Weight Loss Prior to Bariatric Surgery and 30-Day Mortality, Readmission, Reoperation, and Intervention: an MBSAQIP Analysis of 349,016 Cases

A Program of Life-Style Modification Improved the Body Weight and Micronutrient Status in Obese Patients after Bariatric Surgery

INTRODUCTION

Bariatric surgery is an efficient approach to rapidly reduce morbid obesity and associated comorbidities. However, approximately one-fourth of patients experience weight and comorbidity recurrence, and both obesity and bariatric surgery can lead to micronutrient deficiencies. Implementing a structured program of lifestyle modification (PLM) might enhance weight loss and improve micronutrient status.

METHODOLOGY

A total of 121 severely obese patients underwent Roux-en-Y gastric bypass (RYGB). Among them, 71 adhered to a PLM involving dietary changes (low- and very-low-calorie Mediterranean diets) and physical exercises (aerobic and resistance training) both before and after surgery, while 50 patients followed a conventional protocol. Anthropometric measurements and serological parameter quantifications were conducted throughout the procedures.

RESULTS

The obese study population, primarily female (76.9%), with an average age of 47.11 ± 9.68, and a body mass index (BMI) of 44.68 ± 5.08 kg/m2, underwent either RYGB with a PLM or a conventional procedure. Before surgery, the PLM group exhibited significant reductions in body weight (6.3%) and phosphoremia compared to the conventional protocol (0.78%). Post-RYGB, the PLM group demonstrated shortened in-hospital stays and further BMI reductions (-16.12 kg/m2) that persisted for up to 2 years. Furthermore, the PLM group experienced increased plasma vitamin D levels (14.79 ng/mL vs. 1.2 ng/mL) for up to 2 years, as well as elevated folic acid (1.52 vs. -0.29 ng/mL) and phosphorus (0.48 vs. 0.06 mg/dL) levels at 1 month and 1 year after intervention, respectively. Notably, these effects were independent of weight loss.

CONCLUSIONS

Initiating a structured PLM from the early stages of patients' preparation for RYGB could enhance and extend the benefits of weight loss and positively impact micronutrient (vitamin D, phosphorus, and folic acid) status in obese patients.

Roux-en-Y gastric bypass, gastric banding, or sleeve gastrectomy for severe obesity: Baseline data from the By-Band-Sleeve randomized controlled trial

OBJECTIVE

This paper reports the study design, participant characteristics, and recruitment results of By-Band-Sleeve, which investigated the clinical and cost-effectiveness of gastric bypass, gastric banding, and sleeve gastrectomy in adults with severe obesity in the UK.

METHODS

A pragmatic open adaptive noninferiority trial with 3-year follow-up was conducted. Participants were randomly assigned to bypass or band initially and to sleeve after the adaptation. Co-primary end points are weight loss and health-related quality of life assessed using the EQ-5D utility index.

RESULTS

Between December 2012 and August 2015, the study recruited into two groups and, after the adaptation, into three groups until September 2019. The study screened 6960 patients; 4732 (68%) were eligible and 1351 (29%) were randomized; 5 subsequently withdrew consent to use data, leaving 462, 464, and 420 assigned to bypass, band, and sleeve, respectively. Baseline data showed high levels of obesity (mean BMI = 46.4 kg/m2; SD: 6.9) and comorbidities (e.g., 31% diabetes), low scores for health-related quality of life, and high levels of anxiety and depression (e.g., 25% abnormal scores). Nutritional parameters were poor, and the average equivalized household income was low (£16,667).

CONCLUSIONS

By-Band-Sleeve fully recruited. Participant characteristics are consistent with contemporary patients having bariatric surgery, and therefore the results will be generalizable.

Preoperative Weight Loss as a Predictor of Short and Midterm Postoperative Weight Loss in Patients Undergoing Bariatric Surgery

Objective

To examine if preoperative weight loss correlates to postoperative weight loss 2 and 3 years after surgery.

Methods

A review was conducted of bariatric surgery patients who underwent either gastric bypass or sleeve gastrectomy during 2015-2018 and had 3-year follow-up data. Demographic and outcome data were collected. A best-fit regression model for weight loss was constructed.

Results

Eight hundred fifty-nine patients underwent surgery during the selected period, of which 199 patients (23%) were analyzed. Eighty-two percent of patients had gastric bypass and 82% were female. Preoperative percent excess weight loss (%EWL) was not significantly associated with 2- and 3-year postoperative %EWL (p = 0.18). Patients demonstrated significant weight regain at 3 years postoperatively versus 1 year (p < 0.01). Higher preoperative weight loss was associated with lower %EWL 3 years postoperatively versus 1 year (p = 0.04). Postoperative %EWL had a significant negative association with higher preoperative weight, diabetes, baseline use of a mobility device, and sleeve gastrectomy.

Conclusions

In a cohort of bariatric surgery patients, there was no statistically significant association between preoperative and midterm postoperative %EWL. Postoperative %EWL was negatively associated with several patient-specific factors and increasing time since operation.

Clinical characteristics of patients undergoing primary bariatric surgery in the United Kingdom based on the National Bariatric Surgery Registry

Baseline demographic characteristics and operations undertaken for patients having bariatric surgery in the United Kingdom are largely unknown. This study aimed to describe the profile of patients having primary bariatric surgery in the National Health Service (NHS) or by self-pay, and associated operations performed for both pathways. The National Bariatric Surgery Registry dataset for 5 years between January 2015 and December 2019 was used. 34 580 patients underwent primary bariatric surgery, of which 75.9% were NHS patients. Mean patient age and initial body mass index were significantly higher for NHS compared to self-pay patients (mean age 45.8 ± 11.3 [SD] vs. 43.0 ± 12.0 years and initial body mass index 48.0 ± 7.9 vs. 42.9 ± 7.3 kg/m² , p < .001). NHS patients were more likely to have obesity-related complications compared to self-pay patients: prevalence of Type 2 diabetes mellitus 27.7% versus 8.3%, hypertension 37.1% versus 20.1%, obstructive sleep apnoea 27.4% versus 8.9%, severely impaired functional status 19.3% versus 13.9%, musculoskeletal pain 32.5% versus 20.1% and being on medication for depression 31.0% versus 25.9%, respectively (all p < .001). Gastric bypass was the most commonly performed primary NHS bariatric operation 57.2%, but sleeve gastrectomy predominated in self-pay patients 48.7% (both p < .001). In contrast to self-pay patients, NHS patients are receiving bariatric surgery only once they are older and at a much more advanced stage of obesity-related disease complications.

Open abdominal aortic repair in the current era has more complications for occlusive disease than for aneurysm repair

BACKGROUND

Endovascular intervention has become the first-line treatment of patients with abdominal aortic aneurysms (AAAs) or aortoiliac occlusive disease (AIOD). However, open abdominal aortic repair remains a valuable treatment option for patients who are younger, those with unfavorable anatomy, and patients for whom endovascular intervention has failed. The cohort of patients undergoing open repair has become highly selected; nevertheless, updated outcomes or patient selection recommendations have been unavailable. In the present study, we explored and compared the characteristics and postoperative outcomes of patients who had undergone open abdominal aortic repair from 2009 to 2018.

METHODS

Patients who had undergone open AAA (n = 9481) or AIOD (n = 9257) repair were collected from the National Surgical Quality Improvement Program database. The primary outcome was the 30-day mortality. The secondary outcomes included 30-day return to the operating room, total operative time, total hospital stay, and postoperative complications. Unmatched and matched differences between the two groups and changes over time were analyzed. Univariate and multivariate regression analyses were conducted to assess the risk factors predicting for 30-day mortality.

RESULTS

After propensity matching (n = 4980), those in the AIOD group had had a higher 30-day mortality rate (5.1% vs 4.1%; P = .021), a higher incidence of wound complications (7.4% vs 5.1%; P<.0001) and an increased 30-day return to the operating room (14.2% vs 9.1%; P < .0001). More open AIOD cases (P = .02) and fewer open AAA cases (P = .04) had been treated in the second half of the decade than in the first. The factors associated with an increased odds of 30-day mortality included advanced age, American Society of Anesthesiologists score ≥III, functional dependence, blood transfusion <72 hours before surgery, weight loss in previous 6 months, and a history of chronic obstructive pulmonary disease.

CONCLUSIONS

From 2009 to 2018, the number of open AAA repairs decreased and the proportion of open abdominal AIOD cases increased. Open AIOD surgery was associated with higher 30-day mortality, increased return to the operating room, and increased wound complications vs open AAA repair. Multiple risk factors increased the odds for perioperative mortality. Thus, open abdominal aortic repair should be selectively applied to patients with fewer risk factors.

Comparison of automatic liver volumetry performance using different types of magnetic resonance images

Measurements of liver volume from MR images can be valuable for both clinical and research applications. Automated methods using convolutional neural networks have been used successfully for this using a variety of different MR image types as input. In this work, we sought to determine which types of magnetic resonance images give the best performance when used to train convolutional neural networks for liver segmentation and volumetry. Abdominal MRI scans were performed at 3 Tesla on 42 adolescents with obesity. Scans included Dixon imaging (giving water, fat, and T2* images) and low-resolution T2-weighted scout images. Multiple convolutional neural network models using a 3D U-Net architecture were trained with different input images. Whole-liver manual segmentations were used for reference. Segmentation performance was measured using the Dice similarity coefficient (DSC) and 95% Hausdorff distance. Liver volume accuracy was evaluated using bias, precision, intraclass correlation coefficient, normalized root mean square error (NRMSE), and Bland-Altman analyses. The models trained using both water and fat images performed best, giving DSC = 0.94 and NRMSE = 4.2%. Models trained without the water image as input all performed worse, including in participants with elevated liver fat. Models using the T2-weighted scout images underperformed the Dixon-based models, but provided acceptable performance (DSC ≥ 0.92, NMRSE ≤6.6%) for use in longitudinal pediatric obesity interventions. The model using Dixon water and fat images as input gave the best performance, with results comparable to inter-reader variability and state-of-the-art methods.

The relationship between preoperative weight loss and intra and post-bariatric surgery complications: an appraisal of the current preoperative nutritional strategies

Preoperative weight loss before a bariatric surgery reduces long-term complications, but there is no solid evidence for short-term or perioperative complications. This review highlights recent evidence on dietary protocols and the possible correlation between weight loss and surgical complications. Updated evidence was searched in PubMedDirect with the terms "preoperative very low-calorie diet or very-low-calorie ketogenic diet or low-fat diet or intermittent fasting or Mediterranean diet and bariatric surgery or bariatric surgery complications." The main characteristics of each diet, achievements related to weight loss, liver reduction, peri and postoperative outcomes, surgical complications, tolerance, and adherence to the diet are presented from the selected studies. There are few reports about the Mediterranean diet as a strategy to reach these goals. The VLCKD has been associated with better body weight reduction and lesser postoperative complications risk. However, the results in animal models are still controversial. When comparing VLCD with an LCD, there is no apparent superiority between one against the other one. However, LCD has shown better tolerance and adherence than VLCD. There is still a need for more controlled studies to define the best preoperative dietary treatment for weight loss before bariatric surgery since there are controversial positions regarding this issue.

PEX-168 improves insulin resistance, inflammatory response and adipokines in simple obese mice: a mechanistic exploration

BACKGROUND

Polyethylene glycol loxenatide (PEX-168) is a new antidiabetic drug; as such, there are not yet any reports on its weight loss effect. Therefore, this trial was designed to investigate the effect of PEX-168 on simple obese mice.

METHODS

Thirty healthy male C57BL/6 mice were randomly selected and divided into a control group (NC) and an obesity model group. The high-fat diet-induced simple obesity mice were divided into a model control group (HF) and three intervention groups. The intervention groups were injected with different doses of PEX-168 intraperitoneally once a week for 12 weeks (low (LD), medium (MD) and high (HD)). Fasting blood glucose (FBG), body weight and food intake were measured from 1 to 12 weeks after PEX-168 injection. The serum insulin (INS), C-reactive protein (CRP), chemerin and omentin levels were measured after 12 weeks.

RESULTS

Compared with the HF group, the low dose of PEX-168 reduced the body weight of the mice in a short period of time (8 weeks), and the mice in the MD and HD groups showed a significant decrease in body weight (P < 0.05). The low dose of PEX-168 could effectively improve the blood glucose and homeostasis model assessment of insulin resistance (Homa-IR) of the mice (FBG P < 0.05 INS, Homa-IR P < 0.001), but there was no significant difference between different doses (P > 0.05). CRP levels in the MD and HD groups were significantly improved (P < 0.05). The levels of serum chemerin and omentin in the intervention groups were also significantly improved (P < 0.01), but there was no significant difference between the different doses (P > 0.05).

CONCLUSIONS

PEX-168 significantly reduced the body weight of simple obese mice and improved the insulin resistance. PEX-168 may regulate the expression of chemerin and omentin through its hypoglycaemic effect, and the weight-reducing effect of PEX-168 is unlikely to be the reason for the changes in both.

Association between insurance-mandated precertification criteria and inpatient healthcare utilization during 1 year after bariatric surgery

BACKGROUND

Insurance-mandated precertification requirements are barriers to bariatric surgery. The value of their prescription, based on insurance type rather that the clinical necessity, is unclear.

OBJECTIVES

To determine whether there is an association between insurance-mandated precertification criteria for bariatric surgery and short-term inpatient healthcare utilization.

SETTING

Pennsylvania Health Care Cost Containment Council's inpatient care databases for the years 2016-2017.

METHODS

The study included 2717 adults who underwent bariatric surgery in Southeastern Pennsylvania in 2016. Postoperative length of stay and rehospitalizations for these individuals were followed using clinical and claims data during the first year after bariatric surgery.

RESULTS

The requirements for 3- to 6-month preoperative medical weight management, as well as pulmonology and cardiology examinations, were not associated with the patient length of stay, number of all-cause rehospitalizations, or number of all-cause rehospitalization days after adjusting for patient age, sex, race, ethnicity, the Elixhauser comorbidity score, type of the surgery, facility where the surgery was performed, primary payer type, and the estimated median household income. Among commercially insured individuals (n = 1499), the mean number of all-cause rehospitalizations during the study period was lower in patients with no medical weight management requirement by a factor of .57 (lower by 43.1%; 95% confidence interval, .35-.94, P = .03) and higher in patients with no requirement for preoperative cardiology and pulmonology evaluations by a factor of 2.09 (95% confidence interval 1.09-4.02, P = .03).

CONCLUSION

The findings suggest that the precertification requirement for preoperative medical weight management is not associated with a reduction in inpatient healthcare utilization in the first postoperative year.

Structured Lifestyle Modification Prior to Bariatric Surgery: How Much is Enough?

Many healthcare systems require patients to participate in a structured lifestyle modification programme prior to bariatric surgery, even though bariatric consensus guidelines do not recommend this. While there is good evidence that such programmes improve health in other conditions such as metabolic and cardiovascular diseases, there is no evidence that they improve outcomes after bariatric surgery. The distinction needs to be drawn between the well-established need for individualised multidisciplinary dietetic and physical activity care for bariatric surgical patients and the potential harms from mandating participation in compulsory structured lifestyle programmes of fixed duration, frequency and intensity, which may delay surgery, reinforce obesity stigma, or both. Large clinical trials might help to address some of the uncertainty and provide an evidence base for clinicians and policymakers.

Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice

Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.

Effect of Preoperative Weight Loss and Baseline Comorbidity on Short-Term Complications and Reoperations After Laparoscopic Roux-en-Y Gastric Bypass in 2,067 Patients

PURPOSE

Decreasing popularity of Roux-en-Y gastric bypass (RYGB) in bariatric-metabolic surgery may be due to higher perceived peri-operative complications. There are few studies on whether preoperative weight loss can reduce complications or reoperations following RYGB. We investigated this using a standardised operative technique.

MATERIALS AND METHODS

Retrospective single-centre study of RYGB from 2004 to 2019 using a prospective database. Preoperative behavioural management included intentional weight loss. Maximum preoperative weight, weight on the day of operation, and Obesity-Surgery Mortality Risk Score (OS-MRS) class were recorded. Short-term outcomes (post-operative stay, 30-day complication and reoperation rates) were analysed.

RESULTS

In 2,067 RYGB patients (1,901 primary and 166 revisional), median preoperative total body weight loss (TWL) was 6.2% (IQR: 2.5-10.7%). The median age was 46 (interquartile range (IQR) 38-54) and 80.4% were female (n=1,661). For primary surgery, the median body mass index (BMI) was 47.6 kg/m² (IQR: 43.1-53.3). Excluding the 100-procedure learning curve, the complication rate for primary cases was 4.4% and reoperation rate of 2.8% and one peri-operative mortality (0.06%). OS-MRS ≥2 (class B or C) predicted higher risk of complications (6.1%) compared to those with a score <2 (class A) (3.8%, p=0.021), but not reoperations. Five percent preoperative TWL did not decrease complications compared to <5% TWL. Patients with ≥10% TWL had greater baseline risk and had an increased risk of complications (6.6% vs 3.7%, p=0.017) and reoperations (4.5% vs 2.7%, p<0.001).

CONCLUSIONS

RYGB performed using a standardised technique has low overall risk. The influence of preoperative weight loss on outcomes was inconsistent.

Case Report: Off Label Utilization of Topiramate and Metformin in Patients With BMI ≥50 kg/m2 Prior to Bariatric Surgery

FDA approved anti-obesity medications may not be cost effective for patients struggling with pre-operative weight loss prior to bariatric surgery. Metformin, a biguanide, and Topiramate, a carbonic anhydrase inhibitor, both cost effective medications, have demonstrated weight loss when used for the treatment of type 2 diabetes or seizures, respectively. The aim of the three cases is to demonstrate the clinical utility of topiramate and metformin for preoperative weight loss in patients with a body mass index (BMI) ≥ 50 kg/m² prior to bariatric surgery who are unable to follow the bariatric nutritional prescription due to a dysregulated appetite system Each patient was prescribed metformin and/or topiramate in an off-label manner in conjunction with lifestyle modifications and achieved >8% total body weight loss during the preoperative period.

Do Insurance-mandated Precertification Criteria and Insurance Plan Type Determine the Utilization of Bariatric Surgery Among Individuals With Private Insurance?

BACKGROUND

Access to bariatric surgery is restricted by insurers in numerous ways, including by precertification criteria such as 3-6 months preoperative supervised medical weight management and documented 2-year weight history.

OBJECTIVES

To investigate if there is an association between the aforementioned precertification criteria, insurance plan type, and the likelihood of undergoing bariatric surgery, after controlling for potential sociodemographic confounders.

RESEARCH DESIGN

The study was conducted using the Pennsylvania Health Care Cost Containment Council's data in 5 counties of Pennsylvania in 2016 and records of preoperative insurance requirements maintained by the Temple University Bariatric Surgery Program.Privately insured bariatric surgery patients and individuals who met the eligibility criteria but did not undergo surgery were identified and 1:1 matched by sex, race, age group, and zip code (n=1054). Univariate tests and logistic regression analysis were utilized for data analysis.

RESULTS

The insurance requirement for 3-6 months preoperative supervised medical weight management was associated with smaller odds of undergoing surgery [odds ratio (OR)=0.459; 95% confidence interval (CI), 0.253-0.832; P=0.010], after controlling for insurance plan type and the requirement for documented weight history.Preferred provider organization (OR=1.422; 95% CI, 1.063-1.902; P=0.018) and fee-for-service (OR=1.447; 95% CI, 1.021-2.050; P=0.038) plans were associated with greater odds of undergoing surgery, compared with health maintenance organization plans, after controlling for the studied precertification requirements. The documented weight history requirement was not a significant predictor of the odds of undergoing surgery (P=0.132).

CONCLUSIONS

There is a need for consideration of insurance benefits design as a determinant of access to bariatric surgery.

Association of Preoperative Body Weight and Weight Loss With Risk of Death After Bariatric Surgery

IMPORTANCE

Perception of weight loss requirements before bariatric surgery varies among patients, physicians, and health insurance payers. Current clinical guidelines do not require preoperative weight loss because of a lack of scientific support regarding its benefits.

OBJECTIVE

To examine the association of preoperative body mass index (BMI) and weight loss with 30-day mortality after bariatric surgery.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from 480 075 patients who underwent bariatric surgery from 2015 to 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, which covers more than 90% of all bariatric surgery programs in the United States and Canada. Clinical and demographic data were collected at all participating institutions using a standardized protocol. Data analysis was performed from December 2018 to November 2019.

EXPOSURES

Preoperative BMI and weight loss.

MAIN OUTCOMES AND MEASURES

30-day mortality after bariatric surgery.

RESULTS

Of the 480 075 patients (mean [SD] age 45.1 [12.0] years; 383 265 [79.8%] women), 511 deaths (0.1%) occurred within 30 days of bariatric surgery. Compared with patients with a preoperative BMI of 35.0 to 39.9, the multivariable-adjusted odds ratios for 30-day mortality for patients with preoperative BMI of 40.0 to 44.9, 45.0 to 49.9, 50.0 to 54.9, and 55.0 and greater were 1.37 (95% CI, 1.02-1.83), 2.19 (95% CI, 1.64-2.92), 2.61 (95% CI, 1.90-3.58), and 5.03 (95% CI, 3.78-6.68), respectively (P for trend < .001). Moreover, compared with no preoperative weight loss, the multivariable-adjusted odds ratios for 30-day mortality for patients with weight loss of more than 0% to less than 5.0%, 5.0% to 9.9%, and 10.0% and greater were 0.76 (95% CI, 0.60-0.96), 0.69 (95% CI, 0.53-0.90), and 0.58 (95% CI, 0.41-0.82), respectively (P for trend = .003).

CONCLUSIONS AND RELEVANCE

In this study, even moderate weight loss (ie, >0% to <5%) before bariatric surgery was associated with a lower risk of 30-day mortality. These findings may help inform future updates of clinical guidelines regarding bariatric surgery.

High risk of disease-related malnutrition in gastroenterology outpatients

OBJECTIVE

Disease-related malnutrition (DRM) in hospitalized patients is known to have significant negative impact on clinical outcomes. Meanwhile, DRM in gastroenterology outpatients is scarcely investigated. The aim of this study was to investigate the prevalence of unintentional weight loss (UWL) and reduced food intake (RFI) as contributors to the risk of DRM in outpatients. Furthermore, the aim was to investigate if UWL may be used as initial screening for DRM, based on the correlation between UWL and RFI.

METHODS

All outpatients visiting the clinics for Medical and Surgery Gastroenterology, Aalborg University Hospital, Denmark, during 1 wk in September 2018, were invited to participate. Data regarding UWL within the past 3 mo, RFI the past week, and nutritional impact symptoms (NIS) were collected in this questionnaire-based cross-sectional study. Descriptive analysis, χ² test, and multiple logistic regression analysis were used for statistics.

RESULTS

Out of 348 eligible patients, 346 were included at the medical clinic (n = 170) and surgery clinic (n = 176). UWL occurred in 26%, with a mean weight loss of 7.1 kg (standard deviation [SD] 5.2), and 24% had RFI. A significantly increased risk of UWL was identified in patients with body mass index <18.5 kg/m² (odds ratio 6.1; confidence interval 2.0-18.7; P = 0.003). NIS were more common in the medical clinic. The main self-reported reasons for NIS affecting UWL were lack of appetite (15% versus 12%), pain (14% versus 8%), and nausea (12% versus 3%).

CONCLUSIONS

One in four outpatients experienced UWL to an extent that may have a significant negative impact on clinical outcome. A firm correlation was found between UWL and RFI. Thus, based on this superficial study, UWL may be used as initial screening for protein-energy malnutrition in the medical and surgery gastroenterology outpatient setting. The impact on clinical outcome and of early nutritional intervention in these settings need to be investigated.