preoperative vs. 0,17 ± 0,03 m/s at follow-up; p 0,026). There was no significant difference in LV systolic function measured by ejection fraction and fractional shortening. Bariatric surgery promotes improvement in left ventricular structure and diastolic function. There were no changes in left ventricular systolic parameters.

Orientador: Lea Maria Leme Strini Velho / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Geociencias / Made available in DSpace on 2018-08-14T21:18:40Z (GMT). No. of bitstreams: 1 Figueiredo_SimonePallonede_D.pdf: 2349678 bytes, checksum: 9377f7125d3278cd5d8d6b9ab41187c4 (MD5) Previous issue date: 2009 / Resumo: Este trabalho analisa como a obesidade, a exemplo de outros comportamentos, passou para o domínio da medicina, sendo interpretada como doença, sujeita a atenção de médicos, tratamentos, com ou sem o auxílio de medicamentos ou outros procedimentos desse campo, em um processo que se dá o nome de medicalização. É um processo construído socialmente do qual fazem parte profissionais da área da saúde, representantes de governos, do mercado e como se vê neste estudo, a imprensa. O estudo traça um panorama da situação da obesidade no Brasil, EUA e em países europeus, mostrando algumas medidas de ordem política que esses países têm adotado na tentativa de conter o avanço da obesidade. Mostra, também, a existência de um estigma da obesidade que não está relacionado apenas à questão da saúde, mas à busca de um padrão de beleza estabelecido, que leva um grande número de pessoas, em especial as mulheres, às práticas embelezadoras que vão dos exercícios físicos e dietas às cirurgias plásticas e distúrbios alimentares. A partir da análise de 305 matérias publicadas no jornal Folha de S. Paulo no período de 1998 a 2008, o estudo investiga o papel da imprensa como partícipe deste processo. Do total de textos analisados, 72% enfocam a obesidade como doença ou epidemia, relacionando o mal a outras doenças, destacando os riscos, os custos individuais e para o sistema de saúde em geral - público e privado. O estudo longitudinal permite identificar fatos que marcam o processo de medicalização como a divulgação de que o índice de obesos havia superado o de subnutridos no país, o lançamento de novas drogas, a aprovação da realização da cirurgia bariátrica nos hospitais públicos, entre outros. Os médicos foram fontes predominantes nas matérias, principalmente aqueles ligados às instituições públicas e associações médicas. A editoria privilegiada na publicação das matérias sobre obesidade foi o Cotidiano, ganhando o tema um enfoque mais direcionado ao comportamento, ao dia-a-dia das pessoas. O trabalho permite concluir que a imprensa representa um importante papel na construção da epidemia da obesidade, apoiada no discurso médico, autoridade científica que legitima o processo da medicalização, e que conta com o apoio dos laboratórios farmacêuticos e o poder público na disseminação da idéia da doença e de possível cura, mesmo que ela não seja algo realmente iminente. / Abstract: This thesis analyses how obesity, like other physical and behavioral conditions, became part of medicine ascendance, being interpreted as a disease, subject to the medical treatment, with or without drugs, in a process called medicalization. It is discussed that this is a socially constructed process in which its main social actors are health professionals, government and business representatives, and, as analyzed in the present study, the press. The study provides an overview of obesity in Brazil, the United States and European countries, showing some measures of political order that these countries have adopted in trying to slow down the development of obesity. It also shows the obesity stigma, which is not constrained to health issues, but to the search of an established beauty standard, which takes a great number of people, especially women, to practice beauty habits that go from exercising and diets to plastic surgeries and eating disorders. From the analysis of 305 published stories on the Brazilian newspaper Folha de S. Paulo during the period between 1998 to 2008, the present study investigates the role of press as participant in this process. From the analyzed texts, 72% focus on obesity as a disease or epidemic, relating it to other diseases and bringing out the risks, individual and health care costs (public and private). This longitudinal study allows the identification of events that were landmarks in the process of medicalization, such as making public the obesity index having overcome the malnourished in the country, the release of new drugs, the inclusion of bariatric surgery in public hospitals, among others. Doctors were the main sources, specially those participants in public institutions and medical associations. The editorial position in the articles publication on obesity was Cotidiano (Life), making the topic a more targeted approach to behavior and dayto- day lives. The study reveals that the press plays an important role in the obesity epidemic construction, supported by the medical discourse, scientific authority that legitimizes the medicalization process, which has the support of pharmaceutical companies and the public idea dissemination of disease and possible cures, even if it is not something really imminent. / Doutorado / Doutor em Política Científica e Tecnológica

nÃo hà / Na complexidade do tratamento da obesidade, inclui-se a cirurgia bariÃtrica. EntÃo, conhecer os fatores relacionados e caracterÃsticas definidoras dos diagnÃsticos da classe cardiopulmonar associados no perÃodo pÃs-operatÃrio imediato de cirurgia bariÃtrica torna-se essencial para o desenvolvimento da assistÃncia de enfermagem, jà que, a partir dos diagnÃsticos de enfermagem mais prevalentes, intervenÃÃes serÃo instituÃdas. Assim, o estudo teve por objetivo avaliar o perfil de diagnÃstico de enfermagem da classe respostas cardiovasculares/pulmonares de acordo com a taxonomia II da NANDA dos pacientes no pÃs-operatÃrio de cirurgia bariÃtrica. Um estudo transversal foi desenvolvido com 59 pacientes internados em um hospital de referÃncia de cirurgia bariÃtrica no MunicÃpio de Fortaleza/CE, cuja coleta de dados ocorreu no perÃodo de junho de 2010 a junho de 2011. As informaÃÃes foram coletadas por meio de entrevista e exame fÃsico; posteriormente trÃs juÃzes realizaram a inferÃncia dos diagnÃsticos de enfermagem na classe respostas cardiovasculares/pulmonares segundo a Taxonomia da NANDA versÃo 2009-2011. Os dados foram compilados em planilha Excel e a anÃlise estatÃstica realizou-se no STATA versÃo 8.0. O nÃvel de significÃncia adotado no estudo foi 5%. Observou-se o predomÃnio do sexo feminino, com mÃdia de idade 35,3 anos. A maior parte dos pacientes apresentou diagnÃstico de obesidade mÃrbida com IMC > 40 Kg/m2. Os diagnÃsticos reais de maior concordÃncia entre os juÃzes foram PerfusÃo Tissular PerifÃrica Ineficaz (78%), DÃbito CardÃaco DiminuÃdo (76,3%), IntolerÃncia à Atividade e PadrÃo RespiratÃrio Ineficaz (47,5%). Pulsos perifÃricos diminuÃdos, edema, fadiga pÃs-carga alterada e prÃ-carga alterada foram proporcionalmente associados ao diagnÃstico DÃbito CardÃaco DiminuÃdo. AlteraÃÃes na profundidade respiratÃria, dispneia, ortopneia, uso da musculatura acessÃria para respirar, ansiedade, dor, fadiga, fadiga da musculatura respiratÃria foram proporcionalmente associados a PadrÃo RespiratÃrio Ineficaz. Desconforto aos esforÃos, relato verbal de fadiga, relato verbal de fraqueza, resposta anormal da pressÃo sanguÃnea à atividade, estilo de vida sedentÃrio, imobilidade e repouso no leito foram proporcionalmente associados a IntolerÃncia à Atividade. Edema, parestesia, pulsos diminuÃdos, hipertensÃo e tabagismo foram proporcionalmente associados à PerfusÃo Tissular PerifÃrica Ineficaz. Este estudo contribuirà para a construÃÃo da SistematizaÃÃo da AssistÃncia de Enfermagem frente aos diagnÃsticos de enfermagem da classe respostas cardiovasculares/pulmonares, como descrito nos resultados apresentados, e na fundamentaÃÃo cientÃfica para cada diagnÃstico. AlÃm da importante contribuiÃÃo para identificar as reais necessidades e facilitar a utilizaÃÃo de intervenÃÃes adequadas nessa populaÃÃo, està a capacidade de o profissional usufruir dessas informaÃÃes, vista a escassez de pesquisas realizadas com diagnÃsticos de enfermagem em pacientes submetidos à cirurgia bariÃtrica. / The bariatric surgery is included in the complexity of the treatment of obesity. Then, knowing the related factors and defining characteristics of cardiopulmonary diagnostic associated with the immediate postoperative period of bariatric surgery becomes essential for the development of nursing care, since, from the most prevalent nursing diagnoses, interventions will be instituted. Thus, the study aimed to evaluate the profile of nursing diagnosis of the class cardiovascular/pulmonary answers according to NANDA Taxonomy II of the patients after bariatric surgery. A cross-sectional study was conducted with 59 patients hospitalized in a referral hospital for bariatric surgery in the city of Fortaleza, state of CearÃ, which data collection occurred from June 2010 to June 2011. Information was collected through interviews and physical examinations; then three judges made the inference of nursing diagnoses in the class cardiovascular/pulmonary answers according to the NANDA-I Taxonomy 2009-2011. The data were compiled in an Excel spreadsheet and the statistical analysis was carried out in the STATA version 8.0. The significance level in this study was 5%. There was a predominance of females, mean age of 35.3 years. Most patients had a diagnosis of morbid obesity with BMI>40kg/m2. The actual diagnoses of greater agreement among the judges were Ineffective Peripheral Tissue Perfusion (78%), Decreased Cardiac Output (76.3%), and Activity Intolerance and Ineffective Breathing Pattern (47.5%). Decreased peripheral pulses, edema, altered preload and afterload fatigue were proportionally associated with the diagnosis Decreased Cardiac Output. Changes in respiratory depth, dyspnoea, orthopnoea, use of accessory muscles for breathing, anxiety, pain, fatigue, respiratory muscle fatigue were proportionally associated with Ineffective Breathing Patterns. Discomfort in efforts, verbal report of fatigue, verbal report of weakness, abnormal blood pressure response to activity, sedentary lifestyle, immobility and bed rest were proportionally associated with Activity Intolerance. Edema, paresthesia, decreased pulses, hypertension and smoking were proportionally associated with Ineffective Peripheral Tissue Perfusion. This study will contribute to the construction of the Systematization of Nursing Care regarding nursing diagnoses of the class cardiovascular/pulmonary answers, as described in the results presented, and in the scientific basis for each diagnosis. Besides the important contribution to identifying the real needs and facilitating the use of appropriate interventions in this population, it is the ability of the professionals in taking advantage of this information, in view of the scarcity of researches related to nursing diagnoses in patients undergoing bariatric surgery.

Em decorrência do sucesso da cirurgia bariátrica para o tratamento da obesidade grau III e de suas comorbidades associadas, esta cirurgia vem se tornado cada vez mais indicada. A redução do consumo de cuidados com a saúde tem sido relatada após o tratamento cirúrgico, entretanto a utilização de serviços hospitalares não tem sido bem documentada. O conhecimento do consumo destes serviços na cirurgia bariátrica é importante para dimensionar serviços de saúde e custos resultantes desta cirurgia. Objetivos: Analisar o consumo dos serviços hospitalares e de exames bioquímicos em pacientes submetidos à cirurgia bariátrica. Métodos: O estudo foi retrospectivo. A amostra foi constituída por indivíduos do sexo feminino por ser a predominante na população bariátrica. O consumo de serviços hospitalares foi analisado pela quantidade de atendimentos ambulatoriais, hospitalizações, atendimento em pronto-socorro e exames bioquímicos realizados durante quatro anos pós-operatórios e comparados com o período pré-operatório. Os exames bioquímicos analisados foram hemograma completo, colesterol total e frações, triglicérides, albumina, glicemia, insulina, hemoglobina A1c, uréia e creatinina. Estas variáveis foram comparadas com grupos de obesos em tratamento clínico e pacientes cirúrgicos submetidos à cirurgia curativa de câncer colo-retal. Resultados: A quantidade de consultas ambulatoriais não se modificou ao longo do tempo em todos os grupos. O grupo de obesos em tratamento clínico teve maior demanda para esta variável, seguido pelo grupo bariátrico e cirúrgico respectivamente. Hospitalizações aumentaram no grupo bariátrico, entretanto não houve diferenças significativas quando comparadas com os outros grupos. Atendimentos em pronto-socorro não se alteraram durante o estudo e também não houve diferenças para esta variável entre os grupos. O grupo de obesos em tratamento clínico teve maior demanda de exames bioquímicos durante o período, não havendo alteração ao longo do estudo. Já nos grupos bariátrico e cirúrgico esta variável foi reduzida após a cirurgia. O colesterol total e HDL pré-operatório de todos os grupos se apresentaram com valores alterados e houve melhora somente no grupo bariátrico. Triglicérides não estavam elevados no grupo bariátrico e com a cirurgia houve também redução. Valores de glicemia, insulina, hemoglobina A1c e leucócitos (inflamação sistêmica) reduziram-se somente no grupo bariátrico. A creatinina diminuiu nos grupos bariátrico e de obesos em tratamento clínico. Albumina e uréia permaneceram inalteradas em todos os grupos. O Índice de Massa Corporal (IMC) inicial manifestou diferenças entre os grupos, sendo maior no grupo bariátrico, seguido pelos obesos em tratamento clínico e por último o grupo cirúrgico. Somente o grupo bariátrico teve seus valores reduzidos. Conclusão: A cirurgia bariátrica foi capaz de melhorar a maioria das variáveis laboratoriais, juntamente com a perda de peso. Entretanto, há um grande impacto no consumo de visitas ambulatoriais mantendo-se em níveis elevados até o quarto ano após a cirurgia, exceto para a demanda de exames bioquímicos que se reduziu. O consumo de serviços hospitalares destes pacientes é comparável ao de outros pacientes submetidos a cirurgia abdominal de grande porte. A administração hospitalar bem como autoridades de saúde pública devem ficar atentos para as peculiaridades desta demanda face às dimensões do atual problema com a obesidade. / Due to the success of bariatric surgery in the treatment of obesity class III and associated comorbidities, this surgery is becoming more common. Consumption of healthcare has been shown to diminish after surgical treatment but utilization of hospital services has not been well documented. The knowledge of consumption of this service in bariatric surgery is important to project the requirement for health services and the costs resulting from this surgery. Objectives: Analyze the consumption of hospital services and biochemical tests by patients submitted to bariatric surgery. Methods: Retrospective study. Sample was constituted by female individuals because they are predominant in bariatric population. Consumption of hospital services was analyzed by documentation of outpatient visits, hospitalizations, emergency department visits and biochemical tests during four years in the postoperative period, compared to the preoperative year. Variables included hematologic counts, total cholesterol and fractions, triglycerides, albumin, blood glucose, insulin, hemoglobin A1c, urea and creatinine. These variables were compared to conservatively managed obese cases and to surgical patients submitted to curative colorectal cancer operation. Results: Obese nonsurgical participants displayed the highest demand for outpatient visits, followed by bariatric and surgical cases respectively. Hospitalizations increased in bariatric group, however they did reach statistical difference concerning other groups. Emergency visits did not alter along the study and did not have differences between the groups. Obese cases receiving clinical treatment had the highest demand of biochemical tests, without modification along the study. Bariatric and surgical groups demonstrated decrease of this variable after surgery. Preoperatively cholesterol and HDL was abnormal in all groups, subsequent reduction occurring in bariatric group only. Triglycerides were not elevated but again diminished in bariatric group only. Blood glucose, insulin, Hemoglobin A1c and white blood cell count (systemic inflammation) decreased in bariatric subjects only. Creatinine was reduced in bariatric and obese nonsurgical patients. Albumin and urea remained stable in all groups. Initial Body Mass Index was different in all groups, being highest in bariatric group, followed by obese submitted to clinical treatment and colorectal surgical group respectively. Just bariatric subjects had reduction in their values. Conclusion: Bariatric intervention was able to ameliorate most variables, simultaneously to weight loss. However, it has a significant impact on outpatient visits, which maintained high values until four years after surgery. The opposite occurred with biochemical tests which decreased in the follow-up period. Consumption of hospital services by bariatric subjects was comparable to patients requiring major abdominal operations such as colorectal interventions. Hospital administration and public health authorities should consider the characteristics of such demand, since obesity is a significant problem in our days.