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Background & Aims: Sarcopenic obesity (SO) is associated with cardiometabolic disorders and steatotic liver disease and carries major health risks. We assessed the hepatic and metabolic clinical phenotype associated with SO in patients with obesity undergoing bariatric surgery (BS). We also evaluated whether weight-loss and metabolic improvement post-surgery differ between patients with and without SO., Methods: 972 consecutive patients from a single-center BS cohort who underwent whole-body dual-energy X-ray absorptiometry (DXA) and peri-operative liver biopsy were included. SO was diagnosed using the AIM-SO score, an AI-assisted unbiased clustering algorithm based on body composition. One-year post-surgery, 862 patients were reassessed for AIM-SO score changes., Results: Pre-operatively, 207 (21.3 %) patients were diagnosed with SO. These patients had significantly higher prevalence of type-2 diabetes (T2D), arterial hypertension and obstructive sleep apnea (OSA) compared to patients without SO (all p ≤ 0.003). Patients with SO had more severe liver damage: higher grades of moderate/advanced steatosis (64.2 % vs. 47.3 %), steatohepatitis (44.4 % vs. 32.3 %) and advanced fibrosis (12.1 % vs. 6.0 %) (all p ≤ 0.01). One-year post-BS, 58.5 % of patients had remission of SO. Patients with persistent SO exhibited less weight-loss than those with SO remission (-23.8 kg vs. -29.1 kg, p < 0.001) and had lower rates of remission for T2D (41.9 % vs. 69.8 %), arterial hypertension (20.8 % vs. 45.3 %), and metabolic syndrome (47.6 % vs. 75.0 %) (all p ≤ 0.009)., Conclusion: The DXA-based AIM-SO score identifies patients with SO who are at greater risk of hepatic and cardiometabolic comorbidities, and predicts less favorable weight-loss and metabolic improvements post-BS., Competing Interests: Conflict of interest None., (Copyright © 2024 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Obesity is one of the main modifiable risk factors for osteoarthritis (OA). Moreover, obesity is associated with greater pain intensity and functional limitation, but also with a significantly lower responder rate to intra-articular treatments. Consequently, an arthroplasty is indicated earlier and more frequently in patients with obesity. However, pain and functional symptoms improve slightly less after arthroplasty in patients with obesity, who display higher incidence of early and late complications following prosthetic surgery. Bariatric surgery (BS) has increased worldwide and is efficient to induce major and sustainable weight-loss. Importantly, BS significantly reduces pain and functional limitation in patients with symptomatic knee OA. Biomarkers analysis also revealed a decrease in catabolic factors and an increase in anabolic one after BS suggesting a structural protective effect in knee OA. Nevertheless, the impact of BS prior to arthroplasty remains unclear. BS seems to decrease short- and mid-term complications such as infections or thrombosis. However, BS does not appear to modify long-term complications rate, and may even increase it, especially revisions and infections. Although few studies have compared the symptomatic and functional outcomes of joint replacement with or without BS, these are not significantly improved by prior BS. Despite these heterogeneous results, medico-economic studies found that BS prior to arthroplasty was cost-effective. To conclude, BS could significantly reduce the symptoms of OA and potentially slow its progression, but appears more disappointing in preventing long-term complications of arthroplasties and improving their functional results., (Copyright © 2023 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Background: Bariatric surgery (BS) results in major and sustained weight loss and improves comorbidities in patients with obesity but can also lead to malnutrition, especially through severe malabsorption and/or surgical complications. Little is known about the efficacy of artificial nutrition (AN) in this setting., Methods: In this case series, we describe data from consecutive severely malnourished patients after BS (resectional and non-resectional), managed by AN at our hospital unit over a 4-year period., Results: Between January 2018 and June 2022, 18 patients (mean ± SD age 42.2 ± 10.4 years, 94% women) required AN following BS complications. At the time of AN initiation, more than half of the patients (53%) had multiple revisional surgeries (up to four). Mean BMI was 49.7 ± 11.3 kg/m 2 before BS and 29.6 ± 9.6 kg/m 2 when AN was initiated. Most patients (n=16, 90%) received enteral nutrition. AN management resulted in weight regain (+4.7kg ± 8.0, p=0.034), increased serum albumin (+28%, p=0.02), pre-albumin (+88%, p=0.002), and handgrip strength (+38%, p=0.078). No major AN complication nor death was observed. Median total AN duration was 4.5 months [1-12]. During follow-up, the cumulative duration of hospitalization was 33 days [4-88] with a median of 2.5 hospitalizations [1-8] per patient., Conclusion: Malnutrition can occur after any BS procedure, and AN when required in this setting appears safe and effective on nutritional parameters. It is important to recognize the potential risk factors for malnutrition, which include excessive weight loss resulting from surgical complications, eating disorders, multiple revisional BS, and pregnancy., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Randomized controlled trials (RCTs) have demonstrated the superiority of metabolic surgery (MS) over medical therapy (MT) in patients with obesity and type 2 diabetes, leading, to a joint statement in 2016 proposing MS to patients with class I obesity and uncontrolled glycemia. Yet, these RCTs included few patients with class I obesity (body mass index 30-35 kg/m 2 ) and even fewer patients with overweight. Our aim was to provide an updated systematic review (SR) with meta-analysis (MA) of RCTs reporting diabetes remission (DR) after MS in these patients., Research Design and Methods: We included in the SR with MA only RCTs with at least 24-month follow-up found in Medline, Cochrane Library, Embase, and LiSSA between January 2008 and September 2022 comparing DR post-MT versus post-MS. We calculated relative risk (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel random-effects approach to examine differences in DR between patients allocated to MS versus MT., Results: DR was significantly higher in MS versus MT after 36 months' follow-up in patients with obesity (RR = 6.65 [95 %CI 2.24;19.79]; I² = 27 %; 5 trials, 404 patients), but also specifically in patients with class I obesity (RR = 5.27 [1.31;21.23]; I² = 0 %; 4 trials, 80 patients). Furthermore, and in line with previous results, all additional MAs performed in patients with obesity in this work favor MS (specifically Roux-en-Y gastric bypass) over MT at 24, 36 (only) and 60 months of follow-up., Conclusions: Although the data available in patients with class I obesity and type 2 diabetes remains limited, MA shows higher rates of DR after MS compared with MT after 36 months' follow-up in these patients. Consequently, the French National Authority for Health French (HAS) recommends MS for these patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Background and Aims: It remains unclear to what extent and which components of advanced liver disease improve after bariatric surgery. We herein describe the histological outcome in patients with advanced NASH and its relationship with weight loss and metabolic improvement., Approach and Results: One hundred ninety-six patients with advanced NASH underwent bariatric surgery, 66 of whom agreed to a follow-up liver biopsy at 6 ± 3 years (36 with advanced fibrosis [AF] and 30 with high activity [HA] grade without AF). Liver biopsies LBs were centrally read and histological response was defined as the disappearance of AF or HA. Bariatric surgery induced major histological improvement: 29% of patients had normal histology at follow-up biopsy; 74% had NASH resolution without fibrosis progression; and 70% had ≥1 stage fibrosis regression. However, AF persisted in 47% of patients despite NASH resolution and some degree of fibrosis reversal, only evidenced by the EPoS seven-tier staging classification. These patients had lower weight loss and reduced hypertension or diabetes remission rates. Older age and sleeve gastrectomy were the only independent predictors for persistent AF after adjustment for duration of follow-up. All HA patients had major histological improvement: 50% normal histology, 80% NASH resolution, and 86% a ≥1 grade steatosis reduction. Patients with normal liver at follow-up had the largest weight loss and metabolic improvement. Independent predictors of normal liver were amount of weight loss, high histological activity, and the absence of AF before surgery., Conclusions: Although bariatric surgery successfully reverses active steatohepatitis, AF can persist for many years and is associated with lesser weight loss and metabolic improvement. Weight loss alone may not be sufficient to reverse AF., (© 2022 American Association for the Study of Liver Diseases.)

Background and Objectives: We previously showed in a 6-month randomized controlled trial that resistance training and protein supplementation after bariatric surgery (Roux-en-Y gastric bypass, RYGB) improved muscle strength without significant effect on weight loss and body composition changes. We performed a 5-year follow-up study in these subjects with the aim 1) to assess the long-term effect of this exercise training intervention and 2) to analyze associations between habitual physical activity (PA) and weight regain at 5 years., Methods: Fifty-four out of 76 initial participants (follow-up rate of 71%) completed the 5-year follow-up examination (controls, n = 17; protein supplementation, n = 22; protein supplementation and resistance training, n = 15). We measured body weight and composition (DXA), lower-limb strength (leg-press one-repetition maximum) and habitual PA (Actigraph accelerometers and self-report). Weight regain at 5 years was considered low when <10% of 12-month weight loss., Results: Mean (SD) time elapse since RYGB was 5.7 (0.9) y. At 5 years, weight loss was 32.8 (10.1) kg, with a mean weight regain of 5.4 (SD 5.9) kg compared with the 12-month assessment. Moderate-to-vigorous PA (MVPA) assessed by accelerometry did not change significantly compared with pre-surgery values (+5.2 [SD 21.7] min/d, P = 0.059), and only 4 (8.2%) patients reported participation in resistance training. Muscle strength decreased over time (overall mean [SD]: -49.9 [53.5] kg, respectively, P<0.001), with no statistically significant difference between exercise training intervention groups. An interquartile increase in MVPA levels was positively associated with lower weight regain (OR [95% CI]: 3.27 [1.41;9.86])., Conclusions: Early postoperative participation in a resistance training protocol after bariatric surgery was not associated with improved muscle strength after 5 years of follow-up; however, increasing physical activity of at least moderate intensity may promote weight maintenance after surgery. PA may therefore play an important role in the long-term management of patients with obesity after undergoing bariatric procedure., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Little is known about the consequences of COVID-19 lockdowns on physical activity (PA), eating behavior, and mental health in post-bariatric surgery (BS) patients. We aimed to analyze the relations between changes in PA during COVID-19 lockdowns and changes in body weight and a comprehensive set of lifestyle and psychological outcomes in patients who have undergone BS., Material and Methods: In April-May 2020 (lockdown#1), we performed an online survey in a cohort of 937 adults who underwent BS and were followed-up at our university medical center for at least one year. We assessed changes in PA, eating behavior, body weight, fatigue, and depression (PHQ-9). In November-December 2020 (lockdown#2), we recorded body weight in 280 patients who had reported decreased PA during lockdown #1., Results: During lockdown #1 (N = 420 patients included, 44% response rate), decreased PA was reported by 67% patients. Compared to those who reported increased or unchanged PA, patients with decreased PA were more likely to report a ≥ 5% weight gain (OR (95% CI): 3.15 (1.46-7.65), increased fatigue (2.08 (1.36-3.23)), a worsening of eating behavior (2.29 (1.47-3.58)), and moderate-to-severe depressive symptoms (4.74 (2.14-11.76)). During lockdown #2 (N = 225 patients, 80% response rate), significant weight gain since before lockdown #1 was reported (+ 2.8 (95% CI: 1.7-3.8) kg, p < 0.001), with 36% patients reporting a ≥ 5% weight gain., Conclusions: PA may counteract detrimental effects of COVID-19 lockdown on post-BS weight trajectories and mental health outcomes. Follow-up measures are needed in this setting to assess the long-term impact of lockdown., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Context: Serum propeptides of type III and type VI collagen (PRO-C3 and PRO-C6) are elevated in advanced nonalcoholic fatty liver disease (NAFLD), but their value in patients with severe obesity and their evolution after bariatric surgery (BS) is unknown. It is unclear if these markers of fibrogenesis are affected by adipose tissue fibrosis (ATF)., Objective: We studied the association of PRO-C3 and PRO-C6 with liver fibrosis before BS, examined their evolution after BS, and evaluated how much patients' ATF contribute to their levels., Methods: Serum PRO-C3 and PRO-C6 were measured in 158 BS patients and compared with liver, subcutaneous, and omental adipose tissue histology obtained during surgery. PRO-C3 and PRO-C6 levels of 63 patients were determined in follow-up at 3 and 12 months post-BS., Results: Patients in the highest quartile of PRO-C3 had a higher risk of advanced liver fibrosis (stage F3-4; odds ratio 5.8; 95% CI [1.5-29.9]; P = 0.017) vs the lowest quartile (adjustment for age, gender, and BMI). PRO-C3 was positively correlated with markers of insulin resistance and liver enzymes. After BS, PRO-C3 levels decreased in patients with high baseline liver fibrosis. This decrease correlated with improvement of metabolic and liver parameters. PRO-C6 was not related to stage of liver fibrosis. ATF did not correlate with PRO-C3 or PRO-C6 levels at baseline or after BS., Conclusion: PRO-C3 was associated with advanced liver fibrosis in patients with severe obesity, and decreased after BS, without being affected by ATF. These data suggest that BS prominently eliminates drivers of hepatic fibrogenesis in NAFLD., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Bariatric Surgery: TOWARDS NEW RECOMMANDATIONS The french NICE has produced a document describing the current limits to the optimal care of obesity, in particular concerning bariatric surgery. This document also states the perspectives and work that needs to be undergone to improve obesity care. Since october 2020, a working group appointed by the French NICE is writing the clinical recommandations for obesity care in 2nd and 3rd care referral, addressing both the medical and surgical care of obesity. This work has known some delay mainly due to the several waves of COVID-19., Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts.

Background: Ehlers-Danlos syndrome (EDS) is a heterogeneous disease affecting connective tissues. EDS patients have a high susceptibility for developing anastomotic leak after visceral surgery. Although patients with EDS can also develop severe obesity and might be referred to bariatric surgery, there is just 1 case report in the literature regarding the outcomes of bariatric surgery in this specific context., Objective: To report the cases of patients with EDS and severe obesity that underwent bariatric surgery., Setting: Five French hospitals (University Hospital of Nantes, APHP Pitié Salpêtrière Hospital, APHP Bichat Hospital, Clinique St Gregoire Rennes, and Clinique Mutualiste de l'Estuaire St Nazaire)., Methods: We report the cases of 7 patients with EDS and severe obesity who underwent surgery., Results: All patients showed classical postoperative course except for 1 case of excessive bleeding. There was no increased pain, leak, and solid parietal healing was achieved in all patients at 1 month postoperatively. The percent excess weight loss at 1 and 6 months were 13.9 ± 3.8% and 45.3 ± 16%, respectively., Conclusion: Our study shows that bariatric surgery is a relevant and apparently safe surgical option to consider in severely obese patients with EDS., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Severe hypocalcemia complicating cervical endocrine surgery in patients with gastric bypass can constitute a major concern. When usual therapies fail to maintain calcemia within the normal range without secondary adverse events, reversal of the bariatric surgery should be considered. We herein report the outcomes of laparoscopic revision of bariatric surgeries in two patients suffering from severe resistant hypocalcemia following cervical surgery, requiring in one case recombinant PTH administration and, in the other, daily intravenous calcium injections. The Roux-en-Y gastric bypass was switched to sleeve gastrectomy in the first patient, and in the second patient, the biliopancreatic diversion with duodenal switch was revised, to restore the upper and distal parts of the alimentary tract. Rapid improvement of hypocalcemia was observed in both cases.

Purpose of Review: This article summarizes recent literature concerning vitamin deficiency and required supplementation post-bariatric surgery, focusing on vitamin D (and associated clinical adverse effect on bone loss) and on the potential implication of the gut microbiota., Recent Findings: Bariatric surgery induces weight loss and metabolic improvements yet with major inter-individual variability. If it is efficient in most patients, some display poor response (i.e. patients with the lowest weight loss at 1 year or weight regain afterwards, or patients without metabolic disease remission). Despite systematic vitamin supplementation, some patients develop vitamin deficiencies leading to poor clinical outcomes, among which vitamin D deficiency associated with observed bone mass loss and fractures. Recent mechanistic studies led to understand better the involved physiopathology. Furthermore, different intervention studies tested on top of bariatric surgery (using vitamin, diet, or nutrients acting as functional food) have evaluated whether nutritional adverse outcomes could be improved. Importantly, gut microbiota involved in food digestion and metabolization and vitamin synthesis is largely perturbed during severe obesity and is partially restored post-surgery, yet again with large interindividual variability. Whether differential gut microbiota modification could be associated with vitamin deficiencies is an open question., Summary: Future clinical research studies will need to evaluate whether add-on intervention to bariatric surgery using vitamin, diet, or specific food items could help prevent nutritional deficiencies and improve clinical response observed post-surgery. Importantly, personalizing the add-on intervention post-surgery upon gut microbiota composition should be tested in predicted poor-responders to surgery as already performed during diet intervention to further improve metabolic health.

Background: To provide greater insight into bariatric surgery outcomes in aging patients, we compared changes in body weight, body composition, obesity-related comorbidities, and nutritional status between older and younger subjects., Methods: We analyzed data collected between January 2004 and December 2014 from our prospective bariatric cohort. Older patients (OP, ≥ 60 years at the time of surgery, n = 93; 66% Roux-en-Y gastric bypass, 34% sleeve gastrectomy) were compared with younger patients (YP, < 60 years, n = 186), matched 1:2 on sex, body mass index, diabetes, and surgical procedure. Body composition was assessed by dual-energy X-ray absorptiometry., Results: Weight loss and excess weight loss at 12 months were lower in OP vs. YP (mean ± SD, 30.1 ± 10.1 vs. 34.1 ± 11.9 kg, 60.6 ± 21.2 vs. 66.8 ± 23.4%, respectively, p < 0.05 for both). Both lean body mass and fat mass loss were lower in OP vs. YP (8.4 ± 3.4 vs. 9.2 ± 9.0 kg, 19.4 ± 8.7 vs. 21.9 ± 9.1 kg, respectively, p < 0.05). The remission rate for type 2 diabetes was significantly lower in OP vs. YP (24 vs. 45%), as well as improvement in hypertension (14 vs. 46%), dyslipidemia (27 vs. 47%), and knee pain. There was no difference in micronutrient deficiencies between groups., Conclusions: These data indicate that although bariatric surgery is not as effective for weight loss in older as in younger subjects, it is a safe option regarding a comprehensive set of nutritional variables which enables significant improvement in obesity-related outcomes.

Purpose of Review: In this review, we summarize what is currently described in terms of gut microbiota (GM) dysbiosis modification post-bariatric surgery (BS) and their link with BS-induced clinical improvement. We also discuss how the major inter-individual variability in terms of GM changes could impact the clinical improvements seen in patients., Recent Findings: The persisting increase in severe obesity prevalence has led to the subsequent burst in BS number. Indeed, it is to date the best treatment option to induce major and sustainable weight loss and metabolic improvement in these patients. During obesity, the gut microbiota displays distinctive features such as low microbial gene richness and compositional and functional alterations (termed dysbiosis) which have been associated with low-grade inflammation, increased body weight and fat mass, as well as type-2 diabetes. Interestingly, GM changes post-BS is currently being proposed as one the many mechanism explaining BS beneficial clinical outcomes. BS enables partial rescue of GM dysbiosis observed during obesity. Some of the GM characteristics modified post-BS (composition in terms of bacteria and functions) are linked to BS beneficial outcomes such as weight loss or metabolic improvements. Nevertheless, the changes in GM post-BS display major variability from one patient to the other. As such, further large sample size studies associated with GM transfer studies in animals are still needed to completely decipher the role of GM in the clinical improvements observed post-surgery.

The gut bacterial species Akkermansia muciniphila is associated with a healthier clinical profile. The purpose of this study was to determine the association between A. muciniphila and glucose homeostasis in patients undergoing bariatric surgery (BS): gastric banding (GB) or Roux-en-Y gastric bypass (RYGB). This nonrandomized prospective study included 65 women with severe obesity. Longitudinal analysis included subjects for whom A. muciniphila data were available at follow-up [1, 3, and 12 mo; GB ( n = 10) or RYGB ( n = 11)]. Glucose homeostasis markers were measured under fasting conditions (glucose, insulin, and HbA1c) or during an oral glucose tolerance test. Fecal microbiota was analyzed using shotgun metagenomics, and A. muciniphila relative abundance was assessed with 16S rRNA quantitative PCR. A. muciniphila relative abundance was significantly lower in severe obesity [mean body mass index, 45.7 kg/m 2 (SD 5.4)] than in moderate obesity [33.2 kg/m 2 (SD 3.8)] but not associated with glucose homeostasis markers. A significant increase in A. muciniphila relative abundance after RYGB was not correlated with metabolic improvement. Baseline A. muciniphila abundance was correlated with bacterial gene richness and was highest in the high-richness Ruminococcaceae enterotype. A. muciniphila increased in relative abundance after BS in patients with low baseline A . muciniphila abundance, especially those with a Bacteroides type 2 enterotype classification. Although decreased in severe obesity, relative abundance of A. muciniphila was not associated with glucose homeostasis before or after BS. A certain level of A. muciniphila abundance might be required to observe a beneficial link to health. The severity of obesity and gut dysbiosis may partly explain the discrepancy with previous findings in less obese populations.

Obesity is a chronic low-grade inflammatory disease (both at the systemic and adipose tissue level) that continues to rise worldwide. It is associated with an abundance of comorbidities, including type 2 diabetes (T2D). Bariatric surgery, which induces modifications of the intestinal tract, is to date the most successful treatment for obesity. Its use has dramatically increased in number as it enables both weight reduction and metabolic improvements, with 60% of patients even achieving diabetes remission. Several mechanisms are actually demonstrated to be involved in those clinical improvements. Importantly, both obesity and T2D share many phenotypic characteristics, including increased systemic and adipose tissue inflammation, as well as gut microbiota dysbiosis. These characteristics are deeply modulated after bariatric surgery. This review will address the host metabolic changes observed after bariatric surgery, focusing on the induced gut architectural changes, as well as on the modifications of the inflammatory tone and the gut microbiota.

Purpose: DiaRem is a clinical scoring system designed to predict diabetes remission (DR) 1-year post-Roux-en-Y gastric bypass (RYGB). We examined long-term (2- and 5-year) postoperative DR prediction by DiaRem and an advanced-DiaRem (Ad-DiaRem) score following RYGB, sleeve gastrectomy (SG), and gastric banding (GB)., Methods: We accessed data from a computerized database of persons with type 2 diabetes and BMI ≥ 30 kg/m 2 who underwent RYGB, SG, or GB, and determined DR status 2- and 5-year postoperative according to preoperative DiaRem and the Ad-DiaRem calculated scores., Results: Among 1459 patients with 5-year postoperative diabetes status data, 53.6% exhibited DR. For RYGB, Ad-DiaRem trended to exhibit mildly improved predictive capacity 5-year postoperatively compared to DiaRem: Areas under receiver operating characteristic [AUROC] curves were 0.85 (0.76-0.93) and 0.78 (0.69-0.88), respectively. The positive predictive values (PPVs) detecting > 80% of those achieving DR (i.e., sensitivity ≥ 0.8) were 78.2% and 73.2%, respectively, and higher Ad-DiaRem scores more consistently associated with decreased DR rates. Following SG, both scores had an AUROC of 0.82, but Ad-DiaRem still had a higher PPV for predicting > 80% of those with 5-year postoperative DR (76.2% and 71.0%). Predictive capacity parameters were comparatively lower, for both scores, when considering DR 5-year post-GB (AUROC: 0.73 for both scores, PPV: 66.3% and 64.3%, respectively)., Conclusions: Ad-DiaRem provides modest improvement compared to DiaRem in predicting long-term DR 5-years post-RYGB. Both scores similarly provide fair predictive capacity for 5-year postoperative DR after SG.

Objectives: Decreased gut microbial gene richness (MGR) and compositional changes are associated with adverse metabolism in overweight or moderate obesity, but lack characterisation in severe obesity. Bariatric surgery (BS) improves metabolism and inflammation in severe obesity and is associated with gut microbiota modifications. Here, we characterised severe obesity-associated dysbiosis (ie, MGR, microbiota composition and functional characteristics) and assessed whether BS would rescue these changes., Design: Sixty-one severely obese subjects, candidates for adjustable gastric banding (AGB, n=20) or Roux-en-Y-gastric bypass (RYGB, n=41), were enrolled. Twenty-four subjects were followed at 1, 3 and 12 months post-BS. Gut microbiota and serum metabolome were analysed using shotgun metagenomics and liquid chromatography mass spectrometry (LC-MS). Confirmation groups were included., Results: Low gene richness (LGC) was present in 75% of patients and correlated with increased trunk-fat mass and comorbidities (type 2 diabetes, hypertension and severity). Seventy-eight metagenomic species were altered with LGC, among which 50% were associated with adverse body composition and metabolic phenotypes. Nine serum metabolites (including glutarate , 3-methoxyphenylacetic acid and L-histidine ) and functional modules containing protein families involved in their metabolism were strongly associated with low MGR. BS increased MGR 1 year postsurgery, but most RYGB patients remained with low MGR 1 year post-BS, despite greater metabolic improvement than AGB patients., Conclusions: We identified major gut microbiota alterations in severe obesity, which include decreased MGR and related functional pathways linked with metabolic deteriorations. The lack of full rescue post-BS calls for additional strategies to improve the gut microbiota ecosystem and microbiome-host interactions in severe obesity., Trial Registration Number: NCT01454232., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Context: Anti-retroviral therapy (ART) dramatically reduced AIDS development, thus enabling patients to live as long as the general population. New challenges have emerged particularly cardiometabolic diseases and weight gain, with some HIV patients seeking bariatric surgery (BS). However, BS outcomes during HIV remain poorly described, with scarce data on ART pharmacokinetic post-BS., Objective: Describing sleeve gastrectomy (SG) results in HIV patients in terms of ART pharmacokinetic, HIV control, weight loss, and metabolic outcomes., Design, Setting, and Patients: Prospective study of HIV patients undergoing SG in a referral academic center, with at least 6 months follow-up., Main Outcome Measure: Clinical and biological parameters, HIV medical history, and ART pharmacokinetics were gathered before and post-SG., Results: Seventeen patients (mean BMI = 44.2 ± 5.7 kg m -2 ) and major obesity-related diseases (47% type-2 diabetes, 64% obstructive sleep apnea, 70% hypertension) underwent SG during a mean 2 years of follow-up. They displayed an average of 20% reduction of initial BMI and improved body composition, similarly to obese non-HIV patients. SG improved metabolic status. All patients had undetectable viral load before BS. Upon HIV follow-up, 12 patients had undetectable viral load with correct ART kinetic parameters (3 and 6 months); 4 displayed detectable viral load along with significant decrease in raltegravir and atazanavir treatment exposure, leading to ART change with subsequent undetectable viral load; and 1 had persistent detectable viral load despite ART change., Conclusions: SG seems effective and safe in obese HIV patients. However, ART treatment should be monitored post-SG to control HIV infection. We suggest that some ART should be adapted before SG conjoints with infectious disease specialists.

Objective: Non-alcoholic fatty liver disease (NAFLD) is a frequent complication of morbid obesity, but its severity varies greatly and thus there is a strong need to better define its natural history in these patients., Design: Liver biopsies were systematically performed in 798 consecutive patients with severe obesity undergoing bariatric surgery. Histology was compared with clinical, biological, anthropometrical and body composition characteristics., Results: Patients with presumably normal liver (n=179, 22%) were significantly younger at bariatric surgery than patients with NAFLD (37.0 vs 44.4 years, p<0.0001). However, both groups showed quite similar obesity duration, since patients with presumably normal liver reported the onset of obesity at a significantly younger age than those with NAFLD (14.8 vs 20.0 year, p<0.0001). The trunk/limb fat mass ratio increased according to liver disease severity (presumably normal liver: 1.00, steatosis: 1.21, non-alcoholic steatohepatitis (NASH): 1.34, p<0.0001), although the total body fat mass decreased (presumably normal liver: 50%, steatosis: 49.1%, NASH: 47.4%, p<0.0001). The volume of subcutaneous adipocytes increased according to severity of liver disease but only in female patients (presumably normal liver: 8543 picolitres, steatosis: 9156 picolitres, NASH: 9996 picolitres)., Conclusions: These results suggest that young adults are more prone to store fat in subcutaneous tissue and reach the threshold of bariatric surgery indication before their liver is damaged. A shift of fat storage from subcutaneous to visceral adipose tissue compartment is associated with liver damages. Liver might also be targeted by subcutaneous hypertrophic adipocytes in females since hypertrophic adipocytes are more exposed to lipolysis and to the production of inflammatory mediators., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: The number of morbidly obese patients undergoing bariatric surgery (BS) has increased dramatically in recent years. Therefore, monitoring food intake and its consequences in terms of nutritional status is necessary to prevent nutritional deficiencies. The aim of this study was to analyze the effect of food restriction on nutritional parameters in the short-term (≤3 months) period after BS in morbid obesity., Method: In a prospective study, we followed 22 obese women who underwent Roux-en-Y gastric bypass (GBP) or adjustable gastric banding (AGB) at baseline (T0) and 1 (T1) and 3 (T3) months after surgery. We evaluated food intake, nutrient adequacy and serum concentrations of vitamins and minerals known to be at risk for deficiency following BS., Results: Before surgery, we observed suboptimal food intakes, leading to a risk of micronutrient deficiencies. Serum analysis confirmed nutritional deficiencies for iron and thiamine for 27 and 23% of the patients, respectively. The drastic energy and food reduction seen in the short term led to very low probabilities of adequacy for nutrients equivalent across both surgeries. Serum analysis demonstrated a continuous decrease in prealbumin during the follow-up, indicating mild protein depletion in 21 and 57% of GBP patients and 50 and 63% of AGB patients, respectively, at T1 and T3. Regarding vitamins and minerals, systematic supplementation after GBP prevented most nutritional deficiencies. By contrast, AGB patients, for whom there is no systematic supplementation, developed such deficiencies., Conclusions: Our results suggest that cautious monitoring of protein intake after BS is mandatory. Furthermore, AGB patients might also benefit from systematic multivitamin and mineral supplementation at least in the short term.

Context: Extracellular matrix (ECM) in sc adipose tissue (scAT) undergoes pathological remodeling during obesity. However, its evolution during weight loss remains poorly explored., Objective: The objective of the investigation was to study the histological, transcriptomic, and physical characteristics of scAT ECM remodeling during the first year of bariatric surgery (BS)-induced weight loss and their relationships with metabolic and bioclinical improvements., Design, Setting, Patients, and Interventions: A total of 118 morbidly obese candidates for BS were recruited and followed up during 1 year after BS., Main Outcome Measures: scAT surgical biopsy and needle aspiration as well as scAT stiffness measurement were performed in three subgroups before and after BS. Fourteen nonobese, nondiabetic subjects served as controls., Results: Significantly increased picrosirius-red-stained collagen accumulation in scAT after BS was observed along with fat mass loss, despite metabolic and inflammatory improvements and undetectable changes of scAT stiffness. Collagen accumulation positively associated with M2-macrophages (CD163(+) cells) before BS but negatively afterward. Expression levels of genes encoding ECM components (eg, COL3A1, COL6A1, COL6A2, ELN), cross-linking enzymes (eg, lysyl oxidase [LOX], LOXL4, transglutaminase), metalloproteinases, and their inhibitors were modified 1 year after BS. LOX expression and protein were significantly decreased and associated with decreased fat mass as well as other cross-linking enzymes. Although total collagen I and VI staining decreased 1 year after BS, we found increased degraded collagen I and III in scAT, suggesting increased degradation., Conclusions: After BS-induced weight loss and related metabolic improvements, scAT displays major collagen remodeling with an increased picrosirius-red staining that relates to increased collagen degradation and importantly decreased cross-linking. These features are in agreement with adequate ECM adaptation during fat mass loss.

Background: Bariatric surgery is associated to improvements in obesity-associated comorbidities thought to be mediated by a decrease of adipose inflammation. However, the molecular mechanisms behind these beneficial effects are poorly understood., Methodology/principal Findings: We analyzed RNA-seq expression profiles in adipose tissue from 22 obese women before and 3 months after surgery. Of 15,972 detected genes, 1214 were differentially expressed after surgery at a 5% false discovery rate. Upregulated genes were mostly involved in the basal cellular machinery. Downregulated genes were enriched in metabolic functions of adipose tissue. At baseline, 26 modules of coexpressed genes were identified. The four most stable modules reflected the innate and adaptive immune responses of adipose tissue. A first module reflecting a non-specific signature of innate immune cells, mainly macrophages, was highly conserved after surgery with the exception of DUSP2 and CD300C. A second module reflected the adaptive immune response elicited by T lymphocytes; after surgery, a disconnection was observed between genes involved in T-cell signaling and mediators of the signal transduction such as CXCR1, CXCR2, GPR97, CCR7 and IL7R. A third module reflected neutrophil-mediated inflammation; after surgery, several genes were dissociated from the module, including S100A8, S100A12, CD300E, VNN2, TUBB1 and FAM65B. We also identified a dense network of 19 genes involved in the interferon-signaling pathway which was strongly preserved after surgery, with the exception of DDX60, an antiviral factor involved in RIG-I-mediated interferon signaling. A similar loss of connection was observed in lean mice compared to their obese counterparts., Conclusions/significance: These results suggest that improvements of the inflammatory state following surgery might be explained by a disruption of immuno-inflammatory cascades involving a few crucial molecules which could serve as potential therapeutic targets.

Bariatric surgery induces weight loss and major improvement in insulin-resistance through many mechanisms some of which are weight independent. It is now well acknowledged that gut microbiota is involved in the development of obesity and its related metabolic diseases, at least in mice. However, its causal role in human obesity progression remains to be demonstrated. Few studies now pointed at changes in microbiota composition after bariatric surgery, suggesting links between gut microbiota switch and metabolic improvement observed after surgery. As such new potential mechanisms of actions have been proposed. The aim of this review is to describe microbiota modifications observed after bariatric surgery and its potential relationships with improved insulin resistance. We here list some hypotheses, which will need further demonstration.

The gut microbiota is recognized to have an important role in energy storage and the subsequent development of obesity. To date, bariatric surgery (indicated for severe obesity) represents the only treatment that enables substantial and sustained weight loss. Bariatric surgery is also a good model to study not only the pathophysiology of obesity and its related diseases but also the mechanisms involved in their improvement after weight reduction. Scarce data from humans and animal models have demonstrated that gut microbiota composition is modified after Roux-en-Y gastric bypass (RYGB), suggesting that weight reduction could affect gut microbiota composition. However, weight loss might not be the only factor responsible for those modifications. Indeed, bariatric surgery not only improves hormonal and inflammatory status, but also induces numerous changes in the digestive tract that might account for the observed modifications of microbiota ecology. In future bariatric surgery studies in humans or mice, these major surgery-induced modifications will need to be taken into account when analyzing the link between gut microbiota composition, obesity, its complications and their improvement after bariatric surgery. This Review outlines the potential mechanisms by which the major changes in the digestive tract after bariatric surgery can affect the gut microbiota.

Aim: We tested the hypothesis that quantitative changes in high-density lipoprotein (HDL) particles weight loss induced by Roux-en-Y bypass (RYGBP) in morbidly obese subjects might be associated with improved functionality of these particles in the reverse cholesterol transport pathway., Methods and Results: Thirty-four morbidly obese women were recruited and followed up before and 6 months after RYGBP. After surgery, along with a major weight loss (-20%; P < 0.0001), we observed a significant increase in HDL mass concentration (+14%; P < 0.04), reflecting a specific increase in large HDL2 subfraction levels (+42%; P < 0.01), whereas those of HDL3 remained unchanged. Cholesterol ester transfer protein activity decreased significantly (-15%; P < 0.0001). Efflux capacity of total plasma increased significantly via both scavenger receptor class B type I (SR-BI) (+58%; P < 0.0001) and ATP binding cassette G1 (ABCG1) (+26%; P < 0.0001) pathways. Such enhanced capacity resulted from increased capacity of HDL2 particles to mediate cholesterol efflux through the SR-BI pathway (+56%, P < 0.001) and from the increase plasma level of cholesteryl ester-rich HDL2 particles for the ABCG1 pathway., Conclusion: RYGBP-induced weight loss results in improvement in atherogenic lipid profile including a shift toward a more cardioprotective HDL subfraction profile. In addition, our in vitro studies demonstrated an increased in plasma efflux capacity via both SR-BI and ABCG1 after surgery.

Un déséquilibre de la composition du microbiote intestinal ou de ses fonctions est fréquemment observé en cas d'obésité et de maladie métabolique. De nombreuses études sur modèle murin montrent que la modification de la dysbiose du microbiote par diverses méthodes est associée à une amélioration des paramètres métaboliques. Chez l'homme, des interventions diététiques ou la chirurgie bariatrique sont accompagnées de modifications plus ou moins importantes de la composition du microbiote. La transplantation de microbiote fécal (TMF) est une option pleine de potentiel pour modifier la composition de ce microbiote intestinal, néanmoins, elle n'est pour le moment officiellement indiquée que dans le traitement des colites récurrentes à Clostridioides difficile. La littérature documentant l'effet du transfert de microbiote fécal dans les maladies métaboliques est en effet beaucoup moins abondante et réalisée sur des petits effectifs. Il a toutefois été montré que la TMF de donneurs sains à des patients obèses souffrant de syndrome métabolique améliorait leur sensibilité à l'insuline de manière significative en dépit de la grande variabilité de réponse. Cette variabilité semble en grande partie dépendante de la différence de richesse entre le microbiote du donneur et celui du receveur. À ce jour, l'impact du choix du donneur, du protocole de préparation, de conservation et d'administration de l'inoculum, ainsi que de l'éventuelle préparation du receveur sont à explorer. An imbalance of the gut microbiota composition or functions is frequently observed during obesity and metabolic diseases. Studies on rodents showed that the modulation of microbiota dysbiosis by various methods is associated with an improvement in metabolic parameters. In humans, dietary interventions or bariatric surgery are accompanied by changes in the composition of the microbiota. Fecal microbiota transfer is a promising therapeutic approach to change the composition of the gut microbiota, however, it is currently only officially indicated in the treatment of recurrent Clostridioides difficile colitis. Literature documenting the effect of faecal microbiota transplantation in metabolic diseases is much less abundant. Nevertheless, FMT from healthy donors to obese patients with metabolic syndrome significantly improves the insulin sensitivity of the recipients despite the large response variability. This variability seems to be mainly related to the difference in richness between the donor's microbiota and the recipient's microbiota. To date, the impact of the donor's choice, the protocol of preparation, storage and administration of the inoculum, as well as the possible preparation of the recipient are to be explored. [ABSTRACT FROM AUTHOR]

Aujourd'hui en France plus de 8 millions de personnes sont en situation d'obésité (soit 17 % de la population française), avec une prévalence encore exacerbée chez les personnes issues des milieux socioéconomiques défavorisés. Cette pathologie nécessite une prise en charge globale, pluriprofessionnelle, multimodale, adaptée et exhaustive, prenant en compte toutes les comorbidités associées et le potentiel handicap causé par la sévérité de l'obésité. Ces recommandations de bonnes pratiques, publiées en 2022, répondent à la nécessité d'améliorer la prise en charge des patients en situation d'obésité, via : la classification de la sévérité de l'obésité au-delà du seul indice de masse corporelle (IMC) qui permet ensuite d'adresser les patients dans les niveaux de recours adéquats ; la description exhaustive du contenu de l'évaluation (médicale, comportementale, psychologique et sociale) ; la précision des objectifs et du contenu des modifications thérapeutiques du mode de vie à mettre en place ; et enfin l'introduction et les indications du traitement médicamenteux de l'obésité. Ces recommandations ont ensuite permis à un autre groupe de travail, de proposer un guide de parcours de soins de l'adulte en surpoids et en situation d'obésité (paru en février 2023), d'élargir les indications des traitements médicamenteux de l'obésité (avis sur les médicaments, décembre 2022). Enfin, ces recommandations seront complétées par une deuxième partie portant sur la révision des recommandations sur la chirurgie bariatrique (attendues en 2024) afin de proposer une prise en charge uniforme et de qualité des patients en situation d'obésité. © 2023 Société francophone nutrition clinique et métabolisme (SFNCM). Publié par Elsevier Masson SAS. Tous droits réservés. Presently in France, more than 8 million people are affected by obesity (17% of the French population), with an even higher prevalence among people from disadvantaged socio-economic backgrounds. This pathology requires a global, multi-professional, multimodal, adapted, and exhaustive management, taking into account all the associated comorbidities and the potential handicap caused by the severity of obesity. These best practice clinical recommendations, published in 2022, improves the management of patients with obesity through: (i) the development of a new clinical classification that graduates the severity of obesity beyond the sole BMI, allowing patients to be referred to the appropriate level of care; (ii) the exhaustive description of the evaluation content (medical, behavioral, psychological and social); (iii) the precision of the objectives and content of the needed therapeutic lifestyle modifications and (iv) the introduction and description of anti-obesity drug indications. These recommendations were then used by another working group to propose a guide for the care pathway of adults living with overweight and obesity (published in February 2023), and to broaden the indications for drug treatments for obesity (opinion on drugs, December 2022). Finally, these recommendations will be completed by a second part concerning the revision of the bariatric surgery recommendations (expected in 2024) in order to propose uniform and quality management of patients living with obesity. © 2023 Société francophone nutrition clinique et métabolisme (SFNCM). Published by Elsevier Masson SAS. All rights reserved. [ABSTRACT FROM AUTHOR]

L'accompagnement de patients vivant avec l'obésité nécessite une cohérence d'approche des professionnels de santé. La formation à cet accompagnement thérapeutique est une des missions des Centres Spécialisés Obésité (CSO). Un dispositif numérique a été expérimenté par le CSO des Hospices Civils de Lyon (HCL) afin d'en évaluer la pertinence pour la formation de son réseau de professionnels entre septembre et décembre 2022. Deux e-parcours ont ainsi été testés : « nutrition obésité » (38 ateliers) et « chirurgie bariatrique » (23 ateliers) par des professionnels de santé volontaires (n = 282) et par un groupe d'experts (n = 8). Trois grandes catégories de données ont été recueillies pour cette expérimentation afin d'évaluer l'usage, la satisfaction et la pertinence de la plateforme à l'aide d'échelle de Likert sur 10 et de liste de mots à choisir. Les taux de réalisation de la totalité des parcours pour les professionnels de santé sont de 32,8 % (nutrition obésité) et 65,2 % (chirurgie bariatrique). Plus de 90 % des utilisateurs recommandent l'usage de l'outil pour les patients et les professionnels de santé. Le groupe d'experts a évalué l'intérêt de l'outil dans le cadre de la formation des professionnels de santé à 9,3 ± 0,7 sur 10. Le numérique permet aujourd'hui d'enrichir les parcours de soins avec l'usage de dispositifs digitaux sous réserve que ces derniers conservent une cohérence d'approche et de contenus. Cette expérimentation démontre ici que ce dispositif numérique, initialement conçu pour l'éducation thérapeutique des patients, a toute sa place au sein des futurs parcours de formation des soignants. Supporting patients living with obesity requires a consistent approach from healthcare professionals. Training in this therapeutic support is one of the missions of the Specialized Obesity Centers (CSO). A digital device was tested by the CSO of the Hospices Civils de Lyon (HCL) in order to assess its relevance for the training of its network of professionals between September and December 2022. Two e-courses were tested: "obesity nutrition" (38 workshops) and "bariatric surgery" (23 workshops) by volunteer healthcare professionals (n = 282) and by a group of experts (n = 8). Three main categories of data were collected for this experiment in order to assess the use, satisfaction and relevance of the platform using a Likert scale out of 10 and a list of words to choose from. The completion rates for all courses for healthcare professionals are 32.8% (nutrition obesity) and 65.2% (bariatric surgery). More than 90% of users recommend the use of the tool for patients and healthcare professionals. The expert group assessed the interest of the tool in the context of training healthcare professionals at 9.3 ± 0.7 out of 10. Digital technology now makes it possible to enrich care pathways with the use of digital devices provided that the latter maintain a consistency of approach and content. This experiment demonstrates here that this digital device, initially designed for the therapeutic education of patients, has its place in the future training pathways of caregivers. [ABSTRACT FROM AUTHOR]

Although food marketing is often accused of increasing population obesity, the relationship between individual responsiveness to marketing and obesity has yet to be established: Are people with obesity more responsive to food marketing and, if so, is it a stable trait or can it be reversed by bariatric surgery? We studied the responses to three common marketing tactics that frame foods and portions as healthier than they really are in three groups of women: (a) a group of patients with obesity before, 3 months, and 12 months after bariatric surgery, (b) a control group of lean women, and (c) another control group of women with obesity but not seeking any treatment for their obesity. People with obesity were initially more responsive to food marketing, but bariatric surgery reduced their responsiveness down to the level of lean people. In addition to documenting another potential psychological consequence of bariatric surgery, our study suggests that the higher responsiveness of people with obesity is not a stable individual predisposition and supports the notion of a reciprocal relationship between obesity and sensitivity to environmental influences. [ABSTRACT FROM AUTHOR]

We describe a novel device called the AdipoScan that was adapted from the FibroScan to specifically assess shear wave speed (SWS) in human abdominal subcutaneous adipose tissue (scAT). Measurement reproducibility was assessed on tissue-mimicking phantoms with and without repositioning, with resultant coefficients of variation of 1% and 0%, respectively, as well as in vivo (14% and 7%, respectively). The applicability of the AdipoScan was tested on 19 non-obese volunteers, and a scAT thickness >2 cm was found to be mandatory to perform a valid measurement. Abdominal scAT SWS was assessed in 73 severely obese subjects, all candidates for bariatric surgery. Subcutaneous AT SWS was positively associated with scAT fibrosis and obesity-related co-morbidities such as hypertension, glycemic status, dyslipidemia and liver dysfunction. These results suggest that the AdipoScan could be a useful non-invasive tool to evaluate scAT fibrosis and metabolic complications in obesity. Further investigation is required to evaluate the relevance of using the AdipoScan to predict patient weight trajectories and metabolic outcomes after bariatric surgery. [ABSTRACT FROM AUTHOR]

Background & Aims Non-alcoholic steatohepatitis (NASH) is characterized by steatosis, lobular inflammation, hepatocyte ballooning with fibrosis in severe cases, and high prevalence in obesity. We aimed at defining NASH signature in morbid obesity by mass spectrometry-based lipidomic analysis. Methods We analyzed systemic blood before and 12 months after bariatric surgery, along with portal blood and adipose tissue lipid efflux collected from obese women at the time of surgery (9 structural classes, 150 species). Results Increased concentrations of several glycerophosphocholines (PC), glycerophosphoethanolamines (PE), glycerophosphoinositols (PI), glycerophosphoglycerols (PG), lyso-glycerophosphocholines (LPC), and ceramides (Cer) were detected in systemic circulation of NASH subjects. Post-surgery weight loss (12 months) improved the levels of liver enzymes, as well as several lipids, but most PG and Cer species remained elevated. Analysis of lipids from hepatic portal system at the time of surgery revealed limited lipid alterations compared to systemic circulation, but PG and PE classes were found significantly increased in NASH subjects. We evaluated the contribution of visceral adipose tissue to lipid alterations in portal circulation by measuring adipose tissue lipid efflux ex vivo , and observed only minor alterations in NASH subjects. Interestingly, integration of clinical and lipidomic data (portal and systemic) led us to define a NASH signature in which lipids and clinical parameters are equal contributors. Conclusions Circulatory (portal and systemic) phospholipid profiling and clinical data defines NASH signature in morbid obesity. We report weak contribution of visceral adipose tissue to NASH-related portal lipid alterations, suggesting possible contribution from other organs draining into hepatic portal system. [ABSTRACT FROM AUTHOR]