Background: Malnutrition is highly prevalent and associated with increased morbidity and mortality. Studies continue to reveal significant clinical benefits with nutrition support, including improved ...wound healing, reduction in complications and length of stay, and mortality. Due to these benefits, the prevalence of home parenteral and enteral nutrition (HPEN) continues to increase worldwide. In the United States, given our healthcare insurance landscape, it has been very difficult to ascertain the true prevalence of HPEN. Methods: Medicare beneficiary data for 2013 were obtained from Centers for Medicare and Medicaid Services. Commonly used Healthcare Common Procedure Coding System codes were used for home enteral nutrition (HEN) and home parenteral nutrition (HPN). Data regarding number of patients and insurance providers were also obtained from 3 of the largest home infusion providers in the United States (Coram CVS, Option Care Enterprises, and BioScrip Inc). Based on the ratio of Medicare to non-Medicare billing, an estimate of HPEN prevalence was obtained. Results: For 2013, there were 6778 Medicare beneficiaries for HPN and 114,287 for HEN. The ratio of Medicare to non-Medicare was 0.271 for HPN and 0.261 for HEN, leading to an estimated prevalence of 25,011 patients receiving HPN (79 per million U.S. inhabitants) and 437,882 patients receiving HEN (1385 per million U.S. inhabitants). There are an estimated 4129 pediatric patients and 20,883 adult patients receiving HPN; for HEN, 189,036 pediatric patients and 248,846 adult patients. Conclusion: Compared with results from 1992, the prevalence of HEN has increased dramatically, while the prevalence of HPN has declined.
Evolution of NAFLD and Its Management Mundi, Manpreet S.; Velapati, Saketh; Patel, Janki ...
Nutrition in clinical practice,
February 2020, 2020-Feb, 2020-02-00, 20200201, Letnik:
35, Številka:
1
Journal Article
Recenzirano
Odprti dostop
The global prevalence of nonalcoholic fatty liver disease (NAFLD) is estimated to be 25% and continues to rise worldwide in the setting of the obesity epidemic. This increase is especially concerning ...because NAFLD is often a progressive disease that can be associated with significant complications such as liver cirrhosis, hepatocellular carcinoma, and an increase in liver‐related and overall mortality. Because of the devastating complications and comorbidities, NAFLD is a very costly disease for the healthcare system, with estimated annual direct medical costs exceeding $100 billion in the United States alone. Given this progressive course, it is imperative to make the diagnosis in patients with risk factors (metabolic syndrome, weight gain, and insulin resistance/diabetes). Once the diagnosis is made, the focus should shift to treatment and monitoring for the development of associated complications. Given that currently no pharmaceutical intervention is approved for the treatment of NAFLD, focus shifts instead to mitigation of risk factors through avoidance of foods that are rich in red meat, trans fats, refined carbohydrates, and high‐fructose corn syrup; are low fiber; and have high energy density. The landmark of treatment, however, continues to be weight loss and improvement of insulin resistance, often through a multimodality approach. The current manuscript reviews the clinical phenotypes of NAFLD, its risk factors, and pathogenesis, as well as treatment options including lifestyle modifications and dietary interventions, medical therapies, endoscopic bariatric interventions, and bariatric surgery.
Although bariatric surgery is the most effective therapy for obesity, only a small proportion of candidates undergo this surgery. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive ...procedure that reduces the size of the gastric reservoir. We investigated its durability and effects on body weight and gastrointestinal function in a prospective study of obese individuals.
Twenty-five obese individuals (21 female; mean body mass index, 35.5 ± 2.6 kg/m
; mean age, 47.6 ± 10 years) underwent ESG with endoluminal creation of a sleeve along the gastric lesser curve from September 2012 through March 2015 at the Mayo Clinic in Rochester, Minnesota. Subjects were followed for a median period of 9 months. We measured changes in body weight and recorded adverse events; patients were assessed by endoscopy after 3 months. Four participants underwent pre-ESG and post-ESG analyses to measure solid and liquid gastric emptying, satiation (meal tolerance), and fasting and postprandial levels of insulin, glucose, and gut hormones.
Subjects had lost 53% ± 17%, 56% ± 23%, 54% ± 40%, and 45% ± 41% of excess body weight at 6, 9, 12, and 20 months, respectively, after the procedure (P < .01). Endoscopy at 3 months showed intact gastroplasty in all subjects. After ESG, physiological analyses of 4 participants showed a decrease by 59% in caloric consumption to reach maximum fullness (P = .003), slowing of gastric emptying of solids (P = .03), and a trend toward increased insulin sensitivity (P = .06). Three patients had serious adverse events (a perigastric inflammatory collection, a pulmonary embolism, and a small pneumothorax) but made full recoveries with no need for surgical interventions. No further serious adverse events occurred after the technique was adjusted.
ESG delays gastric emptying, induces early satiation, and significantly reduces body weight. ESG could be an alternative to bariatric surgery for selected patients with obesity. ClincialTrials.gov number: NCT 01682733.
The purpose of this overview is to make the case for the establishment and publication of standards for home enteral nutrition (HEN) therapy in adult patients who require a long-term alternative to ...oral feeding. Overviews can provide a broad and often comprehensive summation of a topic area and, as such, have value for those coming to a subject for the first time. It will provide a broad summation, background and rationale, review specific considerations unique to HEN (tubes, products and supplies) and we describe a recent audit of seven HEN programs which highlights tube and process related challenges. Based on the overview of the literature and our experience with the audit we propose a way forward for best home enteral nutrition care.
Body Composition Technology: Implications for the ICU Mundi, Manpreet S.; Patel, Jayshil J.; Martindale, Robert
Nutrition in clinical practice,
February 2019, 2019-Feb, 2019-02-00, 20190201, Letnik:
34, Številka:
1
Journal Article
Recenzirano
Malnutrition continues to be highly prevalent in hospitalized and critically ill patients and is associated with significant morbidity and mortality. Additionally, survivors of critical illness have ...an increased risk for sarcopenia, which leads to weakness and physical debilitation that can persist for years. Nutrition risk assessment tools have been developed and validated in critically ill patients but have limitations. Variables such as body weight, body mass index, weight change, or percentage of food intake can be difficult to obtain in critically ill patients and may be misleading given changes in body composition, such as an increase in body water. Assessment of body composition through new techniques provides a unique opportunity to counter some of these limitations and develop improved methods of nutrition risk assessment based on objective data. The present manuscript provides a review of the most commonly available clinical technology for assessment of body composition (bioimpedance, computed tomography, and ultrasound), including data from trials in critically ill patients highlighting the benefits and weaknesses of each modality.
Background
Endoscopic sleeve gastroplasty (ESG) is a technique for managing mild to moderately obese patients. We aimed to evaluate the long-term outcomes, reproducibility, and predictors of weight ...response in a large multicenter cohort.
Methods
Patients who underwent ESG between January 2013 and December 2015 in three centers were retrospectively analyzed. All procedures were performed using the Apollo OverStitch device (Apollo Endosurgery, Austin, TX). We performed per protocol (PP) and intention-to-treat (ITT) analyses, where patients lost to follow-up were considered failures. Multivariable linear and logistic regression analyses were performed.
Results
We included 248 patients (mean age 44.5 ± 10 years, 73% female). Baseline BMI was 37.8 ± 5.6 kg/m
2
. At 6 and 24 months, 33 and 35 patients were lost to follow-up, respectively. At 6 and 24 months, %TBWL was 15.2 95%CI 14.2–16.3 and 18.6 15.7–21.5, respectively. Weight loss was similar between centers at both follow-up intervals. At 24 months, % of patients achieving ≥10% TBWL was 84.2 and 53% with PP and ITT analyses, respectively. On multivariable linear regression analysis, only %TBWL at 6 months strongly predicted %TBWL at 24 months (adjusted for age, gender, and baseline BMI,
β
= 1.21,
p
< 0.001). The odds of achieving ≥10%TBWL at 24 months if a patient achieved <10%TBWL at 6 months is 0.18 0.034–0.84. Five (2%) serious adverse events occurred.
Conclusions
ESG effectively induces weight loss up to 24 months in moderately obese patients. Failure to achieve adequate weight loss can be predicted early, and patients should be offered adjunctive therapies to augment it.
Randomized clinical trials have proven the efficacy and safety of Food and Drug Administration (FDA) approved anti-obesity medications (AOMs) for long-term use. It is unclear whether these outcomes ...can be replicated in real-world clinical practice where clinical complexities arise. The aim of this study was to evaluate the effectiveness and side effects of these medications in real-world multidisciplinary clinical practice settings.
We reviewed the electronic medical records (EMR) of patients with obesity who were prescribed an FDA-approved AOM for long-term use in academic and community multidisciplinary weight loss programs between January 2016 and January 2020.
We assessed percentage total body weight loss (%TBWL), metabolic outcomes, and side effect profile up to 24 months after AOM initiation.
The full cohort consisted of 304 patients (76% women, 95.2% White, median age of 50 years old IQR, 39-58). The median follow-up time was 9.1 months IQR, 4.2-14.1 with a median number of 3 visits IQR, 2-4. The most prescribed medication was phentermine/topiramate extended-release (ER) (51%), followed by liraglutide (26.3%), bupropion/naltrexone sustained-release (SR) (16.5%), and lorcaserin (6.2%). %TBWL was 5.0%, 6.8%, 9.3%, 10.3%, and 10.5% at 3, 6, 12, 18, and 24 months. 60.2% of the entire cohort achieved at least 5% TBWL. Overall, phentermine/topiramate-ER had the most robust weight loss response during follow-up, with the highest %TBWL at 12 months of 12.0%. Adverse events were reported in 22.4% of patients. Only 9% of patients discontinued the medication due to side effects.
AOMs resulted in significant long-term weight loss, that was comparable to outcomes previously reported in clinical trials.
Background
Metabolic and bariatric surgery (MBS) has been shown to be safe and effective in the elderly population. Unfortunately, utilization of MBS in patients aged 70 years or older remains low, ...as MBS was just recently endorsed by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity (IFSO) for septuagenarians.
Materials and Methods
We performed a single-center retrospective cohort study of 103 patients aged ≥ 70 years who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from January 2008 until March 2023. The data analyzed included patient demographics, post-operative complications, resolution of obesity-related comorbidities, and weight loss.
Results
A total of 103 patients (71% female; age 72.1 ± 2.5 years; BMI 43.7 ± 6.8 kg/m
2
) were included. Sixty-two patients (60.2%) underwent RYGB while the remaining 41 underwent SG (39.8%), with a mean follow-up of 4.7 ± 3.7 years. There was no MBS-related mortality. All-cause mortality rates were 7.3% for the SG group after a mean period of 4.5 ± 3.9 years compared to 8.1% for the RYGB cohort after 7.7 ± 3.5 years (
p
= 0.601). RYGB was reported to have a higher rate of early and late complications when compared to LSG (
p
= 0.083 and
p
= 0.274). T2DM (
p
= 0.011) and OSA (
p
= 0.019) resolved significantly after RYGB.
Conclusion
Our study demonstrates that bariatric surgery is safe and effective in patients aged 70 years and older. Bariatric surgery should not be denied to this group of patients based on chronological age alone. Further studies are required to support these findings.
Graphical Abstract
It is estimated that over 25,000 Americans receive home parenteral nutrition (HPN), mostly because of intestinal failure (IF). Although there is significant variability in the fluid and energy needs ...of patients receiving HPN, intravenous lipid emulsions (ILEs) are an essential part of the macronutrient composition, serving as an excellent source of non‐protein energy, as well as supplying essential fatty acids. However, the long‐term use of ILEs in particular may be associated with some detrimental health effects, such as intestinal failure associated liver disease (IFALD). Although there is lack of unifying diagnosis, IFALD can present as cholestasis, steatosis, or fibrosis, with a prevalence that ranges between 5% and 43%. The development of IFALD tends to be multifactorial. Risk factors of IFALD can include those related to IF, inflammation/infection, and long‐term parenteral nutrition. Some studies have shown a link between development of IFALD and ILE dose, especially if the dose is >1 g/kg/d, with high ω‐6:ω‐3 polyunsaturated fatty acid (PUFA) ratio and phytosterol content being theorized as some contributing factors. Thus, efforts have been made to use alternative oils (olive oil, medium‐chain triglycerides, and fish oil) to reduce the soybean‐oil content of ILE, which tends to be high in ω‐6 PUFA and phytosterols. Although additional long‐term clinical data are emerging, this strategy, as reviewed in the current manuscript, has shown to provide some benefit in both prevention and treatment of IFALD and other sequelae of HPN.
Background
Despite malnutrition being associated with increased mortality and morbidity, there continues to be great difficulty in defining criteria and implementing widespread screening. Tools used ...to diagnose decreased fat‐free mass (FFM sarcopenia) should be easy to use, relatively inexpensive, and safe. Bioelectrical impedance analysis (BIA) has the potential to meet these criteria, but reliability across body mass index (BMI) classes is a concern.
Methods
A total of 176 healthy ambulatory participants (aged 18–65 years) were recruited equally (n = 44) in 4 BMI categories: (1) 18.5–24.9, (2) 25.0–29.9, (3) 30–34.9, and (4) ≥35.0. Participants were fasting overnight and had S‐MFBIA (InBody 770) measurements the next morning, with DXA being performed subsequently within 30 minutes.
Results
The measurement (mean ± SD) for FFM with DXA was 52.8 ± 11.0, and BIA was 53.6 ± 11.0. Delta (S‐MFBIA vs DXA) was 0.8 ± 2.2 (5% limits of agreement −3.5 to +5.2), and concordance correlation coefficient (CCC) was 0.98 (95% CI, 0.97–0.98). The measurements (mean ± SD) for PBF with DXA was 37.5 ± 10.6% and S‐MFBIA was 36.6 ± 11.3%. Delta (S‐MFBIA vs DXA) was −0.9 ± 2.6 (5% limits of agreement 6.0 to +4.2), and CCC was 0.97 (95% CI, 0.96–0.98). The CCC according to the 4 BMI groups for FFM and PBF was between 0.96–0.98 and 0.90–0.94, respectively.
Conclusions
FFM and PBF measured by S‐MFBIA had good agreement with DXA across all BMI categories measured in the current study of ambulatory participants.
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