BackgroundObesity interventions rely predominantly on managing dietary intake and/or increasing physical activity but sustained adherence to behavioural regimens is often poor. Avatar technology is well established within the computer gaming industry and evidence suggests that virtual representations of self may impact real-world behaviour, acting as a catalyst for sustained weight loss behaviour modification. However, the effectiveness of avatar technology in promoting weight loss is unclear.AimsWe aimed to assess the quantity and quality of empirical support for the use of avatar technologies in adult weight loss interventions.MethodA systematic review of empirical studies was undertaken. The key objectives were to determine if: (i) the inclusion of avatar technology leads to greater weight loss achievement compared to routine intervention; and (ii) whether weight loss achievement is improved by avatar personalisation (avatar visually reflects self).ResultsWe identified 6 papers that reported weight loss data. Avatar-based interventions for weight loss management were found to be effective in the short (4–6 weeks) and medium (3–6 months) term and improved weight loss maintenance in the long term (12 months). Only 2 papers included avatar personalisation, but results suggested there may be some added motivational benefit.ConclusionsThe current evidence supports that avatars may positively impact weight loss achievement and improve motivation. However, with only 6 papers identified the evidence base is limited and therefore findings need to be interpreted with caution.

Continuously reducing excess blood glucose is a primary goal for the management of type 2 diabetes (T2D). Most patients with T2D require glucose-lowering medications to achieve and maintain adequate glycemic control; however, treatment failure may occur, limiting treatment options. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are an emerging therapeutic class that can be prescribed for patients instead of basal insulin after the failure of oral therapies. Recent studies have focused on the durability and tolerability of long-term GLP-1RA therapy. This review summarizes the key efficacy and safety findings from prospective phase 3 clinical studies of at least 76 weeks’ duration for the GLP-1RAs currently approved in the United States and the European Union (albiglutide, dulaglutide, exenatide twice daily [BID], exenatide once weekly [QW], liraglutide, and lixisenatide). Currently, most of the long-term data are from uncontrolled extension studies, and continuous patient benefit has been observed for up to 3 years with multiple GLP-1RAs. Four-year comparative data demonstrated a longer time to treatment failure for exenatide BID than for sulfonylurea, and 3-year comparative extension data demonstrated greater glycated hemoglobin (HbA1c) reductions and weight loss with exenatide QW than with insulin glargine. Currently, the longest extension study for a GLP-1RA is the DURATION-1 study of exenatide QW, with >7 years of clinical data available. Data from DURATION-1 demonstrated that continuous HbA1c reductions and weight loss were observed for the patients continuing on the treatment, with no unexpected adverse events. Taken together, these data support GLP-1RAs as a long-term noninsulin treatment option after the failure of oral therapies.

Background: Liraglutide may be less effective in patients with more advanced type 2 diabetes. This study from the Association of British Clinical Diabetologists Nationwide Liraglutide Audit analysed changes in HbA1c of patients after 26 weeks of treatment with liraglutide 1.2 mg, stratified according to the intensity of their background diabetes therapy, or according to their duration of diabetes. Methods: Patients using liraglutide as add-on therapy were stratified for receipt to one, two or three oral antidiabetic agents (OADs) or insulin (± OAD), or for diabetes duration of 0-5 years, 6-10 years, or >10 years. Changes

The ageing population is expected to increase the burden of osteoporosis on the health care system. Secondary causes of osteoporosis are found in a proportion of patients. There is much controversy regarding the best work-up for patients who have been diagnosed as having osteoporosis based on bone mineral density. It is difficult to decide where interventions should be targeted both from a patient's perspective and for cost effectiveness. We evaluated the utility of a standard panel (full blood count, plasma viscosity, plasma protein, electrophoresis, urine Bence Jones protein, thyroid function test, bone profile, fasting lipids and liver function test) of biochemical investigations in 327 consecutive patients (287 females, 40 males) referred to the new patient osteoporosis clinic from April 1999 to March 2000. Patients were characterised after measurement of spinal/femoral neck bone mineral density after a dual energy X-ray absorptiometry (DEXA) scan. There were 88 patients with osteoporosis, 91 with osteopenia, 130 had normal bone mineral density and 20 who did not have a bone scan. No case of multiple myeloma was found in this cohort of patients. There was no difference in the mean plasma viscosity of patients with and without osteoporosis (P=0.182). There was no significant difference in the abnormal urine calcium/creatinine (Ca/Cr ratio) in patients with osteoporosis and those without osteoporosis (P=0.316). There was no significant difference in the prevalence of hypothyroidism (P=0.213) or thyrotoxicosis (P=0.138) in patients with and without osteoporosis. There was no strong correlation between cholesterol concentrations and osteoporosis (r=0.069). We found no utility in performing a myeloma screen. A small proportion of patients had abnormalities of calcium homeostasis or thyroid disease. We recommend that a screening biochemical evaluation should be restricted to calcium/bone profile and thyroid function tests in patients with a presumptive diagnosis of osteoporosis.

Acute hypoglycaemia is a pathological state induced by low plasma glucose concentration that results in a combination of early adrenergic symptoms due to catecholamine release and neuroglycopenic manifestations secondary to a deficient glucose influx to the brain. The initial adrenergic symptom acts as an early warning system so that hypoglycaemia can be corrected. However, subacute or chronic hypoglycaemia can be insidious and symptoms are not apparent. In chronic recurrent hypoglycaemia, sympathetic activity is reduced or delayed until profound hypoglycaemia develops and this can lead to increased confusion, behavioural changes and life-threatening complications such as convulsions, coma and death.In patients with diabetes, hypoglycaemia is commonly the result of excess insulin, oral hypoglycaemic medication or due to impairment of glucose counterregulation. Other conditions associated with subacute/chronic hypoglycaemia include ethanol consumption, congenital or acquired insulin excess, starvation, hormone deficiencies (hypoadrenalism, hypopituitarism, GH or isolated adrenocorticotropic hormone deficiency), critical illness and major organ failure. Hypoglycaemia in people without diabetes is uncommon. Rarely, symptomatic fasting hypoglycaemia can be induced by solid tumours and can present a diagnostic challenge as illustrated in this case report.A 70-year-old man presented with an intermittent history of violent, inappropriate behaviour, confusion, impaired consciousness and progressive memory and cognitive decline over a period of two years. He was periodically brought to the accident and emergency department with low blood glucose readings ranging between 1.9 mmol/L and 3.5 mmol/L. His symptoms rapidly resolved with intravenous dextrose. Hypoglycaemia was presumed to be secondary to reduced food intake. After correction of hypoglycaemia, he was discharged home from the emergency department. There was no past medical or family history of note. He was not on any regular medication, his alcohol intake was minimal and he was an ex-smoker. None of his family members was on hypoglycaemic agents. The physical examination was unremarkable. However, in view of his recurrent hypoglycaemic episodes, gradual weight loss and worsening cognition, he was admitted to hospital.The results of initial investigations, including full blood count, bone profile, renal, liver and thyroid function tests, prostate specific antigen, tumour markers and myeloma screening, were all within a normal range. Short synacthen and pituitary function tests were also normal. A supervised 24-h fast, which induced symptomatic hypoglycaemia yielded normal insulin (< 10 mU/L) and C-peptide concentrations (< 94 ng/ml). IGF-I and IGF-II were measured and found to be abnormal with a high IGF-II:IGF-I ratio at 15.6 (reference range < 10). Abdominal and pelvic MRI scan revealed a large pelvic tumour (figure 1) and histological features were consistent with retroperitoneal sarcoma. However, surgical excision was thought to be high risk because the patient...

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Francesca Lake, Managing Editor, speaks to Chinnadorai Rajeswaran. Dr Rajeswaran is a consultant physician (Diabetes & Endocrinology) at Mid Yorkshire NHS Trust. He gained specialist training in Leeds, in diabetes and endocrinology. He has a special interest in obesity and is involved in research in obesity and diabetes. He also has a number of publications, book chapters and presentations to his credit. He along with other co-authors has published a book on weight loss surgery, titled: “The Ultimate Guide to Weight Loss Surgery.” He leads the specialist obesity service at the Mid Yorkshire Trust and Kirklees weight management service. With the help of colleagues in diabetes and obesity he set up the National Diabesity Forum. Dr Rajeswaran is also the medical advisor for Simplyweight, a global specialist weight management organization. He is also involved in both local and international charity work.

This is the first reported case of intussusception in a patient with type 1 diabetes mellitus complicated by gastroparesis and autonomic neuropathy. Literature on the reported cases of intussusception in patients with diabetes, its aetiopathology and possible association with gastroparesis has been systematically reviewed following a Medline database search (1951 to June 2003) Intussusception should be considered in the differential diagnosis of gastrointestinal symptoms in diabetic patients presenting with hyperglycaemia.