Nutritional deficiencies in morbidly obese patients: A new form of malnutrition? Part A: vitamins. Obes Surg. 2008;18:870-876. [PMID: 18465178 DOI: 10.1007/s11695-007-9349-y]

The Interplay Between Adipose Tissue and Vasculature: Role of Oxidative Stress in Obesity

Cardiovascular diseases (CVDs) rank the leading cause of morbidity and mortality globally. Obesity and its related metabolic syndrome are well-established risk factors for CVDs. Therefore, understanding the pathophysiological role of adipose tissues is of great importance in maintaining cardiovascular health. Oxidative stress, characterized by excessive formation of reactive oxygen species, is a common cellular stress shared by obesity and CVDs. While plenty of literatures have illustrated the vascular oxidative stress, very few have discussed the impact of oxidative stress in adipose tissues. Adipose tissues can communicate with vascular systems, in an endocrine and paracrine manner, through secreting several adipocytokines, which is largely dysregulated in obesity. The aim of this review is to summarize current understanding of the relationship between oxidative stress in obesity and vascular endothelial dysfunction. In this review, we briefly describe the possible causes of oxidative stress in obesity, and the impact of obesity-induced oxidative stress on adipose tissue function. We also summarize the crosstalk between adipose tissue and vasculature mediated by adipocytokines in vascular oxidative stress. In addition, we highlight the potential target mediating adipose tissue oxidative stress.

Significance of nutritional status in the development of periprosthetic infections : A retrospective analysis of 194 patients

BACKGROUND

Malnutrition caused by protein and vitamin deficiencies is a significant negative prognostic factor in surgical wound healing disorders and infections. Particularly in elective surgery, preoperative compensation of deficiencies is advisable to avoid negative postoperative consequences. This study examined the nutritional and protein balance of patients with periprosthetic hip and knee joint infections.

MATERIAL AND METHODS

Patients with periprosthetic hip or knee joint infections constituted the study group (SG). Control group I (CG I) included patients with primary implants and CG II included patients who required revision surgery because of aseptic loosening. Relevant nutritional and protein parameters were determined via analysis of peripheral venous blood samples. In addition, a questionnaire was used to evaluate the nutritional and eating patterns of all patients. The nutritional risk screening (NRS) 2002 score and body mass index (BMI) were also calculated for all participants.

RESULTS

Differences were found in the albumin level (SG: 36.23 ± 7.34, CG I: 44.37 ± 3.32, p < 0.001, CG II: 44.06 ± 4.24, p < 0.001) and total protein in serum (SG: 65.42 ± 8.66, CG I: 70.80 ± 5.33, p = 0.004, CG II: 71.22 ± 5.21, p = 0.004). The number of patients with lowered albumin levels (SG 19/61, CG I 1/78, CG II 2/55) and total protein in serum (SG: 12/61, CG I 5/78, CG II 2/55) also showed considerable variation. The number of patients with a NRS 2002 score ≥3 differed significantly between SG and both CGs (SG: 5/61, CG I 1/78, CG II 0/55); however, these differences could not be confirmed using BMI.

CONCLUSION

As expected, lowered albumin and total protein levels were observed in PJI due to the acute phase reaction. The NRS can be performed to exclude nutritional deficiency, which cannot be excluded based on BMI. In cases of periprosthetic joint infection it is reasonable to compensate the nutritional deficiency with dietary supplements.

Ultra-processed food targets bone quality via endochondral ossification

Ultra-processed foods have known negative implications for health; however, their effect on skeletal development has never been explored. Here, we show that young rats fed ultra-processed food rich in fat and sugar suffer from growth retardation due to lesions in their tibial growth plates. The bone mineral density decreases significantly, and the structural parameters of the bone deteriorate, presenting a sieve-like appearance in the cortices and poor trabecular parameters in long bones and vertebrae. This results in inferior mechanical performance of the entire bone with a high fracture risk. RNA sequence analysis of the growth plates demonstrated an imbalance in extracellular matrix formation and degradation and impairment of proliferation, differentiation and mineralization processes. Our findings highlight, for the first time, the severe impact of consuming ultra-processed foods on the growing skeleton. This pathology extends far beyond that explained by the known metabolic effects, highlighting bone as a new target for studies of modern diets.

Selenium, Zinc, Chromium, and Vanadium Levels in Serum, Hair, and Urine Samples of Obese Adults Assessed by Inductively Coupled Plasma Mass Spectrometry

The objective of this study was to investigate of selenium (Se), zinc (Zn), chromium (Cr), and vanadium (V) levels in blood serum, hair, and urine of adult obese patients. A total of 199 lean and 196 obese subjects were enrolled in the study. Serum, hair, and urinary metal and metalloid analysis were performed by inductively coupled plasma mass spectrometry at NexION 300D (PerkinElmer Inc., USA). The results established that obese subjects were characterized by 47% and 30% lower serum Cr and V levels compared with controls, respectively, whereas serum Se levels exceeded control values by 9%. In contrast, hair Cr, Se, and V content in obese subjects exceeded the control values by 51%, 21%, and 50%, respectively. In turn, hair Zn levels were found to be significantly lower by 11% compared with the lean control values. In urine, the levels of V and Zn were found to be 30% and 18% higher in obese patients. Prevalence of hypertension in obese subjects was associated with a trend for impaired Se and Zn levels. In a regression model adjusted for age, gender, hypertension, atherosclerosis, and glucose intolerance, serum Cr, V, and hair Zn were inversely associated with body mass index (BMI), whereas hair Se was considered as the positive predictor. Our data allow proposing that the observed alterations may at least partially contribute to metabolic disturbances in obesity. In turn, monitoring of Se exposure in a well-nourished adult population is required to reduce its potential contribution to obesity.

Sex-related associations among anemia, body mass index, and kidney function in Koreans: A cross-sectional study with propensity analysis

The association between anemia and body mass index (BMI) in Koreans, considering kidney function, has not been clarified. Thus, we aimed to examine the association between anemia and BMI among Korean adults aged ≥19 years.This retrospective cross-sectional study evaluated male and female Korean adults aged ≥19 years who participated in the 5th, 6th, and 7th Korean National Health and Nutrition Examination Surveys (KNHANES) conducted between 2010 and 2017 were used. The participants were classified as underweight, normal weight, and overweight according to their BMI. Anemia was defined as hemoglobin levels of <13 g/dL for men and <12 g/dL for women according to the World Health Organization standards. Kidney function was evaluated according to the estimated glomerular filtration rate (eGFR), with abnormal kidney function in men defined as eGFR <60 mL/min/1.73 m2. Clinicodemographic variables were analyzed using logistic regression adjusted for weight. After propensity score matching (PSM), 6596 study participants were divided into 2 groups of 3298 participants each. Additionally, subgroup analysis by sex and kidney function was performed.On PSM, similar distribution patterns were obtained between the anemia and non-anemia groups; significant differences in BMI; kidney function; level of hemoglobin, hematocrit, and serum creatinine; iron intake; and eGFR were also observed between these groups. Anemia and BMI showed a significant association in both crude and adjusted logistic regression models. In model 2, which was adjusted for age, sex, education level, household income, alcohol consumption, smoking status, and exercise period, underweight men with abnormal kidney function showed a significantly higher risk of anemia than did normal weight men (odds ratio [OR]: 3.27; 95% confidence interval [CI]: 1.25-8.57; P = .016). Meanwhile, overweight men showed a significantly lower risk of anemia than did normal weight men (OR: 0.48; 95% CI: 0.33-0.70, P < .001).Anemia is associated with BMI according to sex. Compared with normal weight men, underweight men with abnormal kidney function had a significantly higher prevalence of anemia after adjusting for kidney function and sex, thus highlighting their need for careful management for anemia.

The implications of vitamin D deficiency on COVID-19 for at-risk populations

Novel coronavirus disease 2019 (COVID-19) has spread to > 10 000 000 individuals in a short time. With no pharmacological agents successfully implemented to control the outbreak, the use of less invasive nonpharmacological agents, such as vitamin D, are increasingly being studied. This purpose of this article is to determine the current knowledge about the risk of COVID-19 development for populations at risk for vitamin D deficiency, including individuals living with overweight and obesity, those of older age, and racial or ethnic minorities. Despite the documented impact of vitamin D on viral disease prevention, many subgroups at risk for contracting COVID-19 are also known to have increased rates of vitamin D deficiency. Because vitamin D is most commonly obtained from sunlight, when interpreted alongside the stay-at-home orders, the importance of identifying safe approaches to obtain sufficient vitamin D is apparent. Furthermore, elucidating the cause-and-effect relationship between vitamin D and COVID-19, including optimal dosing for COVID-19 outcomes, is also warranted for immediate investigation.

Conjunctural hunger and structural obesity in the global scenario: reflections on what Covid-19 masks reveal

ABSTRACT This essay is a reflection on the interconnection of the Covid-19 pandemic, social inequality, food insecurity and obesity in the global scenario. The pandemic health crisis is bound to an economic and social crisis marked by an increase in unemployment and a decrease in income with a consequent growth of food and nutritional insecurity. The impacts are felt worldwide, although the situation in each country, with regard to the conditions of social inequality and access to food, influences the magnitude of the pandemic consequences. At the same time, we are aware that food and nutritional insecurity is associated with low food quality and higher rates of obesity, which impairs the immune response and predisposes to worse prognosis. Thus, more economically vulnerable populations must face poorer disease outcome, besides the worsening of the economic situation and food and nutritional insecurity and the increase in obesity rates.

Novel approaches to sarcopenic obesity and weight management before and after kidney transplantation

PURPOSE OF REVIEW

Although a widely recognized and complex pathophysiological condition, sarcopenic obesity remains less appreciated and may elude diagnosis and workup in both kidney transplant waitlisted candidates and kidney transplant recipients. The lack of consensus definition, and practical diagnostic tools for evaluating waitlisted candidates and transplant recipients are barriers to early detect and initiate therapeutic management for sarcopenic obesity. Although sarcopenia leads to poor clinical outcomes, posttransplant obesity yields conflicting results. Exercise and nutritional managements are common therapies for sarcopenic obese patients; however, surgery weight loss or bariatric surgery in both transplant candidates and potential living kidney donors shows promising benefits for kidney transplant access in waitlist obese candidates but may require to be selected for appropriate patients.

RECENT FINDINGS

Pathogenesis and management for sarcopenia and obesity are interconnected. The benefits of exercise to improve muscle mass and function is clear in waitlist kidney transplant candidates and transplant recipients. However, there are several barriers for those to increase exercise and improve physical activity including patient, provider, and healthcare or environmental factors. The advantages of fat mass reduction to lose weight can promote muscle mass and strength. However, epidemiological data regarding the obesity paradox in dialysis-dependent patients when overnutrition provides survival benefits for this population should be taken into account when performing weight loss especially bariatric surgery.

SUMMARY

Barriers in providing optimal care to kidney transplant waitlisted candidates and transplant recipients may partly result from underdiagnosis of sarcopenic obesity; notwithstanding that this entity has increasingly been more recognized. Mechanistic studies to better understand pathogenesis of sarcopenic obesity will help determine pathogenesis and clinical tools for diagnosis of this entity, which can facilitate further studies related to the outcomes and weight management to ultimately improve kidney transplant outcomes.

The Impact of Obesity in End of Life Care in Patients With End Stage Liver Disease: An Observational Study

BACKGROUND

Both obesity and end stage liver disease (ESLD) are increasing. Obesity's impact on hospice and palliative care in patients with ESLD is unknown.

METHODS

We retrospectively evaluated patients admitted to an academic, Midwestern, tertiary center between January 2016 and May 2019 with a diagnosis of ESLD. Body Mass Index and MELD Na were calculated for each patient's first admission during the study period. Patients with MELD Na scores ≥ 21 or 18-20 with additional criteria were considered potentially eligible for hospice and palliative care referrals.

RESULTS

Of 3863 patients admitted with ESLD, 1556 (40%) were potentially eligible for hospice and palliative care referrals. Of these, 703 (45%) were obese. Comorbidity burden was higher in obese patients (15.6% of obese patients had a Charlson Comorbidity Index ≥ 5, while 5% of non-obese patients had a comorbidity index of ≥ 5 (p < 0.001). Referral rates to hospice and palliative services in obese patients were 10.1% and 16.4% respectively. Hospice and palliative referral rates among non-obese patients were similar (10.1% and 15.5%). Among patients who died within 6 months of the first hospitalization, the mean time to referral to hospice or palliative care from index admission was longer in obese patients.

CONCLUSION

Obesity is common in patients hospitalized with ESLD who may be approaching the end of life. Referral rates to hospice and palliative care services are low and similar regardless of BMI and despite higher co-morbidity burdens in obese patients. Obesity may delay referrals to hospice and palliative care.

Prevalence of nutritional deficiencies in bariatric surgery candidates and its effect on metabolic status

BACKGROUND

Nutritional deficiencies are common among obese individuals and constitute one of the main concerns in the bariatric field. The aim of this study was to investigate nutritional status in bariatric surgery candidates, comparing individuals with and without metabolic syndrome (MetS) and to explore possible associations between nutritional and metabolic status.

METHODS

Patients accepted for gastric sleeve surgery between 2010 and 2015 were included and anthropometric and metabolic parameters were recorded before surgery. Univariate and multivariate analyses were applied in order to find possible associations between MetS, nutritional, anthropometric, and metabolic parameters.

RESULTS

A total of 330 patients were evaluated (285 females, mean age of 41.88 ± 10.4 years old, mean body mass index 43.91 ± 6.2 kg/m²) and MetS was present in 47% of them. Patients without MetS presented a higher prevalence of folate deficiency (12 vs. 2%, p < 0.001). Male gender, older age, lower magnesium levels, and higher BMI and calcium levels were predictors of a greater number of MetS components. Male gender, a greater number of MetS components, and lower magnesium were predictors of higher homeostatic model assessment for insulin resistance (HOMA-IR).

CONCLUSIONS

The rising prevalence of obesity is causing a parallel increase in the use of bariatric surgery. The high occurrence of preoperative nutritional deficiencies can impair metabolic status and contribute to a worse outcome after surgery. Nutritional assessment and improvement before surgery may be crucial to optimize patient status, and future studies should explore the effect of the correction of these deficiencies in the metabolic status of these patients.

Obesity population at risk of COVID-19 complications

Introduction

Global public health is challenged by two concurrent epidemics; COVID-19 and obesity. Considering the global prevalence of obesity, exploring relationships with COVID-19 are of clinical importance. The aim was to provide a comprehensive summary and recommendations on this relationship between COVID-19 and obesity.

Method

A literature search was performed to prepare a narrative review of COVID-19 and obesity.

Results

An obesity state promotes chronic inflammation, vitamin D deficiency, hinders immunity and causes mechanical lung compression. These increase susceptibilities to COVID-19 infection, complications including the requirement of invasive ventilation. Existing co-morbidities enhances these complications. Preventive measures of social distancing and self-isolation may increase stigmatisation and psychological deterrents. Hence, special recommendations targeting this vulnerable population are required.

Conclusion

The obese population is a COVID-19 vulnerable group, requiring special attention during this pandemic to avoid complications and healthcare systems burden. Lacking COVID-19 vaccination, regular physical activity and a healthy diet are recommended with attention to mental health. A prolonged quarantine duration and administration of prophylactic vitamin D may be considered.

The Relevance of Thiamine Evaluation in a Practical Setting

Thiamine is a crucial cofactor involved in the maintenance of carbohydrate metabolism and participates in multiple cellular metabolic processes. Although thiamine can be obtained from various food sources, some common food groups are deficient in thiamine, and it can be denatured by high temperature and pH. Additionally, different drugs can alter thiamine metabolism. In addition, the half-life of thiamine in the body is between 1 and 3 weeks. All these factors could provide an explanation for the relatively short period needed to develop thiamine deficiency and observe the consequent clinical symptoms. Thiamine deficiency could lead to neurological and cardiological problems. These clinical conditions could be severe or even fatal. Marginal deficiency too may promote weaker symptoms that might be overlooked. Patients undergoing upper gastrointestinal or pancreatic surgery could have or develop thiamine deficiency for many different reasons. To achieve the best outcome for these patients, we strongly recommend the execution of both an adequate preoperative nutritional assessment, which includes thiamine evaluation, and a close nutritional follow up to avoid a nutrient deficit in the postoperative period.

Older adults with obesity have higher risks of some micronutrient inadequacies and lower overall dietary quality compared to peers with a healthy weight, National Health and Nutrition Examination Surveys (NHANES), 2011-2014

OBJECTIVE

To evaluate total usual intakes and biomarkers of micronutrients, overall dietary quality and related health characteristics of US older adults who were overweight or obese compared with a healthy weight.

DESIGN

Cross-sectional study.

SETTING

Two 24-h dietary recalls, nutritional biomarkers and objective and subjective health characteristic data were analysed from the National Health and Nutrition Examination Survey 2011-2014. We used the National Cancer Institute method to estimate distributions of total usual intakes from foods and dietary supplements for eleven micronutrients of potential concern and the Healthy Eating Index (HEI)-2015 score.

PARTICIPANTS

Older adults aged ≥60 years (n 2969) were categorised by sex and body weight status, using standard BMI categories. Underweight individuals (n 47) were excluded due to small sample size.

RESULTS

A greater percentage of obese older adults compared with their healthy-weight counterparts was at risk of inadequate Mg (both sexes), Ca, vitamin B6 and vitamin D (women only) intakes. The proportion of those with serum 25-hydroxyvitamin D < 40 nmol/l was higher in obese (12 %) than in healthy-weight older women (6 %). Mean overall HEI-2015 scores were 8·6 (men) and 7·1 (women) points lower in obese than in healthy-weight older adults. In addition, compared with healthy-weight counterparts, obese older adults were more likely to self-report fair/poor health, use ≥ 5 medications and have limitations in activities of daily living and cardio-metabolic risk factors; and obese older women were more likely to be food-insecure and have depression.

CONCLUSIONS

Our findings suggest that obesity may coexist with micronutrient inadequacy in older adults, especially among women.

Reported nutrient intake over 7 years after Roux-en-Y gastric bypass in the Longitudinal Assessment of Bariatric Surgery-3 (LABS-3) psychosocial study

BACKGROUND

Bariatric surgery is the most effective therapy for severe obesity. It reduces gastric capacity and may modify regulation of appetite, satiety, insulin, and other physiologic processes, resulting in weight loss.

OBJECTIVE

Long-term data on postsurgical nutrient intake are lacking.

SETTING

The Longitudinal Assessment of Bariatric Surgery-3 psychosocial study.

METHODS

Reported dietary intake was assessed in a subset of participants (n = 72) of the Longitudinal Assessment of Bariatric Surgery-3 psychosocial study who underwent Roux-en-Y gastric bypass surgery. Two 24-hour diet recalls at presurgery and annual assessments over 7 years were obtained. Reported diets were evaluated for energy, macro- and micronutrient intake, and assessed for adequacy by comparison to the dietary reference intakes.

RESULTS

After surgery, reported intake of total energy, and all macronutrients were significantly reduced. At least a quarter of participants reported protein intake below the recommended dietary allowance. Over half of participants reported intake of several vitamins (C, D, A, E, thiamin, folate) and minerals (zinc, calcium) below recommended levels over 7 years. Compared with presurgery, reported energy intake was reduced over 7 years. This study was registered at ClinicalTrials.gov as NCT02495142.

CONCLUSIONS

The reduction in energy resulted in intakes below the dietary reference intakes for many micronutrients among the majority of participants and below the recommended dietary allowance for protein in a substantial subgroup. These data support continued long-term nutrition education, monitoring, and supplementation.

Hypoalbuminemia Is Associated With Increased Postoperative Mortality and Complications in Hand Surgery

Background: Malnutrition has been associated with increased perioperative morbidity and mortality in orthopedic surgery. This study was designed with the hypothesis that preoperative hypoalbuminemia, a marker for malnutrition, is associated with increased complications after hand surgery. Methods: A retrospective cohort study of 208 hand-specific Current Procedural Terminology codes was conducted with the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013. In all, 629 patients with low serum albumin were compared with 4079 patients with normal serum albumin. The effect of hypoalbuminemia was tested for association with 30-day postoperative mortality, and major and minor complications. Results: Hypoalbuminemia was independently associated with emergency surgery, diabetes mellitus, dependent functional status, hypertension, end-stage renal disease, current smoking status, and anemia. Patients with hypoalbuminemia had a higher rate of mortality, minor complications, and major complications. Conclusions: Hypoalbuminemia is associated with an increased risk of postoperative morbidity and mortality in patients undergoing hand surgery. As such, increased focus on perioperative nutrition optimization may lead to improved outcomes for patients undergoing hand surgery.

Obesity or BMI Paradox? Beneath the Tip of the Iceberg

The obesity paradox refers to extant evidence showing that obesity in older subjects or in patients with several chronic diseases may be protective and associated with decreased mortality. A number of mechanisms have been postulated to support the existence of obesity paradox; however, marked heterogeneity was found across studies and this has cast doubt on the actual presence of this phenomenon. The aim of the present narrative review is to summarize evidence underlying the concept of obesity paradox, focusing on limitations and bias related to this phenomenon, with emphasis on the use of body mass index (BMI). A major cause of the discrepancy between studies may be related to the use of BMI in the definition of obesity, that should consider, instead, excess body fat as the main characteristic of this disease and as the unique determinant of its complications. In addition, the adjustment for potential confounders (e.g., stage and grade of diseases, smoking habit, inability to capture the presence of signs of undernutrition in the normal-weight comparative group, consideration of body composition) may significantly scale down the protective role of obesity in terms of mortality. However, it is still necessary to acknowledge few biases (e.g., reverse causation, attrition bias, selection bias of healthy obese subjects or resilient survivors) that would still apply to obesity even when defined according with body composition. Further research should be prompted in order to promote correct phenotyping of patients in order to capture properly the trajectories of mortality in a number of diseases.

Obesity and adiposity: the culprit of dietary protein efficacy

Obesity and increased body adiposity have been alarmingly increasing over the past decades and have been linked to a rise in food intake. Many dietary restrictive approaches aiming at reducing weight have resulted in contradictory results. Additionally, some policies to reduce sugar or fat intake were not able to decrease the surge of obesity. This suggests that food intake is controlled by a physiological mechanism and that any behavioural change only leads to a short-term success. Several hypotheses have been postulated, and many of them have been rejected due to some limitations and exceptions. The present review aims at presenting a new theory behind the regulation of energy intake, therefore providing an eye-opening field for energy balance and a potential strategy for obesity management.

Wernicke's encephalopathy, refeeding syndrome and wet beriberi after laparoscopic sleeve gastrectomy: the importance of thiamine evaluation

We described the case of a young man with morbid obesity who underwent bariatric surgery who experiences different complications. After the discharge the patient starts to complain about nausea, dizziness, and visual impairment. After a first access to an emergency department, with a diagnosis of labyrinthopathy, the patient gets worse. He then has been hospitalized and a wernicke's encephalopathy was diagnosed. During the hospitalization other comploication of low thiamine appeared such as wet beriberi. The clinical picture was also complicated with the refeeding syndrome. Wernicke's encephalopathy, wet beriberi, and refeeding syndrome are life-threatening conditions that can be prevented and treated. Both physicians and patients must be warned about these potential risks in order to put in act a prompt treatment.

Bariatric Surgery in Obesity: Effects on Gut Microbiota and Micronutrient Status

Obesity is associated with reduced gut microbial diversity and a high rate of micronutrient deficiency. Bariatric surgery, the therapy of choice for severe obesity, produces sustained weight loss and improvements in obesity-related comorbidities. Also, it significantly alters the gut microbiota (GM) composition and function, which might have an important impact on the micronutrient status as GM is able to synthesize certain vitamins, such as riboflavin, folate, B12, or vitamin K2. However, recent data have reported that GM is not fully restored after bariatric surgery; therefore, manipulation of GM through probiotics represents a promising therapeutic approach in bariatric patients. In this review, we discuss the latest evidence concerning the relationship between obesity, GM and micronutrients, the impact of bariatric surgery on GM in relation with micronutrients equilibrium, and the importance of the probiotics' supplementation in obese patients submitted to surgical treatment.

Zinc supplementation improves body weight management, inflammatory biomarkers and insulin resistance in individuals with obesity: a randomized, placebo-controlled, double-blind trial

BACKGROUND

The present study was designed to determine whether zinc supplementation would increase the effects of restricted calorie diet (RCD) on obesity.

METHODS AND MATERIALS

A randomized, double-blind clinical trial was performed on 40 obese subjects who were randomly assigned to receive zinc supplements (30 mg/day) or placebo for a period of 15-weeks. Both groups were under a restricted calorie diet (~ 300 kcal lower than the estimated energy requirement). Anthropometric measurements, biochemical markers, appetite, and dietary intakes were determined during the study period.

RESULTS

The reductions of body weight, body mass index, waist circumference, and hip circumference were significantly higher in the zinc group compared to the placebo group (P = 0.032, 0.025, 0.003, and 0.0001, respectively). Lower levels of high sensitivity C-reactive protein, apelin, homeostatic model assessment of insulin resistance (HOMA-IR), and appetite score were observed in the zinc group in comparison with the placebo group (P = 0.0001, 0.001, 0.031 and 0.001 respectively).

CONCLUSION

This study indicates that Zn supplementation with a restricted calorie diet has favorable effects in reducing anthropometric measurements, inflammatory markers, insulin resistance and appetite in individuals with obesity, and may play an effective role in the treatment of obesity.Trial registration This clinical trial was registered at clinicaltrials.gov at the U.S. National Library of Medicine (NCT02516475).

Hypoalbuminemia is a risk factor for predicting early postoperative complications after proximal humerus fracture fixation

Background

Hypoalbuminemia is a marker for malnourishment and is associated with poor outcomes in the setting of hip fractures, periprosthetic joint fractures, and spine surgery. We hypothesized that hypoalbuminemia is associated with higher rates of early complication in patients undergoing surgical treatment for proximal humerus fractures.

Methods

Utilizing the ACS NSQIP database, all proximal humerus fractures treated with plate fixation were extracted from 2006 to 2015. Two cohorts were compared based on hypoalbuminemia (albumin <3.5 g/dL) versus normoalbuminemia (albumin >3.5 g/dL). Patient demographics and postoperative complications were analyzed with multivariable regression.

Results

Out of 916 patients undergoing PHF surgery, 290(31.7%) satisfied criteria for hypoalbuminemia (mean age: 65.9, female: 71%). Among 339 obese patients with BMI>30, 87 (25.7%) were hypoalbuminemic. Patients with hypoalbuminemia were overall at higher risk of any (29.7% vs 12.1%, p < 0.001), major (10.0% vs 2.4%, p < 0.001), and minor complications (24.1% vs 11.0%, p < 0.001) as well as readmissions (12.7% vs 5.1%, p < 0.001). Obese hypoalbuminemic patients had similar rates of complication as non-obese hypoalbuminemic patients. Multivariable regression showed that hypoalbuminemia had an odds ratio of 1.85(p = 0.003) for predicting any complication within 30 days of surgery.

Conclusion

Hypoalbuminemia is associated with higher risk for complications and readmission after PHFs. It occurs more frequently in patients with chronic disease and is predictive of malnourishment. Paradoxically, hypoalbuminemia is not uncommon in obese patients.

Level of evidence

III; Retrospective Cohort Study.

COPD and the gut-lung axis: the therapeutic potential of fibre

Current management strategies for chronic obstructive pulmonary disease (COPD) incorporate a step-wise, multidisciplinary approach to effectively manage patient symptoms and prevent disease progression. However, there has been limited advancement in therapies to address the underlying cause of COPD pathogenesis. Recent research has established the link between the lungs and the gut-the gut-lung axis -and the gut microbiome is a major component. The gut microbiome is likely perturbed in COPD, contributing to chronic inflammation. Diet is a readily modifiable factor and the diet of COPD patients is often deficient in nutrients such as fibre. The metabolism of dietary fibre by gut microbiomes produces anti-inflammatory short chain fatty acid (SCFAs), which could protect against inflammation in the lungs. By addressing the 'fibre gap' in the diet of COPD patients, this targeted dietary intervention may reduce inflammation, both systemically and in the airways, and value-add to the paradigm shift in respiratory medicine, from reactive to personalised and participatory medicine.

Broad-Ranging Nutritional Deficiencies Predict Amputation in Diabetic Foot Ulcers

Diabetic foot ulcers present across the spectrum of nonhealing wounds, be it acute or many months duration. There is developing literature highlighting that despite this group having high caloric intake, they often lack the micronutrients essential for wound healing. This study reports a retrospective cohort of patients’ micro- and macro-nutritional state and its relationship to amputation. A retrospective cohort was observed over a 2-month period at one of Australia’s largest tertiary referral centers for diabetic foot infection and vascular surgery. Patient information, duration of ulcer, various biochemical markers of nutrition and infection, and whether the patient required amputation were collected from scanned medical records. A cohort of 48 patients with a broad-spectrum of biochemical markers was established. Average hemoglobin A1c (HbA1c) was 8.6%. A total of 58.7% had vitamin C deficiency, including 30.4% with severe deficiency, average 22.6 Ł} 5.8 μmol/L; 61.5% had hypoalbuminemia, average albumin 28.7 Ł} 2.5 g/L. Average vitamin B12 was 294.6 Ł} 69.6 pmol/L; 57.9% had low vitamin D, average 46.3 Ł} 8.3 nmol/L. Basic screening scores for caloric intake failed to suggest this biochemical depletion. There was a 52.1% amputation rate; biochemical depletion was associated with risk of amputation with vitamin C ( P < .01), albumin ( P = .03), and hemoglobin ( P = .01), markedly lower in patients managed with amputation than those managed conservatively. There was no relation between duration of ulceration and nutrient depletion. Patients with diabetic foot ulceration rely on multidisciplinary care to optimize their wound healing. An important but often overlooked aspect of this is nutritional state, with micronutrients being very important for the healing of complex wounds. General nutritional screening often fails to identify patients at risk of micronutrient deficiency. There is a high prevalence of vitamin deficiency in patients with diabetic foot ulcers. This presents an excellent avenue for future research to assess if aggressive nutrient replacement can improve outcomes in this cohort of patients.

Systematic review of nutrition screening and assessment in inflammatory bowel disease

BACKGROUND

Malnutrition is prevalent in inflammatory bowel disease (IBD). Multiple nutrition screening (NST) and assessment tools (NAT) have been developed for general populations, but the evidence in patients with IBD remains unclear.

AIM

To systematically review the prevalence of abnormalities on NSTs and NATs, whether NSTs are associated with NATs, and whether they predict clinical outcomes in patients with IBD.

METHODS

Comprehensive searches performed in Medline, CINAHL Plus and PubMed. Included: English language studies correlating NSTs with NATs or NSTs/NATs with clinical outcomes in IBD. Excluded: Review articles/case studies; use of body mass index/laboratory values as sole NST/NAT; age < 16.

RESULTS

Of 16 studies and 1618 patients were included, 72% Crohn’s disease and 28% ulcerative colitis. Four NSTs (the Malnutrition Universal Screening Tool, Malnutrition Inflammation Risk Tool (MIRT), Saskatchewan Inflammatory Bowel Disease Nutrition Risk Tool (SaskIBD-NRT) and Nutrition Risk Screening 2002 (NRS-2002) were significantly associated with nutritional assessment measures of sarcopenia and the Subjective Global Assessment (SGA). Three NSTs (MIRT, NRS-2002 and Nutritional Risk Index) were associated with clinical outcomes including hospitalizations, need for surgery, disease flares, and length of stay (LOS). Sarcopenia was the most commonly evaluated NAT associated with outcomes including the need for surgery and post-operative complications. The SGA was not associated with clinical outcomes aside from LOS.

CONCLUSION

There is limited evidence correlating NSTs, NATs and clinical outcomes in IBD. Although studies support the association of NSTs/NATs with relevant outcomes, the heterogeneity calls for further studies before an optimal tool can be recommended. The NRS-2002, measures of sarcopenia and developments of novel NSTs/NATs, such as the MIRT, represent key, clinically-relevant areas for future exploration.

Malnutrition in obesity before and after bariatric surgery

Bariatric surgeries are considered the only effective way of weight loss therapy in morbidly obese patients, i.e. body mass index ≥ 35. However, micronutrient deficiencies and malnutrition are common after most bariatric procedures and thus, pre- and postoperative nutritional assessment and corrections are advised. The present review is presented in an effort to describe in some detail about prevalence, and mechanisms of macro- and micronutrient deficiencies in obese and post-bariatric surgery individuals. We also aimed to summarize the data on screening and supplementation of macro- and micronutrients before and after bariatric surgeries.

Increased concentration of serum MDA, decreased antioxidants and altered trace elements and macro-minerals are linked to obesity among Bangladeshi population

BACKGROUND AND OBJECTIVE

Obesity is an emerging public health concern in Bangladesh. This study aimed to find the levels of the serum malondialdehyde (MDA), non-enzymatic antioxidants (vitamin A, C and E), trace elements (zinc and iron) and macro-minerals (calcium, potassium and sodium) in obesity and its action in disease advancement.

METHODS

Level of lipid peroxidation was estimated by measurement of the serum concentrations of malondialdehyde (MDA). Vitamin A and E concentration was found by RP-HPLC method and vitamin C was assessed for serum ascorbic acid by UV spectrophotometric method. Serum trace elements (Zn and Fe) and macro-minerals (Na, K and Ca) were estimated by Atomic Absorption Spectroscopy (AAS).

RESULTS

Our study observed significantly elevated concentrations of MDA (p < 0.001) and depleted concentrations of antioxidants (vitamin A, E and C) (p < 0.05) in the patient than control group. Analysis of serum trace elements (Zn and Fe) and macro-minerals (Na, K and Ca) and found that the mean values of Zn, Fe, Na, K and Ca were 0.39 ± 0.02 and 0.43 ± 0.03, 3284.81 ± 34.51, 162.18 ± 3.72, 44.62 ± 2.13 mg/L for the patient and 0.91 ± 0.13, 0.88 ± 0.06, 2562.74 ± 95.92, 243.58 ± 8.97, 87.66 ± 2.10 mg/L for the controls, consequently. There was a substantial difference in trace elements and macro-minerals between the patients and controls (p < 0.001).

CONCLUSION

Our study proposes that increased serum concentrations of MDA and decreased non-enzymatic antioxidant and altered trace elements and macro-minerals are powerfully related with obesity.

The Future of Bread in View of its Contribution to Nutrient Intake as a Starchy Staple Food

The growing, ageing, more urbanized and more sedentary global population urges for increased, more nutritious and more secure food supply. To combat undernutrition, adequate nutrient intake is required. Staple foods, especially starch based ones, like (pseudo)cereals, roots and tubers, are by definition contributing for a very large extent to our nutrient intake. It is important therefore that the contribution of ready to consume staple foods to the recommended intakes of nutrients are compared. This can be done in a transparent and simple way by calculating the nutrient contribution of ready to eat staple foods to the recommended daily allowances (RDA) or daily reference intakes (DRI). By using online nutrition tables from the USA and Europe, and DRI by USA and RDA by European food authorities, the potential nutrient contributions of staple foods were calculated. It can be concluded that consumption of ready to eat staple foods from the bread category and lentils overall contribute most to the recommended nutrient intakes. In view of its convenience, bread, especially whole grain bread is the staple food of choice to combat the future food supply challenges ahead.

Reuniting overnutrition and undernutrition, macronutrients, and micronutrients

Over-nutrition and its late consequences are a dominant theme in medicine today. In addition to the health hazards brought on by over-nutrition, the medical community has recently accumulated a roster of health benefits with obesity, grouped under "obesity paradox." Throughout the world and throughout history until the 20^th century, under-nutrition was a dominant evolutionary force. Under-nutrition brings with it a mix of benefits and detriments that are opposite to and continuous with those of over-nutrition. This continuum yields J-shaped or U-shaped curves relating body mass index to mortality. The overweight have an elevated risk of dying in middle age of degenerative diseases while the underweight are at increased risk of premature death from infectious conditions. Micronutrient deficiencies, major concerns of nutritional science in the 20^th century, are being neglected. This "hidden hunger" is now surprisingly prevalent in all weight groups, even among the overweight. Because micronutrient replacement is safe, inexpensive, and predictably effective, it is now an exceptionally attractive target for therapy across the spectrum of weight and age. Nutrition-related conditions worthy of special attention from caregivers include excess vitamin A, excess vitamin D, and deficiency of magnesium.

Interactions between nutrients in the maternal diet and the implications for the long-term health of the offspring

Nutritional science has traditionally used the reductionist approach to understand the roles of individual nutrients in growth and development. The macronutrient dense but micronutrient poor diets consumed by many in the Western world may not result in an overt deficiency; however, there may be situations where multiple mild deficiencies combine with excess energy to alter cellular metabolism. These interactions are especially important in pregnancy as changes in early development modify the risk of developing non-communicable diseases later in life. Nutrient interactions affect all stages of fetal development, influencing endocrine programming, organ development and the epigenetic programming of gene expression. The rapidly developing field of stem cell metabolism reveals new links between cellular metabolism and differentiation. This review will consider the interactions between nutrients in the maternal diet and their influence on fetal development, with particular reference to energy metabolism, amino acids and the vitamins in the B group.

MANAGEMENT OF ENDOCRINE DISEASE: Which metabolic procedure? Comparing outcomes in sleeve gastrectomy and Roux-en Y gastric bypass

Obesity and its associated comorbidities have become one of the largest challenges for health care in the near future. Conservative therapy for obesity and related comorbidities has a very high failure rate and poor long-term results. Similarly, the conservative and medical management of the majority of metabolic diseases such as type 2 diabetes mellitus are only able to slow down disease progression but have no causal effect on the disease process. Obesity surgery has evolved as a highly effective therapy for severe obesity achieving long-lasting weight loss. Furthermore, several studies have demonstrated the beneficial effects of obesity surgery on reduction of overall mortality, reduction of cardiovascular events and superior control of obesity-related diseases such as type 2 diabetes mellitus, dyslipidemia and also the non-alcoholic steatohepatitis compared to medical therapy. Based on these findings, the term 'metabolic surgery' with the focus on treating metabolic diseases independent of body weight has been coined. Of great interest are recent studies that show that even existing complications of metabolic diseases such as diabetic nephropathy or the non-alcoholic steatohepatitis can be reversed by metabolic surgery. Although metabolic surgery has proven to be a safe and effective treatment for obesity, resolution of comorbidities and enhancing quality of life, it is still uncertain and unclear, which surgical procedure is the most effective to achieve these metabolic effects. The aim of this review is to compare the effects of the two currently most widely used metabolic operations, the Roux-en-Y gastric bypass and the sleeve gastrectomy in the treatment of obesity and its related comorbidities.

The relationship between preoperative nutritional state and adverse outcome following abdominal and thoracic surgery in children: Results from the NSQIP database

INTRODUCTION

Anthropometric measurements can be used to define pediatric malnutrition. Our study aims to: (1) characterize the preoperative nutritional status of children undergoing abdominal or thoracic surgery, and (2) describe the associations between WHO-defined acute (stunting) and chronic (wasting) undernutrition (Z-scores <-2) and obesity (BMI Z-scores >+2) with 30-day postoperative outcomes.

METHODS

We queried the Pediatric NSQIP Participant Use File and extracted data on patients' age 29days to 18years who underwent abdominal or thoracic procedures. Normalized anthropometric measures were calculated, including weight-for-height for <2years, BMI for ages ≥2years, and height for age. Logistic regression models were developed to assess nutritional outlier status as an independent predictor of postoperative outcome.

RESULTS

23,714 children (88% ≥2y) were evaluated. 4272 (18%) were obese, while 2640 (11.1%) and 904 (3.8%) were stunted and wasted, respectively, after controlling for gender, ASA/procedure/wound classification, preoperative steroid use, need for preoperative nutritional support, and obese children had higher odds of SSIs (OR 1.29, 95% CI 1.1-1.5, p=0.001), while stunted children were at increased risk of any 30-day postoperative complication (OR 1.16, 95% CI 1.0-1.3, p=0.036).

CONCLUSION

Children who are stunted or obese are at increased risk of adverse outcome after abdominal or thoracic surgery.

LEVEL OF EVIDENCE

III.

Vitamin D limits inflammation-linked microRNA expression in adipocytes in vitro and in vivo: A new mechanism for the regulation of inflammation by vitamin D

Inflammation of adipose tissue is believed to be a contributing factor to many chronic diseases associated with obesity. Vitamin D (VD) is now known to limit this metabolic inflammation by decreasing inflammatory marker expression and leukocyte infiltration in adipose tissue. In this study, we investigated the impact of VD on microRNA (miR) expression in inflammatory conditions in human and mouse adipocytes, using high-throughput methodology (miRNA PCR arrays). Firstly, we identified three miRs (miR-146a, miR-150, and miR-155) positively regulated by TNFα in human adipocytes. Interestingly, the expression of these miRs was strongly prevented by 1,25(OH)₂D preincubation. These results were partly confirmed in 3T3-L1 adipocytes (for miR-146a and miR-150). The ability of VD to control the expression of these miRs was confirmed in diet-induced obese mice: the levels of the three miRs were increased following high fat (HF) diet in epididymal white adipose tissue and reduced in HF diet fed mice supplemented with VD. The involvement of NF-κB signaling in the induction of these miRs was confirmed in vitro and in vivo using aP2-p65 transgenic mice. Finally, the ability of VD to deactivate NF-κB signaling, via p65 and IκB phosphorylation inhibition in murine adipocyte, was observed and could constitute a driving molecular mechanism. This study demonstrated for the first time that VD modulates the expression of miRs in adipocytes in vitro and in adipose tissue in vivo through its impact on NF-κB signaling pathway, which could represent a new mechanism of regulation of inflammation by VD.

Association Between Enteral Feeding, Weight Status, and Mortality in a Medical Intensive Care Unit

BACKGROUND

Clinical practice guidelines recommend enteral nutrition for most patients receiving mechanical ventilation. However, recently published evidence on the effect of enteral nutrition on mortality, particularly for patients who are well nourished, is conflicting.

OBJECTIVES

To examine the association between enteral feeding and hospital mortality in critically ill patients receiving mechanical ventilation and to determine if body mass index mediates this relationship.

METHODS

A retrospective cohort study of patients receiving mechanical ventilation admitted to a medical intensive care unit in 2013. Demographic and clinical variables were collected. Cox proportional hazards regression was used to examine the relationship between an enteral feeding order and hospital mortality and to determine if the relationship was mediated by body mass index.

RESULTS

Of 777 patients who had 811 hospitalizations requiring mechanical ventilation, 182 (23.4%) died in the hospital. A total of 478 patients (61.5%) received an order for enteral tube feeding, which was associated with a lower risk of death (hazard ratio, 0.41; 95% CI, 0.29-0.59). Body mass index did not mediate the relationship between mortality and receipt of an order for enteral feeding. Median stay in the unit was 3.6 days. Most deaths (72.0%) occurred more than 48 hours after admission.

CONCLUSION

The finding of a positive association between an order for enteral feeding and survival supports enteral feeding of patients in medical intensive care units. Furthermore, the beneficial effect of enteral feeding appears to apply to patients regardless of body mass index.

Feeding the critically ill obese patient: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify effective enteral nutritional regimens targeting protein and calorie delivery for the critically ill obese patient on morbidity and mortality.More specifically, the review question is:In the critically ill obese patient, what is the optimal enteral protein and calorie target that improves mortality and morbidity?

BACKGROUND

The World Health Organization (WHO) defines obesity as abnormal or excessive fat accumulation that may impair health, or, empirically, as a body mass index (BMI) ≥ 30 kg/m. Twenty-eight percent of the Australian population is obese with the prevalence rising to 44% in rural areas, and there is evidence that rates of obesity are increasing. The prevalence of obese patients in intensive care largely mirrors that of the general population. There is concern, however, that this may also be rising. A recently published multi-center nutritional study of critically ill patients reported a mean BMI of 29 in their sample, suggesting that just under 50% of their intensive care population is obese. It is inevitable, therefore, that the intensivist will care for the critically ill obese patient.Managing the critically ill obese patient is challenging, not least due to the co-morbid diseases frequently associated with obesity, including diabetes mellitus, cardiovascular disease, dyslipidaemia, sleep disordered breathing and respiratory insufficiency, hepatic steatohepatitis, chronic kidney disease and hypertension. There is also evidence that metabolic processes differ in the obese patient, particularly those with underlying insulin resistance, itself a marker of the metabolic syndrome, which may predispose to futile cycling, altered fuel utilization and protein catabolism. These issues are compounded by altered drug pharmacokinetics, and the additional logistical issues associated with prophylactic, therapeutic and diagnostic interventions.It is entirely plausible that the altered metabolic processes observed in the obese intensify and compound the metabolic changes that occur during critical illness. The early phases of critical illness are characterized by an increase in energy expenditure, resulting in a catabolic state driven by the stress response. Activation of the stress response involves up-regulation of the sympathetic nervous system and the release of pituitary hormones resulting in altered cortisol metabolism and elevated levels of endogenous catecholamines. These produce a range of metabolic disturbances including stress hyperglycemia, arising from both peripheral resistance to the effects of anabolic factors (predominantly insulin) and increased hepatic gluconeogenesis. Proteolysis is accelerated, releasing amino acids that are thought to be important in supporting tissue repair, immune defense and the synthesis of acute phase reactants. There is also altered mobilization of fuel stores, futile cycling, and evidence of altered lipoprotein metabolism. In the short term this is likely to be an adaptive response, but with time and ongoing inflammation this becomes maladaptive with a concomitant risk of protein-calorie malnutrition, immunosuppression and wasting of functional muscle tissue resulting from protein catabolism, and this is further compounded by disuse atrophy. Muscle atrophy and intensive care unit (ICU) acquired weakness is complex and poorly understood, but it is postulated that the provision of calories and sufficient protein to avoid a negative nitrogen balance mitigates this process. Avoiding lean muscle mass loss in the obese intuitively has substantial implications, given the larger mass that is required to be mobilized during their rehabilitation phase.There is, in addition, evolving evidence that hormones derived from both the gut and adipose tissue are also involved in the response to stress and critical illness, and that adipose tissue in particular is not a benign tissue bed, but rather should be considered an endocrine organ. Some of these hormones are thought to be pro-inflammatory and some anti-inflammatory; however both the net result and clinical significance of these are yet to be fully elucidated.The provision of adequate nutrition has become an integral component of supportive ICU care, but is complex. There is ongoing debate within critical care literature regarding the optimal route of delivery, the target dose, and the macronutrient components (proportion of protein and non-protein calories) of nutritional support. A number of studies have associated caloric deficit with morbidity and mortality, with the resultant assumption that prescribing sufficient calories to match energy expenditure will reduce morbidity and mortality, although the evidence base underpinning this assumption is limited to observational studies and small, randomized trials.There is research available that suggests hyper-caloric feeding or hyper-alimentation, particularly of carbohydrates, may result in increased morbidity including hyperglycemia, liver steatosis, respiratory insufficiency with prolonged duration of mechanical ventilation, re-feeding syndrome and immune suppression. But the results from studies of hypo-caloric and eucaloric feeding regimens in critically ill patients are conflicting, independent of the added metabolic complexities observed in the critically ill obese patient.Notwithstanding the debate regarding the dose and components of nutritional therapy, there is consensus that nutrition should be provided, preferably via the enteral route, and preferably initiated early in the ICU admission. The enteral route is preferred for a variety of reasons, not the least of which is cost. In addition there is evidence to suggest the enteral route is associated with the maintenance of gut integrity, a reduction in bacterial translocation and infection rates, a reduction in the incidence of stress ulceration, attenuation of oxidative stress, release of incretins and other entero-hormones, and modulation of systemic immune responses. Yet there is evidence that the initiation of enteral nutritional support for the obese critically ill patient is delayed, and that when delivered is at sub-optimal levels. The reasons for this remain obscure, but may be associated with the false assumption that every obese patient has nutritional reserves due to their adipose tissues, and can therefore withstand longer periods with no, or reduced nutritional support. In fact obesity does not necessarily protect from malnutrition, particularly protein and micronutrient malnutrition. It has been suggested by some authors that the malnutrition status of critically ill patients is a stronger predictor of mortality than BMI, and that once malnutrition status is controlled for, the apparent protective effects of obesity observed in several epidemiological studies dissipate. This would be consistent with the large body of evidence that associates malnutrition (BMI < 20 kg/m) with increased mortality, and has led some authors to postulate that the weight-mortality relationship is U-shaped. This has proven difficult to demonstrate, however, due to recognized confounding influences such as chronic co-morbidities, baseline nutritional status and the nature of the presenting critical illness.This has led to interest in nutritional regimens targeting alternative calorie and protein goals to protect the obese critically ill patient from complications arising from critical illness, and particularly protein catabolism. However, of the three major nutritional organizations, the American Society of Parenteral and Enteral Nutrition (ASPEN) is the only professional organization to make specific recommendations about providing enteral nutritional support to the critically ill obese patient, recommending a regimen targeting a hypo-caloric, high-protein goal. It is thought that this regimen, in which 60-70% of caloric requirements are provided promotes steady weight loss, while providing sufficient protein to achieve a neutral, or slightly positive, nitrogen balance, mitigating lean muscle mass loss, and allowing for wound healing. Targeting weight loss is proposed to improve insulin sensitivity, improve nursing care and reduce the risk of co-morbidities, although how this occurs and whether it can occur over the relatively short time frame of an intensive care admission (days to weeks) remains unclear. Despite these recommendations observational data of international nutritional practice suggest that ICU patients are fed uniformly low levels of calories and protein across BMI groups.Supporting the critically ill obese patient will become an increasingly important skill in the intensivist's armamentarium, and enteral nutritional therapy forms a cornerstone of this support. Yet, neither the optimal total caloric goal nor the macronutrient components of a feeding regimen for the critically ill obese patient is evident. Although the suggestion that altering the macronutrient goals for this vulnerable group of patients appears to have a sound physiological basis, the level of evidence supporting this remains unclear, and there are no systematic reviews on this topic. The aim of this systematic review is to evaluate existing literature to determine the best available evidence describing a nutritional strategy that targets energy and protein delivery to reduce morbidity and mortality for the obese patient who is critically ill.

Characteristics and Outcomes of Adult Inpatients With Malnutrition

BACKGROUND

The diagnosis of malnutrition remains controversial. Furthermore, it is unknown if physician diagnosis of malnutrition impacts outcomes. We sought to compare outcomes of patients with physician diagnosed malnutrition to patients recognized as malnourished by registered dietitians (RDs), but not physicians, and to describe the impact of each of 6 criteria on the diagnosis of malnutrition.

METHODS

We conducted a retrospective cohort study of adult patients identified as meeting criteria for malnutrition. Pediatric, psychiatric, maternity, and rehabilitation patients were excluded. Patient demographics, clinical data, malnutrition type and criteria, nutrition interventions, and outcomes were abstracted from the electronic medical record.

RESULTS

RDs identified malnutrition for 291 admissions during our study period. This represents 4.1% of hospital discharges. Physicians only diagnosed malnutrition on 93 (32%) of these cases. Physicians diagnosed malnutrition in 43% of patients with a body mass index <18.5 but only 26% of patients with body mass index higher than 18.5. Patients with a physician diagnosis had a longer length of stay (mean 14.9 days vs 7.1 days) and were more likely to receive parenteral nutrition (PN) (20.4% vs 4.6%). Of the patients, 62% had malnutrition due to chronic illness. Of the 6 criteria used to identify malnourished patients, weight loss and reduced energy intake were the most common.

CONCLUSIONS

Malnutrition is underrecognized by physicians. However, further research is needed to determine if physician recognition and treatment of malnutrition can improve outcomes. The most important criteria for identifying malnourished patients in our cohort were weight loss and reduced energy intake.

Assessment of Folate Status in Obese Patients: Should We Measure Folate in Serum or in Red Blood Cells?

BACKGROUND

Recent studies revealed that obesity is associated with decreased serum but at the same time increased red blood cell (RBC) folate concentrations compared with lean subjects, thus casting doubt upon the agreement between serum and RBC folate measurements for assessing folate status. This work aimed to determine whether these two metrics lead to the same classification of folate status in obese patients.

METHODS

RBC and serum folate concentrations were measured with a chemiluminescent immunoassay in 263 adults with body mass index ≥30 kg/m² and without previous bariatric surgery. Among them, 68.1 % were eligible for bariatric surgery. Each serum and RBC folate result was classified as deficient or not according to thresholds recommended by the kit manufacturer (model A) or by the World Health Organization (model B). The agreement between serum and RBC folate results was evaluated using the proportion of overall agreement and the prevalence-adjusted bias-adjusted kappa (PABAK) statistics.

RESULTS

The overall percentage agreements between serum and RBC measurements were 91.6 % (95 % CI 87.6-94.7 %) and 92.4 % (95 % CI 88.5-95.3 %) with PABAK coefficients of 0.87 (95 % CI 0.82-0.93) and 0.88 (95 % CI 0.83-0.94) in the models A and B, respectively, corresponding to almost perfect agreement. The same was true in the subgroup of patients eligible for bariatric surgery. Gender, age, and BMI did not influence the quality of agreement between the two parameters.

CONCLUSIONS

The present study showed that folate measurements in serum and in RBC display similar performances to assess folate status in obese patients.

Investigating Nutritional Deficiencies in a Group of Patients 3 Years Post Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure has shown to be effective in achieving significant weight loss and resolving obesity-related co-morbidities. However, its nutrition consequences have not been extensively explored. This study aims to investigate weight loss and evolution of nutritional deficiencies in a group of patients 3 years post LSG.

METHODS

Retrospective data of a group of patients, 3 years following LSG as a stand-alone procedure was collected. Data included anthropometry, nutritional markers (hemoglobin, iron studies, folate, calcium, iPTH, vitamins D, and B₁₂), and compliancy with supplementations.

RESULTS

Ninety-one patients (male/female; 28:63), aged 51.9 ± 11.4 years with a BMI of 42.8 ± 6.1 kg/m² were identified to be 3 years post LSG. Percentage of weight loss at 1 and 3 years post-operatively was 29.8 ± 7.0 and 25.9 ± 8.8 %, respectively. Pre-operatively, the abnormalities included low hemoglobin (4 %), ferritin (6 %), vitamin B₁₂ (1 %), vitamin D (46 %), and elevated iPTH (25 %). At 3 years post-operatively, the abnormal laboratory values included low hemoglobin (14 % females, P = 0.021), ferritin (24 %, P = 0.011), vitamin D (20 %, P = 0.018), and elevated iPTH (17 %, P = 0.010). Compliancy with multivitamin supplementation was noted in 66 % of patients.

CONCLUSION

In these patients, LSG resulted in pronounced weight loss at 1 year post-operatively, and most of this was maintained at 3 years. Nutritional deficiencies are prevalent among patients prior to bariatric surgery. These deficiencies may persist or exacerbate post-operatively. Routine nutrition monitoring and supplementations are essential to prevent and treat these deficiencies.

Bariatric surgery and long-term nutritional issues

Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro- and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related co-morbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multi-vitamins and mineral supplements according to the patient's needs.