Nonalcoholic fatty liver disease and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Bioelectrical Impedance Analysis Demonstrates Reliable Agreement with Dual-Energy X-ray Absorptiometry in Identifying Reduced Skeletal Muscle Mass in Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease and Hypertension

Background/Objectives: Body composition (BC) affects the risk of developing metabolic dysfunction-associated steatotic liver disease (MASLD) and hypertension (HTN). Currently, dual-energy X-ray absorptiometry (DEXA) is considered the gold standard for assessing BC, even though it has some limitations, including immobility, ionizing radiation, and patient weight restrictions. The aim of the study was to evaluate the correlations of BC parameters measured by bioelectrical impedance analysis (BIA) with those measured by DEXA in patients with MASLD and HTN. Methods: Overall, 78 patients with MASLD and HTN underwent the following study procedures: compilation of an anamnesis, physical examination of a patient, laboratory tests, abdominal ultrasound, BIA, DEXA, and anthropometric measurements. Results: The agreement between BIA and DEXA in diagnosing reduced skeletal muscle mass (SMM) in patients with MASLD and HTN was moderate (kappa values were 0.440 and 0.404 in males and females, respectively). Significant strong direct correlations were found between fat mass (FM) and body fat percentage measured by BIA with corresponding measurements by DEXA (p < 0.001 for both). The area under the receiver operating characteristic curves (AUC) of SMM to body weight ratios calculated using BIA data were 0.834 and 0.929 for reduced appendicular SMM determined by DEXA in males and females with MASLD and HTN, respectively. Conclusions: In conclusion, BIA is an easy-to-use and widely available tool for assessing SMM and FM in patients with MASLD and HTN, demonstrating reliable agreement with DEXA measurement results and completely free of its limitations.

Characterizing outcomes in a large cohort of latinx patients with autoimmune hepatitis

INTRODUCTION AND OBJECTIVES

This study aimed to characterize a large cohort of Latinx patients with autoimmune hepatitis (AIH) and analyze clinical outcomes, including biochemical remission, duration of steroid treatment, fibrosis regression, and incidence of clinical endpoints (hepatic decompensation, need for liver transplant, and death).

MATERIALS AND METHODS

This was a retrospective descriptive study of patients with biopsy proven AIH (2009-2019) at a single urban center. Demographics, medical comorbidities, histology, treatment course, biochemical markers, fibrosis using dynamic non-invasive testing (NIT), and clinical outcomes at three months and at one, two, and three years were analyzed.

RESULTS

121 adult patients with biopsy-proven AIH were included: 43 Latinx (35.5%) and 78 non-Latinx (65.5%). Latinx patients were more likely to have metabolic dysfunction-associated steatotic liver disease (MASLD) (p = 0.004), and had higher Fibrosis-4 (FIB-4) (p = 0.0279) and AST-to-Platelet-Ratio-Index (APRI) (p = 0.005) at one year. Latinx patients took longer to reach biochemical remission than non-Hispanic Whites (p = 0.031) and longer to stop steroids than non-Hispanic Blacks (p = 0.016). There were no significant differences based on ethnicity in histological fibrosis stage at presentation or incidence of clinical endpoints.

CONCLUSIONS

MASLD overlap is highly prevalent in Latinx AIH patients. Longer time to biochemical remission and worse NITs support that this population may have slower fibrosis regression with standard of care AIH treatment. This may indicate differing response rates due to genetic polymorphisms affecting drug metabolism and immune response among Latinx individuals and is less likely related to AIH/MASLD overlap based on the findings of this study.

Prognostic utility of Fibrosis-4 Index for risk of subsequent liver and cardiovascular events, and all-cause mortality in individuals with obesity and/or type 2 diabetes: a longitudinal cohort study

Background

The Fibrosis-4 Index (FIB-4) is used as a non-invasive tool for the presence of advanced liver fibrosis in metabolic dysfunction-associated steatotic liver disease and type 2 diabetes. However, evidence for an association between FIB-4 and risk of mortality and/or liver-related clinical outcomes is limited. The aim of this study was to investigate the association between FIB-4 and subsequent liver events, cardiovascular events, and all-cause mortality in individuals with obesity and/or type 2 diabetes examined in routine general practice.

Methods

This was a longitudinal cohort study in which eligible adults had obesity and/or type 2 diabetes and ≥1 FIB-4 score calculable from UK Clinical Practice Research Datalink GOLD after 1 January 2001. No alcohol-related disorders and/or chronic liver diseases (except non-alcoholic fatty liver disease) and/or no prescriptions of drugs inducing liver disease were permitted. Individuals were followed until time of first event, 10 years, or 1 January 2020. Analyses were conducted using Aalen-Johansen cumulative incidence functions and Cox proportional hazards models.

Findings

Among 44,481 included individuals (mean age 58·8 years; 54% female), there were 979 liver, 6002 cardiovascular, and 8971 mortality events during the 10 years of follow-up. At 10 years, the cumulative incidence of liver events in the high (>2·67), indeterminate (1·30-2·67), and low (<1·30) baseline FIB-4 risk groups were 15%, 3%, and 1%, respectively. Age- and sex-adjusted hazard ratios (HRs) for liver events were elevated in high (16·46; 95% confidence interval [CI] 13·65-19·85) and indeterminate (2·45; 95% CI 2·07-2·90) versus low FIB-4 risk groups. Similar results were found for cardiovascular events and all-cause mortality. Among 20,433 individuals with ≥2 FIB-4 measurements, increase/decrease in FIB-4 12 months after baseline was directly associated with risk of liver events: compared with individuals with low baseline FIB-4 and no change in FIB-4 (reference), the adjusted HR (95% CI) for those with high baseline FIB-4 was 24·27 (16·98-34·68) with a one-unit FIB-4 increase, and 10·90 (7·90-15·05) with a one-unit decrease.

Interpretation

In addition to its value as a diagnostic tool, FIB-4 has clinical utility as a prognostic biomarker. Sequential measurement provides a pragmatic, tractable monitoring biomarker that refines risk assessment for liver events, cardiovascular events, and mortality.

Funding

Novo Nordisk A/S.

The Efficacy of Anthropometric Indicators in Predicting Non-Alcoholic Fatty Liver Disease Using FibroScan® CAP Values among the Taiwanese Population

The controlled attenuation parameter (CAP) measurement obtained from FibroScan® is a low-risk method of assessing fatty liver. This study investigated the association between the FibroScan® CAP values and nine anthropometric indicators, including the abdominal volume index (AVI), body fat percentage (BFP), body mass index (BMI), conicity index (CI), ponderal index (PI), relative fat mass (RFM), waist circumference (WC), waist-hip ratio (WHR), and waist-to-height ratio (WHtR), and risk of non-alcoholic fatty liver disease (fatty liver). We analyzed the medical records of adult patients who had FibroScan® CAP results. CAP values <238 dB/m were coded as 0 (non- fatty liver) and ≥238 dB/m as 1 (fatty liver). An individual is considered to have class 1 obesity when their body mass index (BMI) ranges from 30 kg/m2 to 34.9 kg/m2. Class 2 obesity is defined by a BMI ranging from 35 kg/m2 to 39.9 kg/m2, while class 3 obesity is designated by a BMI of 40 kg/m2 or higher. Out of 1763 subjects, 908 (51.5%) had fatty liver. The BMI, WHtR, and PI were found to be more strongly correlated with the CAP by the cluster dendrogram with correlation coefficients of 0.58, 0.54, and 0.54, respectively (all p < 0.0001). We found that 28.3% of the individuals without obesity had fatty liver, and 28.2% of the individuals with obesity did not have fatty liver. The BMI, CI, and PI were significant predictors of fatty liver. The BMI, PI, and WHtR demonstrated better predictive ability, indicated by AUC values of 0.72, 0.68, and 0.68, respectively, a finding that was echoed in our cluster group analysis that showed interconnected clustering with the CAP. Therefore, of the nine anthropometric indicators we studied, the BMI, CI, PI, and WHtR were found to be more effective in predicting the CAP score, i.e., fatty liver.

Coagulation Dysfunctions in Non-Alcoholic Fatty Liver Disease-Oxidative Stress and Inflammation Relevance

Non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases. Its incidence is progressively rising and it is possibly becoming a worldwide epidemic. NAFLD encompasses a spectrum of diseases accounting for the chronic accumulation of fat within the hepatocytes due to various causes, excluding excessive alcohol consumption. In this study, we aimed to focus on finding evidence regarding the implications of oxidative stress and inflammatory processes that form the multifaceted pathophysiological tableau in relation to thrombotic events that co-occur in NAFLD and associated chronic liver diseases. Recent evidence on the pathophysiology of NAFLD suggests that a complex pattern of multidirectional components, such as prooxidative, proinflammatory, and prothrombotic components, better explains the multiple factors that promote the mechanisms underlying the fatty acid excess and subsequent processes. As there is extensive evidence on the multi-component nature of NAFLD pathophysiology, further studies could address the complex interactions that underlie the development and progression of the disease. Therefore, this study aimed to describe possible pathophysiological mechanisms connecting the molecular impairments with the various clinical manifestations, focusing especially on the interactions among oxidative stress, inflammation, and coagulation dysfunctions. Thus, we described the possible bidirectional modulation among coagulation homeostasis, oxidative stress, and inflammation that occurs in the various stages of NAFLD.

Artificial intelligence and obesity management: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2023

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides clinicians an overview of Artificial Intelligence, focused on the management of patients with obesity.

Methods

The perspectives of the authors were augmented by scientific support from published citations and integrated with information derived from search engines (i.e., Chrome by Google, Inc) and chatbots (i.e., Chat Generative Pretrained Transformer or Chat GPT).

Results

Artificial Intelligence (AI) is the technologic acquisition of knowledge and skill by a nonhuman device, that after being initially programmed, has varying degrees of operations autonomous from direct human control, and that performs adaptive output tasks based upon data input learnings. AI has applications regarding medical research, medical practice, and applications relevant to the management of patients with obesity. Chatbots may be useful to obesity medicine clinicians as a source of clinical/scientific information, helpful in writings and publications, as well as beneficial in drafting office or institutional Policies and Procedures and Standard Operating Procedures. AI may facilitate interactive programming related to analyses of body composition imaging, behavior coaching, personal nutritional intervention & physical activity recommendations, predictive modeling to identify patients at risk for obesity-related complications, and aid clinicians in precision medicine. AI can enhance educational programming, such as personalized learning, virtual reality, and intelligent tutoring systems. AI may help augment in-person office operations and telemedicine (e.g., scheduling and remote monitoring of patients). Finally, AI may help identify patterns in datasets related to a medical practice or institution that may be used to assess population health and value-based care delivery (i.e., analytics related to electronic health records).

Conclusions

AI is contributing to both an evolution and revolution in medical care, including the management of patients with obesity. Challenges of Artificial Intelligence include ethical and legal concerns (e.g., privacy and security), accuracy and reliability, and the potential perpetuation of pervasive systemic biases.

Clinical review: Guide to pharmacological management in pediatric obesity medicine

Introduction

Newer pharmacotherapy agents (anti-obesity medication [AOM]) are revolutionizing the management of children and adolescents with obesity. Previously, treatment based on intensive behavioral therapy involved many patient and family contact hours and yielded improvements in obesity status of 1-3 percent of the 95th percentile of the body mass index (BMI). Newer AOMs are yielding more clinically significant improvement of 5-18 percent. This review provides guidance for practitioners in the care of children and adolescents with obesity who frequently have complex medical and behavioral health care needs. Specifically, we discuss the use of newer AOMs in these complex patients.

Methods

This review details an approach to the care of the child and adolescent with obesity using AOMs. A shared decision-making process is presented in which the provider and the patient and family collaborate on care. Management of medical and behavioral components of the disease of obesity in the child are discussed.

Results

Early aggressive treatment is recommended, starting with an assessment of associated medical and behavioral complications, weight promoting medications, use of AOMs and ongoing care. Intensive behavioral therapy is foundational to treatment, but not a specific treatment. Patients and families deserve education on expected outcomes with each therapeutic option.

Conclusions

The use of new AOMs in children and adolescents has changed expected clinical outcomes in the field of pediatric obesity management. Clinically significant improvement in obesity status occurs when AOMs are used early and aggressively. Ongoing, chronic care is the model for optimizing outcomes using a shared decision-making between provider and patient/family. Depending on the experience and comfort level of the primary care practitioner, referral to an obesity medicine specialist may be appropriate, particularly when obesity related co-morbidities are present and pharmacotherapy and metabolic and bariatric surgery are considerations.

A Review of the Effects of Fucoxanthin on NAFLD

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent form of chronic liver disease. Fucoxanthin, a red-orange marine carotenoid, is found in natural marine seaweeds with high antioxidant activity and several other remarkable biological features. The aim of this review is to gather evidence of the positive benefits of fucoxanthin on NAFLD. Fucoxanthin provides an extensive list of physiological and biological properties, such as hepatoprotective, anti-obesity, anti-tumor, and anti-diabetes properties, in addition to antioxidant and anti-inflammatory properties. This review focuses on published research on the preventative effects of fucoxanthin on NAFLD from the perspective of human clinical trials, animal experiments in vivo, and in vitro cell investigations. Using a variety of experimental designs, including treatment dosage, experiment model, and experimental periods, the positive effects of fucoxanthin were demonstrated. Fucoxanthin's biological activities were outlined, with an emphasis on its therapeutic efficacy in NAFLD. Fucoxanthin showed beneficial effects in modulating lipid metabolism, lipogenesis, fatty acid oxidation, adipogenesis, and oxidative stress on NAFLD. A deeper comprehension of NAFLD pathogenesis is essential for the development of novel and effective therapeutic strategies.

Malicia honey (Mimosa quadrivalvis L.) produced by the jandaíra bee (Melipona subnitida D.) improves depressive-like behaviour, somatic, biochemical and inflammatory parameters of obese rats

Malícia honey produced by the jandaíra bee has hypoglycaemic and hypolipidemic effects and antioxidant activity in vitro and in vivo, which makes it potential adjuvant treatment for obesity. This study aimed to evaluate the effects of malícia honey on somatic and biochemical parameters, depressive-like behaviour and anti-inflammatory activity in obese rats. A total of 40 adult male Wistar rats were initially randomized into a healthy group (HG, n = 20) that consumed a control diet, and an obese group (OG, n = 20) which consumed a cafeteria diet for eight weeks. Then, they were subdivided into four groups: healthy (HG, n = 10); healthy treated with malícia honey (HGH, n = 10); obese (OG, n = 10); and obese treated with malícia honey (OGH, n = 10), maintaining their diets for another eight weeks. The HGH and OGH groups received malícia honey (1000 mg/kg body weight) via gavage. Food intake was monitored daily and body weight was monitored weekly. Biochemical tests related to obesity and glucose and insulin tolerance test, somatic parameters, histological parameters and quantification of NF-κB in the brain were performed. Treatment with malícia honey improved depressive-like behaviour, reduced weight (14 %), body mass index (6 %), and improved lipid profile, leptin, insulin, HOMA-β, and glucose and insulin tolerance in obese rats. It also decreased NF-κB (58.08 %) in the brain. Malícia honey demonstrated anti-obesity and anti-inflammatory effects, and reversed changes in obesity-induced depressive-like behaviour.