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Purpose Preoperative very low-calorie diets (VLCDs) have been shown to reduce liver volume and improve bariatric surgery safety. Here, we compare two VLCD that differ in macronutrient composition. Material/Methods Ninety patients awaiting obesity surgery were included in a prospective, open-label, randomized mono-centre trial comparing the effects of 2-week preoperative VLCDs: BCM Diät™ (diet 1) versus Optifast™ (diet 2). Results Data from 33 patients in diet 1 and 36 in diet 2 could be analysed. There was no significant difference between the two diet intervention arms on outcome parameters. Overall, both VLCD strategies led to a mean weight reduction of 5.24 [4.72–5.76] kg (p p 2 (p p In addition, hip/waist circumferences, body fat and fat-free mass decreased significantly. We found an increase of ALAT/ASAT and a significant decrease of triglycerides, LDL-cholesterol and HbA1c. Parameters of inflammatory were significantly reduced upon VLCD. Conclusion Independently of the macronutrient composition, VLCD leads to a significant decrease of body weight, reduction of liver volume and improved parameters of inflammation, glucose and lipid metabolism. Preoperative diets are widely used in conditioning; however, VLCD should be considered as option for patients with obesity undergoing other abdominal surgeries. Graphical abstract

Purpose Roux-en-Y gastric bypass (RYGB) surgery is currently the most efficient treatment to achieve long-term weight loss in individuals with severe obesity. This is largely attributed to marked reductions in food intake mediated in part by changes in gut-brain communication. Here, we investigated for the first time whether weight loss after RYGB is associated with alterations in central noradrenaline (NA) neurotransmission. Materials and Methods We longitudinally studied 10 individuals with severe obesity (8 females; age 43.9 ± 13.1 years; body mass index (BMI) 46.5 ± 4.8 kg/m2) using (S,S)-[11C]O-methylreboxetine and positron emission tomography to estimate NA transporter (NAT) availability before and 6 months after surgery. NAT distribution volume ratios (DVR) were calculated by volume-of-interest analysis and the two-parameter multilinear reference tissue model (reference region: occipital cortex). Results The participants responded to RYGB surgery with a reduction in BMI of 12.0 ± 3.5 kg/m2 (p p = 0.019) and a general tendency towards reduced DVR throughout the brain. Furthermore, we found a strong positive correlation between pre-surgery DVR in hypothalamus and the change in BMI (r = 0.78; p = 0.01). Conclusion Reductions in BMI after RYGB surgery are associated with NAT availability in brain regions responsible for decision-making and homeostasis. However, these results need further validation in larger cohorts, to assess whether brain NAT availability could prognosticate the outcome of RYGB on BMI. Graphical abstract

Purpose People with obesity often develop non-alcoholic fatty liver disease (NAFLD) and are at high risk of progression to non-alcoholic steatohepatitis (NASH). Few therapies are effective other than bariatric surgery. We therefore analyzed data from duodenal-jejunal bypass liner (DJBL) patients regarding steatosis, fibrosis, and NASH. Methods Consecutive DJBL patients with type 2 diabetes underwent standardized assessments up to device removal at 48 weeks. These included aspartate and alanine transaminase (AST, ALT), controlled attenuation parameter (CAP, for steatosis), and liver stiffness measurement (LSM, for fibrosis). The NAFLD fibrosis score (NFS), fibrosis-4 score (FIB4), and enhanced liver fibrosis (ELF) test were also used to assess fibrosis and the Fibroscan-AST (FAST) score to assess NASH. Mixed models were used and missing data were accounted for with multiple imputation. Results Thirty-two patients (18 female, mean age 55.1, mean BMI 40.2 kg/m2) were included. After 48 weeks, the change compared to baseline with 95% CI was a factor 0.74 (0.65 to 0.84) for AST, 0.63 (0.53 to 0.75) for ALT, and a difference of − 0.21 (− 0.28 to − 0.13) for FAST, all with p Conclusions One year of DJBL therapy is associated with relevant improvements in non-invasive markers of steatosis and NASH, but not fibrosis, and is accompanied by a substantial number of complications. Given the lack of alternatives, DJBL deserves further attention. Graphical abstract

Background: the Practical Guideline is based on the current scientific ESPEN guide on Clinical Nutrition in Liver Disease. Methods: it has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. Results: a total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. Disease-related recommendations are preceded by general recommendations on the diagnosis of nutritional status in liver patients and on liver complications associated with medical nutrition. Conclusion: this Practical Guideline gives guidance to health care providers involved in the management of liver disease on how to offer optimal nutritional care.Introducción: la Guía Práctica se basa en la actual guía científica de la ESPEN sobre nutrición clínica en las enfermedades hepáticas. Métodos: se ha reducido y transformado en diagramas de flujo para facilitar su uso en la práctica clínica. La guía está dedicada a todos los profesionales, incluidos médicos, dietistas, nutricionistas y enfermeras, que trabajan con pacientes con enfermedad hepática crónica. Resultados: la guía presenta un total de 103 pronunciamientos y recomendaciones con breves comentarios para el manejo nutricional y metabólico de pacientes con (i) insuficiencia hepática aguda grave, (ii) esteatohepatitis alcohólica, (iii) enfermedad hepática grasa no alcohólica, (iv) cirrosis hepática, y (v) cirugía o trasplante de hígado. Conclusión: las recomendaciones relacionadas con enfermedades están precedidas por recomendaciones generales sobre el diagnóstico del estado nutricional en los pacientes hepáticos y sobre las complicaciones hepáticas asociadas a la nutrición médica.

ZusammenfassungDer Leitfaden Ernährungstherapie in Klinik und Praxis (LEKuP) stellt eine grundlegende Überarbeitung des zuletzt im Jahr 2004 von der Deutschen Akademie für Ernährungsmedizin e. V. (DAEM) herausgegebenen Rationalisierungsschemas dar. Dabei erfolgte die Erstellung des LEKuP in enger Zusammenarbeit der verschiedenen Fachgesellschaften: Deutsche Gesellschaft für Ernährung e. V. (DGE) und die Deutsche Akademie für Ernährungsmedizin e. V. (DAEM) mit der Deutschen Gesellschaft für Ernährungsmedizin e. V. (DGEM), dem Berufsverband Deutscher Ernährungsmediziner e. V. (BDEM), der Deutschen Adipositas-Gesellschaft e. V. (DAG), dem Verband der Diätassistenten – Deutscher Bundesverband e. V. (VDD) und dem Berufsverband Oecotrophologie e. V. (VDOE).Gemeinsames Ziel der beteiligten Fachgesellschaften und -verbände war es, auf Grundlage evidenzbasierter Leitlinien einen aktuellen und konsensbasierten Leitfaden für die praktische Ernährungstherapie in Klinik und Praxis zu verfassen. Ein weiteres Ziel der Überarbeitung war es, damit eine Vorlage zu schaffen, aus der ein Kostformenkatalog für stationäre und ambulante medizinische Einrichtungen nach den lokalen Bedürfnissen abgeleitet werden kann.Die dem LEKuP zugrunde liegenden Empfehlungen basieren auf den D-A-CH-Referenzwerten für die Nährstoffzufuhr der Deutschen Gesellschaft für Ernährung e. V. (DGE) für Erwachsene und entsprechen einer vollwertigen und gesundheitsförderlichen Ernährung. Mittelmeerkost und vegetarische Ernährung werden als gleichwertig betrachtet. Abhängig von krankheitsspezifischen Erfordernissen werden Abweichungen und Ergänzungen vorgenommen, sodass eine Ernährungstherapie umgesetzt werden kann, die alle ernährungsbezogenen Maßnahmen zur Wiederherstellung von Gesundheit und Wiedererlangung des Handlungsvermögens von Patienten darstellt. Der vorliegende Leitfaden beschränkt sich auf die Darstellung der Prinzipien der Ernährungstherapie und deren praktische Umsetzung.

BackgroundThe microbiome has emerged as an environmental factor contributing to obesity and type 2 diabetes (T2D). While the majority of studies have focused on associations between the gut microbiome and metabolic disease, increasing evidence suggests links between circulating bacterial components (i.e. bacterial DNA) and cardiometabolic disease as well as blunted response to metabolic interventions such as bariatric surgery. In this aspect, thorough next generation sequencing based and contaminant aware approaches are lacking. To address these points, we tested whether bacterial DNA could be amplified in the blood of subjects with obesity and high metabolic risk under strict experimental and analytical control to minimize bacterial contamination. Moreover we characterized a bacterial signature associated with the individual metabolic risk and explored its dynamics alongside metabolic improvement after bariatric surgery.MethodsSubjects undergoing elective bariatric surgery were recruited into sex and BMI matched subgroups with (n=24) or without T2D (n=24). Bacterial DNA in the blood was quantified and prokaryotic 16S rRNA gene amplicons were sequenced. A contaminant aware approach was applied to derive a compositional microbial signature from bacterial sequences in subjects with and without T2D and within subjects at baseline and at three and twelve months post bariatric surgery. We modelled associations between bacterial load and composition with host metabolic and anthropometric markers. We further tested whether compositional shifts were related to weight loss response and T2D remission after bariatric surgery. Lastly, Catalyzed Reporter Deposition (CARD) - Fluorescence In Situ Hybridization (FISH) was employed to visualize bacteria in blood samples.ResultsContaminant aware classification of bacterial 16S rRNA sequences allowed the derivation of a blood bacterial signature, which was associated with metabolic health. Based on bacterial phyla and genera detected in the blood samples, a metabolic syndrome classification index score was derived and shown to robustly classify subjects along their actual clinical group. T2D was characterized by decreased bacterial richness and a loss of genera associated with improved metabolic health. Moreover, circulating bacterial load was significantly associated with metabolic health and increased after bariatric surgery. Weight loss and metabolic improvement following bariatric surgery were associated with an early and stable increase of these genera in parallel with improvements in key cardiometabolic risk parameters. CARD-FISH allowed the detection of living Bacteria in blood samples in obesity.ConclusionsWe show that the circulating bacterial signature reflects metabolic disease and its improvement after bariatric surgery. Our work provides contaminant aware evidence for the presence of living bacteria in the blood and suggests a putative crosstalk between components of the blood and metabolism in metabolic health regulation.

Summary Background The Practical guideline is based on the current scientific ESPEN guideline on Clinical Nutrition in Liver Disease. Methods It has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. Results A total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in liver patients and on liver complications associated with medical nutrition. Conclusion This practical guideline gives guidance to health care providers involved in the management of liver disease to offer optimal nutritional care.

Objectives We tested the hypothesis that a genetic deletion (Del) variant in the REPIN1 gene is associated with the severity of nonalcoholic fatty liver disease (NAFLD) in humans. Methods Sixty-three donors of liver biopsies from individuals with obesity and different degrees of NAFLD and fibrosis were screened for a Del REPIN1 gene variant and liver REPIN1 mRNA expression. Results In 8 homozygous Del carriers, we found significantly lower NAFLD activity and fibrosis scores compared with 55 wild-type allele carriers. Discussion A Del variant of REPIN1 may be associated with a lower risk of the development of NAFLD.

Bariatric surgery has become the gold standard for the treatment of morbid obesity (body mass index (BMI) ≥ 40 kg/m2), but only few studies investigated its plastic influences on the obese brain. In this longitudinal study, we combined structural and functional magnetic resonance brain imaging (MRI) in 27 patients (BMI 47.8 ± 5.5 kg/m2) undergoing gastric-bypass surgery and 14 non-obese matched controls (BMI 24.7 ± 3.4 kg/m2). Over the first year after surgery, patients presented widespread changes in white matter density (WMD) as well as gray matter density (GMD) in the cerebral cortex of all lobes, subcortical structures, the brainstem as well as the cerebellum, but no changes in white matter water diffusivity throughout the brain. Voxel-by-voxel regression analyses revealed that all GMD and WMD changes were well associated with elevated regional homogeneity of spontaneous neural activity (ReHo) in blood-oxygenation level-dependent signals. Spatial-temporal integration of structural and functional MRI suggests that gastric-bypass surgery induces widespread plastic changes in brain structure that concurrently homogenizes the functional profile of the cortex, subcortical regions as well as white matter structures.

International audience; Background: The European study MetaCardis aims to investigate the role of the gut microbiota in health and cardiometabolic diseases in France, Germany, and Denmark. To evaluate long-term diet-disease relationships, a food frequency questionnaire (FFQ) was found to be the most relevant dietary assessment method for the MetaCardis study.Objective: The objectives of this study were to describe the development of three semiquantitative online FFQs used in the MetaCardis study-one FFQ per country-and to assess the relative validity of the French MetaCardis FFQ.Design: The layout and format of the MetaCardis FFQ was based on the European Prospective Investigation of Cancer (EPIC)-Norfolk FFQ and the content was based on relevant European FFQs. Portion size and nutrient composition were derived from national food consumption surveys and food composition databases. To assess the validity of the French MetaCardis FFQ, a cross-sectional study design was utilized.Participants/setting: The validation study included 324 adults recruited between September 2013 and June 2015 from different hospitals in Paris, France.Main outcome measures: Food intakes were measured with both the French MetaCardis FFQ and 3 consecutive self-administered web-based 24-hour dietary recalls (DRs).Statistical analyses performed: Several measures of validity of the French MetaCardis FFQ were evaluated: estimations of food groups, energy, and nutrient intakes from the DRs and the FFQ, Spearman and Pearson correlations, cross-classification, and Bland-Altman analyses.Results: The French MetaCardis FFQ tended to report higher food, energy, and nutrient intakes compared with the DRs. Mean correlation coefficient was 0.429 for food, 0.460 for energy, 0.544 for macronutrients, 0.640 for alcohol, and 0.503 for micronutrient intakes. Almost half of participants (44.4%) were correctly classified within tertiles of consumption, whereas 12.9% were misclassified in the opposite tertile. Performance of the FFQ was relatively similar after stratification by sex.Conclusions: The French MetaCardis FFQ was found to have an acceptable level of validity and may be a useful instrument to rank individuals based on their food and nutrient intakes.

There is increased interest in whether bariatric surgeries such as Roux-en-Y gastric bypass (RYGB) achieve their profound weight-lowering effects in morbidly obese individuals through the brain. Hypothalamic inflammation is a well-recognized etiologic factor in obesity pathogenesis and so represents a potential target of RYGB, but clinical evidence in support of this is limited. We therefore assessed hypothalamic T2-weighted signal intensities (T2W SI) and fractional anisotropy (FA) values, 2 validated radiologic measures of brain inflammation, in relation to BMI and fat mass, as well as circulating inflammatory (C-reactive protein; CrP) and metabolic markers in a cohort of 27 RYGB patients at baseline and 6 and 12 months after surgery. We found that RYGB progressively increased hypothalamic T2W SI values, while it progressively decreased hypothalamic FA values. Regression analyses further revealed that this could be most strongly linked to plasma CrP levels, which independently predicted hypothalamic FA values when adjusting for age, sex, fat mass, and diabetes diagnosis. These findings suggest that RYGB has a major time-dependent impact on hypothalamic inflammation status, possibly by attenuating peripheral inflammation. They also suggest that hypothalamic FA values may provide a more specific radiologic measure of hypothalamic inflammation than more commonly used T2W SI values.

BACKGROUND 3.9% of men and 5.2% of women in Germany suffer from second-degree obesity (body mass index [BMI] ≥ 35 to

The quantification of visceral adipose tissue (VAT) is increasingly being considered for risk assessment and treatment monitoring in obese patients, but is generally time-consuming. The goals of this work were to semi-automatically segment and quantify VAT areas of MRI slices at previously proposed anatomical landmarks and to evaluate their predictive power for whole-abdominal VAT volumes on a relatively large number of patients. One-hundred and ninety-seven overweight to severely obese patients (65 males; body mass index, 33.3 ± 3.5 kg/m(2); 132 females; body mass index, 34.3 ± 3.2 kg/m(2)) underwent MRI examination. Total VAT volumes (VVAT-T ) of the abdominopelvic cavity were quantified by retrospective analysis of two-point Dixon MRI data (active-contour segmentation, visual correction and histogram analysis). VVAT-T was then compared with VAT areas determined on one or five slices defined at seven anatomical landmarks (lumbar intervertebral spaces, umbilicus and femoral heads) and corresponding conversion factors were determined. Statistical measures were the coefficients of variation and standard deviations σ1 and σ5 of the difference between predicted and measured VAT volumes (Bland-Altman analysis). VVAT-T was 6.0 ± 2.0 L (2.5-11.2 L) for males and 3.2 ± 1.4 L (0.9-7.7 L) for females. The analysis of five slices yielded a better agreement than the analysis of single slices, required only a little extra time (4 min versus 2 min) and was substantially faster than whole-abdominal assessment (24 min). Best agreements were found at intervertebral spaces L3-L4 for females (σ5/1 = 523/608 mL) and L2-L3 for males (σ5/1 = 613/706 mL). Five-slice VAT volume estimates at the level of lumbar disc L3-L4 for females and L2-L3 for males can be obtained within 4 min and were a reliable predictor for abdominopelvic VAT volume in overweight to severely adipose patients. One-slice estimates took only 2 min and were slightly less accurate. These findings may contribute to the implementation of analytical methods for fast and reliable (routine) estimation of VAT volumes in obese patients.

Objective: The efficacy of bariatric surgery has been proven; however, a subset of patients fails to achieve expected long-term weight loss postoperatively. As differences in surgery outcome may be influenced by heterogeneous psychological profiles in pre-bariatric patients, previous subtyping models differentiated patients based on temperament traits. The objective of the present study was to expand these models by additionally considering emotion dysregulation and disinhibited eating behaviors for subtyping, as these factors were associated with maladaptive eating behaviors and poor post-bariatric weight loss outcome. Methods: Within a prospective multicenter registry, N = 370 pre-bariatric patients were examined using interview and self-report questionnaires. A latent profile analysis was performed to identify subtypes based on temperament traits, emotion dysregulation, and disinhibited eating behaviors. Results: Five pre-bariatric subtypes were identified with specific profiles regarding self control, emotion dysregulation, and disinhibited eating behaviors. Subtypes were associated with different levels of eating disorder psychopathology, depression, and quality of life. The expanded model increased variance explanation compared to temperament-based models. Conclusion: By adding emotion dysregulation and disinhibited eating behaviors to previous subtyping models, specific pre-bariatric subtypes emerged with distinct psychological deficit patterns. Future investigations should test the predictive value of these subtypes for post bariatric weight loss and health-related outcomes.

Subcutaneous (SAT) and visceral adipose tissue (VAT) differ in composition, endocrine function and localization in the body. VAT is considered to play a role in the pathogenesis of insulin resistance, type 2 diabetes, fatty liver disease, and other obesity-related disorders. It has been shown that the amount, distribution, and (cellular) composition of adipose tissue (AT) correlate well with metabolic conditions. In this study, T1 relaxation times of AT were measured in severely obese subjects and compared with those of healthy lean controls. Here, we tested the hypothesis that T1 relaxation times of AT differ between lean and obese individuals, but also between VAT and SAT as well as superficial (sSAT) and deep SAT (dSAT) in the same individual. Twenty severely obese subjects (BMI 41.4 ± 4.8 kg/m2) and ten healthy lean controls matched for age (BMI 21.5 ± 1.9 kg/m2) underwent MRI at 1.5 T using a single-shot fast spin-echo sequence (short-tau inversion recovery) at six different inversion times (TI range 100–1000 ms). T1 relaxation times were computed for all subjects by fitting the TI-dependent MR signal intensities of user-defined regions of interest in both SAT and VAT to a model function. T1 times in sSAT and dSAT were only measured in obese patients. For both obese patients and controls, the T1 times of SAT (275 ± 14 and 301 ± 12 ms) were significantly (p

Summary Purpose The nomenclature in clinical nutrition differs locally, among (para)medical disciplines, and both nationally and internationally. The inconsistencies hamper public, professional and scientific discussions. A working group of the German Society of Nutritional Medicine (DGEM) was established to work out definitions for the relevant terms used in nutritional support within Germany. Methods Terms were searched in (inter)national hard print technical literature (medical dictionaries, text books, (inter)national guidelines and online (PubMed, Embase, CINAHL, Google Scholar, general internet). (Inter)nationally agreed definitions published by Clinical Nutrition Societies were preferred to other reports. Results The terms were organised into four categories totaling 53 definitions: 1. Fields and structure: medical nutrition, clinical nutrition, nutrition steering committee, nutritional care, care catering, dietetics (dietary advice), obesity as part of clinical nutrition (obesity team), nutritional support (nutrition support team, malnutrition screening, nutritional support therapy), functional nutrition, nutritional assessment, nutrition therapy plan, nutritional therapy, 2. Nutritional conditions: disease-related malnutrition (starvation induced malnutrition, chronic disease-related malnutrition, acute disease-related malnutrition), cachexia, sarcopenia, specific nutrient deficiencies, refeeding syndrome, 3. Forms of nutrition: diet (regular diet, therapeutic diet, fortified food), artificial nutritional support (oral nutritional supplementation, enteral nutrition, parenteral nutrition) 4. Products: oral nutritional supplements and enteral formulas (whole protein formula, peptide-based formula, free amino acid formula, standard formula), parenteral solutions (total nutrient admixtures, multi-chamber systems, multiple bottle systems). Conclusion A comprehensive list of definitions for terms in nutritional support has been established for the first time and is made available to the international community for further development and discussions.

nutritionDay ist ein weltweites Projekt mit dem Ziel ein genaues Bild über Ernährungsrisikofaktoren, Ernährungsstatus, Ernährungspraxis und Outcome in Krankenhäusern, Intensivstationen und Pflegeheimen zu bekommen. Gleichzeitig ermöglicht nutritionDay einen Vergleich zwischen Stationen der gleichen Fachrichtung im Sinne des Benchmarking. Die Datenerhebung erfolgt einmal jährlich seit 2006 in 32 Sprachen. Insgesamt haben 4'877 Stationen mit 151'666 Patienten aus 51 Ländern teilgenommen. In Krankenhäusern hatten 8.1 % einen BMI < 18.5, 45.4 % hatten Gewicht verloren in den letzten 3 Monaten und 49.9 % hatten in der letzten Woche nicht normal gegessen. 41.5 % hatten am nutritionDay die ganze Mahlzeit gegessen und 14 % aßen gar nichts. Gewichtsverlust erhöht die Mortalität (OddsRatio 2.76 [2.50, 3.05]) ebenso wie vermindertes Essen in der Vorwoche (OddsRatio 6.17 [5.54, 6.88]) oder am nutritionDay (OddsRatio 7.66 [6.72, 8.74]). Mangelnder Appetit ist die häufigste Ursache für weniger Essen. Weniger als ein Drittel der Patienten, die nichts essen erhalten eine künstliche Ernährung. Krankheits-assoziierte Mangelernährung ist häufig und mit einer deutlichen Erhöhung eines ungünstigen Krankheitsverlaufs verbunden. nutritionDay ist ein einfaches Messinstrument zur strukturierten Erfassung von Symptomen der Mangelernährung und unterstützt das lokale Benchmarking im Ernährungsbereich.

Summary Background & aims The selection of appropriate outcome variables in clinical nutrition is particularly challenging, since nutrition is an adjunct therapy in most cases. Therefore, its effect may be confounded with the primary therapy, and classic biomedical outcomes may not reflect the effect of the nutritional intervention. This paper scrutinizes different alternatives to the biomedical perspective. Results Five different outcome models are proposed and analyzed for their suitability in clinical nutrition studies: biomedical, patient-centered/-reported, health economic, decision-making, and integration of classical and patient-reported endpoints. Most published studies in the field of clinical nutrition make use of biomedical endpoints, but the growing importance of patient-centered/-reported and health economic outcomes is recognized. We recommend avoiding to focus solely on biomedical endpoints in clinical nutrition studies. The availability and value of a broader set of outcome-models should be acknowledged. Conclusion Patient-centered/-reported, health economic or combined endpoints are particularly useful to assess the effect of nutritional therapies, especially when applied in conjunction with a primary therapy. The proposed outcome models can also contribute to refine clinical nutrition guidelines in assessing the clinical relevance of the study results.

Image-based quantifications of visceral adipose tissue (VAT) volumes from segmented VAT areas are increasingly considered for risk assessment in obese patients. The goal of this study was to determine the power of partial VAT areas to predict total VAT volume in morbidly obese patients (BMI40 kg/m(2)) as a function of gender, age and anatomical landmarks. 130 morbidly obese patients (mean BMI 46.5 kg/m(2); 94 females) underwent IRB-approved MRI. Total VAT volumes were predicted from segmented VAT areas (of single or five adjacent slices) at common axial landmark levels and compared with the measured ones (VVAT-T, about 40 slices between diaphragm and pelvic floor). Standard deviations σ1 and σ5 of the respective VAT volume differences served as measures of agreement. Mean VVAT-T was 4.9 L for females and 8.1 L for males. Best predictions were found at intervertebral spaces L3-L4 for females (σ5 = 688 ml, σ1 = 832 ml) and L1-L2 for males (σ5 = 846 ml, σ1 = 992 ml), irrespective of age. In conclusion, VAT volumes in morbidly obese patients can be reliably predicted by multiplying the segmented VAT area at a gender-specific lumbar reference level with a fixed scaling factor and effective slice thickness.

Background Inadequate nutrition during hospitalization is strongly associated with poor patient outcome, but ensuring adequate food intake is not a priority in clinical routine worldwide. This lack of priority results in inadequate and unbalanced food intake in patients and huge amounts of wasted food. Objectives We evaluate the main factors that are associated with reduced meal intake in hospitalized patients and the differences between geographical regions. Design We conducted a descriptive analysis of data from 9 consecutive, annual, and cross-sectional nutritionDay samples (2006-2014) in a total of 91,245 adult patients in 6668 wards in 2584 hospitals in 56 countries. A general estimation equation methodology was used to develop a model for meal intake, and P-value thresholding was used for model selection. Results The proportion of patients who ate a full meal varied widely (24.7-61.5%) across world regions. The factors that were most strongly associated with reduced food intake on nutritionDay were reduced intake during the previous week (OR: 0.20; 95% CI: 0.17, 0.22), confinement to bed (OR: 0.49; 95% CI: 0.44, 0.55), female sex (OR: 0.53; 95% CI: 0.5, 0.56), younger age (OR: 0.74; 95% CI: 0.64, 0.85) and older age (OR: 0.80; 95% CI: 0.74; 0.88), and low body mass index (OR: 0.84; 95% CI: 0.79, 0.90). The pattern of associated factors was homogenous across world regions. Conclusions A set of factors that are associated with full meal intake was identified and is applicable to patients hospitalized in any region of the world. Thus, the likelihood for reduced food intake is easily estimated through access to patient characteristics, independent of world regions, and enables the easy personalization of food provision. This trial was registered at clinicaltrials.gov as NCT02820246.

To present software for supervised automatic quantification of visceral and subcutaneous adipose tissue (VAT, SAT) and evaluates its performance in terms of reliability, interobserver variation, and processing time, since fully automatic segmentation of fat-fraction magnetic resonance imaging (MRI) is fast but susceptible to anatomical variations and artifacts, particularly for advanced stages of obesity.Twenty morbidly obese patients (average BMI 44 kg/m(2) ) underwent 1.5-T MRI using a double-echo gradient-echo sequence. Fully automatic analysis (FAA) required no user interaction, while supervised automatic analysis (SAA) involved review and manual correction of the FAA results by two observers. Standard of reference was provided by manual segmentation analysis (MSA).Average processing times per patient were 6, 6+4, and 21 minutes for FAA, SAA, and MSA (P< 0.001), respectively. For VAT/SAT assessment, Pearson correlation coefficients, mean (bias), and standard deviations of the differences were R = 0.950, +0.003, and 0.043 between FAA and MSA and R = 0.981, +0.009, and 0.027 between SAA and MSA. Interobserver variation and intraclass correlation were 3.1% and 0.996 for SAA, and 6.6% and 0.986 for MSA, respectively.The presented supervised automatic approach provides a reliable option for MRI-based fat quantification in morbidly obese patients and was much faster than manual analysis. J. Magn. Reson. Imaging 2013;37:1144-1150. © 2012 Wiley Periodicals, Inc.

Bariatric surgery has become the gold standard for the treatment of morbid obesity (body mass index (BMI) ⩾ 40 kg/m2), but its plastic influences on the obese brain remain largely unexplored. Here, we combined structural and functional magnetic resonance brain imaging (MRI) in twenty-seven patients (BMI 47.8 ± 5.5 kg/m2) undergoing gastric-bypass surgery and fourteen non-obese controls (BMI 24.7 ± 3.4 kg/m2). Over the first year after surgery, patients presented changes in gray matter density (GMD) in the cerebral cortex of all lobes, subcortical structures as well as the cerebellum, but no changes in white matter water diffusivity throughout the brain. Related to the BMI loss, we identified altered GMD in the hypothalamus, the brain’s homeostatic control site, the lateral orbitofrontal cortex, assumed to host reward and gustatory processes, as well as bilateral abdominal representations in somatosensory cortex. Voxel-by-voxel regression analyses revealed that all GMD changes were associated with elevated regional homogeneity of spontaneous neural activity (ReHo) in blood-oxygenation level-dependent signals. Spatial–temporal integration of structural and functional MRI suggests that gastric-bypass surgery induced widespread plastic changes in cortical structure that concurrently homogenized the functional profile of the cortex.

Parenteral nutrition (PN) offers the possibility to increase or to ensure nutrient intake in patients, in whom sufficient nutrition by oral or enteral alone is insufficient or impossible. Complementary to the ESPEN guideline on enteral nutrition of liver disease (LD) patients the present guideline is intended to give evidence-based recommendations for the use of PN in LD. For this purpose three paradigm conditions of LD were chosen: alcoholic steatohepatitis (ASH), liver cirrhosis and acute liver failure. The guideline was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was presented on the ESPEN website and visitors’ criticism and suggestions were welcome and included in the final revision. PN improves nutritional state and liver function in malnourished patients with ASH. PN is safe and improves mental state in patients with cirrhosis and severe HE. Perioperative (including liver transplantation) PN is safe and reduces the rate of complications. In acute liver failure PN is a safe second-line option to adequately feed patients in whom enteral nutrition is insufficient or impossible.

Nutritional status and liver disease influence each other. Liver function is compromized by malnutrition and this impairment can be overcome by nutritional intervention. Depending on disease severity, especially chronic liver disease leads to malnutrition which is an indicator of a poor prognosis. Both presence and degree of malnutrition can be diagnosed clinically without the need for techniqual equipment. In severe acute liver disease, indication and practice of nutritional therapy are not different from those in critically ill patients due to other etiology. In chronic liver disease, spontaneous food intake often is inadequate and frequently there is protein malnutrition. In a stepwise approach individualized dietary counselling, supplemental oral sip feeding, enteral tube feeding or parenteral nutrition as a second line option should be used. Nutritional therapy ensuring adequate provision of energy and protein can improve morbidity and mortality.

Background/Aims: To search for changes in body composition and energy metabolism associated with the repeatedly observed weight gain of cirrhotic patients after portosystemic shunting. Methods: Twenty-one patients were studied prospectively before and 6 and 12 months after transjugular intrahepatic portosystemic shunt (TIPS) to assess body cell mass by two independent methods (total body potassium counting: body cell mass determined by TBP, BCMTBP, bioelectric impedance analysis: body cell mass determined by BIA, BCMBIA), muscle mass (anthropometry), resting energy expenditure (REECALO) by indirect calorimetry, and nutritional intake by dietary recall analysis. Results: Prior to TIPS patients were hypermetabolic in terms of measured vs. predicted REE (REECALO median 1423 (range 1164– 1838) vs. REEPRED 1279 (1067 –1687) kcal; P< 0.05) and their body cell mass was lower (19.1 (10.9 –33.4) vs. 31.7 (16.8 –47.1) kg; P 5 0.001). After TIPS body cell mass (BCMBIA) increased to 23.5 (12.7 –44.3) ( P< 0.025) and 25.7 (14.2 – 39.7) kg (P 5 0.05) at 6 and 12 months after TIPS and this was confirmed by total potassium counting (BCMTBP before TIPS: 18.8 (10.6 –26.7) vs. 22.4 (12.9 – 28.5) kg at 6 months; P< 0.01). Hypermetabolism persisted throughout the study period. Energy and protein intake increased significantly by 26 and 33%. Conclusions: An increase of prognostically relevant variables body cell and muscle mass contributes to the weight gain after TIPS in malnourished patients with cirrhosis and hypermetabolism. q 2003 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

The quantification of visceral adipose tissue (VAT) is increasingly being considered for risk assessment and treatment monitoring in obese patients, but is generally time-consuming. The goals of this work were to semi-automatically segment and quantify VAT areas of MRI slices at previously proposed anatomical landmarks and to evaluate their predictive power for whole-abdominal VAT volumes on a relatively large number of patients. One-hundred and ninety-seven overweight to severely obese patients (65 males; body mass index, 33.3 ± 3.5 kg/m(2); 132 females; body mass index, 34.3 ± 3.2 kg/m(2)) underwent MRI examination. Total VAT volumes (VVAT-T ) of the abdominopelvic cavity were quantified by retrospective analysis of two-point Dixon MRI data (active-contour segmentation, visual correction and histogram analysis). VVAT-T was then compared with VAT areas determined on one or five slices defined at seven anatomical landmarks (lumbar intervertebral spaces, umbilicus and femoral heads) and corresponding conversion factors were determined. Statistical measures were the coefficients of variation and standard deviations σ1 and σ5 of the difference between predicted and measured VAT volumes (Bland-Altman analysis). VVAT-T was 6.0 ± 2.0 L (2.5-11.2 L) for males and 3.2 ± 1.4 L (0.9-7.7 L) for females. The analysis of five slices yielded a better agreement than the analysis of single slices, required only a little extra time (4 min versus 2 min) and was substantially faster than whole-abdominal assessment (24 min). Best agreements were found at intervertebral spaces L3-L4 for females (σ5/1 = 523/608 mL) and L2-L3 for males (σ5/1 = 613/706 mL). Five-slice VAT volume estimates at the level of lumbar disc L3-L4 for females and L2-L3 for males can be obtained within 4 min and were a reliable predictor for abdominopelvic VAT volume in overweight to severely adipose patients. One-slice estimates took only 2 min and were slightly less accurate. These findings may contribute to the implementation of analytical methods for fast and reliable (routine) estimation of VAT volumes in obese patients.

nutritionDay is a worldwide project to determine prevalence of symptoms of malnutrition and reduced nutrient intake as well as risk factors and outcome. Individual units can benchmark their data against data from the reference database of the same specialty. Questionnaires are available in 32 languages. 151'666 patients from 4'877 units in 51 countries have participated between 2006 - 2012. In hospitals 8.1 % had a BMI18.5, 45.4 % indicated having lost weight and 49.9 % had not eaten normally last week. On nutritionDay 41.5 % ate the full meal at lunch or dinner and 14 % ate nothing. The odds ratio for death in hospital within 30 days was 2.76 [2.50, 3.05] if having lost weight, increased to a maximum of 6.17 [5.54, 6.88] with a history of decreased intake last week and 7.66 [6.72, 8.74] if no intake was found on nutritionDay despite being allowed to eat. All factors remained significant in multivariate analysis. The most frequent reason for not eating is loss of appetite. Only a maximum of one third of all patients that eat nothing receive support with enteral or parenteral nutrition. Disease-related undernutrition is very frequent in hospitals and is associated with poor outcome. nutritionDay is a measurement tool to determine the prevalence of undernutrition and to benchmark regularly nutrition risk factors and level of interventions against a large recent reference database.nutritionDay ist ein weltweites Projekt mit dem Ziel ein genaues Bild über Ernährungsrisikofaktoren, Ernährungsstatus, Ernährungspraxis und Outcome in Krankenhäusern, Intensivstationen und Pflegeheimen zu bekommen. Gleichzeitig ermöglicht nutritionDay einen Vergleich zwischen Stationen der gleichen Fachrichtung im Sinne des Benchmarking. Die Datenerhebung erfolgt einmal jährlich seit 2006 in 32 Sprachen. Insgesamt haben 4'877 Stationen mit 151'666 Patienten aus 51 Ländern teilgenommen. In Krankenhäusern hatten 8.1 % einen BMI18.5, 45.4 % hatten Gewicht verloren in den letzten 3 Monaten und 49.9 % hatten in der letzten Woche nicht normal gegessen. 41.5 % hatten am nutritionDay die ganze Mahlzeit gegessen und 14 % aßen gar nichts. Gewichtsverlust erhöht die Mortalität (OddsRatio 2.76 [2.50, 3.05]) ebenso wie vermindertes Essen in der Vorwoche (OddsRatio 6.17 [5.54, 6.88]) oder am nutritionDay (OddsRatio 7.66 [6.72, 8.74]). Mangelnder Appetit ist die häufigste Ursache für weniger Essen. Weniger als ein Drittel der Patienten, die nichts essen erhalten eine künstliche Ernährung. Krankheits-assoziierte Mangelernährung ist häufig und mit einer deutlichen Erhöhung eines ungünstigen Krankheitsverlaufs verbunden. nutritionDay ist ein einfaches Messinstrument zur strukturierten Erfassung von Symptomen der Mangelernährung und unterstützt das lokale Benchmarking im Ernährungsbereich.

The cause of chronic inflammatory bowel disease (IBD) remains unclear. A recent hypothesis suggests that ulcerative colitis may be caused by one or more reactive xenobiotic metabolites. If so, the presence, distribution, and activity of drug-metabolizing enzymes in the gut could be important, because those enzymes represent a first defense against ingested xenobiotics. To assess whether patients with IBD express certain enzymes differently in the gastrointestinal tract than do subjects without IBD, biopsy samples of the terminal ileum and various regions of the colon were stained immunohistochemically for cytochrome P-450 (CYP) isoenzymes (CYP1A1, CYP2D6, CYP2E1, CYP3A), epoxide hydrolase, α and π forms of glutathione- S -transferase (GST), and metallothionein (MTTH). One hundred fifty biopsy samples from 21 patients with irritable colon (no clinical or histologic signs of inflammation; control group), 25 patients with Crohn's disease (CD), and 37 patients with ulcerative colitis (UC) were evaluated. The patients' sex, age, smoking habits, and disease state were not related significantly to the frequency of positive versus negative staining of the samples. All enzymes were expressed less frequently in the colon than in the terminal ileum. With the exception of CYP1A1, all enzymes were detectable with similar frequency in the three study groups: CYP2E1, 77.4% to 84.6% positive stainings; CYP3A, 53.8% to 58.5%; CYP2D6, 23.1% to 36.9%; GST α , 14.1% to 20.8%; GST π , 19.2% to 24.5%; epoxide hydrolase, 1.9% to 3.8%; and MTTH, 19.2% to 25.4%. However, CYP1A1 staining was positive significantly more often in patients with CD (39.6%) and UC (39.4%) than in patients in the control group (19.2%). Because cells with CYP1A1 were found in the intestines of patients with IBD significantly more frequently than in patients in the control group (ie, with an irritable colon), this may suggest a function of this enzyme in the etiology or pathogenesis of inflammation in these disorders. Alternatively, the more frequent expression of CYP1A1 could be due secondarily to the presence of xenobiotics that then lead to inflammation.

Subcutaneous (SAT) and visceral adipose tissue (VAT) differ in composition, endocrine function and localization in the body. VAT is considered to play a role in the pathogenesis of insulin resistance, type 2 diabetes, fatty liver disease, and other obesity-related disorders. It has been shown that the amount, distribution, and (cellular) composition of adipose tissue (AT) correlate well with metabolic conditions. In this study, T1 relaxation times of AT were measured in severely obese subjects and compared with those of healthy lean controls. Here, we tested the hypothesis that T1 relaxation times of AT differ between lean and obese individuals, but also between VAT and SAT as well as superficial (sSAT) and deep SAT (dSAT) in the same individual. Twenty severely obese subjects (BMI 41.4 ± 4.8 kg/m(2) ) and ten healthy lean controls matched for age (BMI 21.5 ± 1.9 kg/m(2) ) underwent MRI at 1.5 T using a single-shot fast spin-echo sequence (short-tau inversion recovery) at six different inversion times (TI range 100-1000 ms). T1 relaxation times were computed for all subjects by fitting the TI -dependent MR signal intensities of user-defined regions of interest in both SAT and VAT to a model function. T1 times in sSAT and dSAT were only measured in obese patients. For both obese patients and controls, the T1 times of SAT (275 ± 14 and 301 ± 12 ms) were significantly (p 0.01) shorter than the respective values in VAT (294 ± 20 and 360 ± 35 ms). Obese subjects also showed significant (p 0.01) T1 differences between sSAT (268 ± 11 ms) and dSAT (281 ± 19 ms). More important, T1 differences in both SAT and VAT were highly significant (p 0.001) between obese patients and healthy subjects. The results of our pilot study suggest that T1 relaxation times differ between severely obese patients and lean controls, and may potentially provide an additional means for the non-invasive assessment of AT conditions and dysfunction.

Prevalence rates of obesity are still rising. Weight loss surgery (WLS) is the most invasive but also most effective treatment option when behavioral modification has failed. Research indicates that health care professionals hold ambivalent views on bariatric surgery, while views of the general public have not yet been investigated.In a German representative sample of n = 3,003 respondents in a computer-assisted telephone interview, n = 1,008 persons were interviewed on their views of the effectiveness of bariatric surgery and other interventions for obesity. Also, willingness to recommend a treatment was assessed.Lifestyle-based interventions were viewed as most effective in terms of weight loss. About 50 % of the population stated that WLS is "very effective" while still a quarter of respondents did not ascribe effectiveness to WLS. Higher age was associated with lower expectations of effectiveness while higher stigmatizing attitudes and genetic attributes for obesity were associated with higher expectations of effectiveness. Seventy-two percent would not recommend WLS or undergo it, if applicable, themselves. Higher educated respondents and those that viewed WLS as effective were more likely to recommend WLS.The German general public seems to be rather cautious regarding bariatric surgery. It may be assumed that false beliefs on the effectiveness and risk patterns of bariatric surgery are still very common, despite rising surgery numbers. Our results further emphasize the need for providing evidence-based information on bariatric surgery to the general public.

Obesity in transplant recipients is a frequent phenomenon but data from body composition analyses in long-term survivors are limited. Body composition and energy metabolism were studied in patients after liver (LTX) and kidney (KTX) transplantation and patients with liver cirrhosis (LCI) or on chronic hemodialysis (HD) and compared to healthy controls.In 42 patients 50.0 mo (median; range 17.1-100.6) after LTX and 30 patients 93.0 mo (31.2-180.1) after KTX as wells as in LCI (n = 39) or HD (n = 10) patients mid-arm muscle and fat area, body cell mass, and phase angle (bioimpedance analysis), and resting energy expenditure (indirect calorimetry, REE(CALO)) were measured.Obesity was more prevalent in LTX (17%) than LCI (3%) and in KTX (27%) than in HD (10%). In LTX and KTX, phase angle was higher than in end-stage disease (LTX 5.6° [4.1-7.2] versus LCI 4.4° [2.9-7.3], P0.001; KTX 5.9° [4.4-8.7] versus HD 4.3° [2.9-6.8]) but was lower in all patient groups than in controls (7.1°; 4.6-8.9; P0.001). In LCI and HD REE(CALO) was higher than predicted, while in LTX and KTX REE(CALO) was not different from predicted REE.Despite excellent graft function, many long-term LTX or KTX survivors exhibit a phenotype of sarcopenic obesity with increased fat but low muscle mass. This abnormal body composition is observed despite normalization of the hypermetabolism found in chronic disease and cannot be explained by overeating. The role of appropriate nutrition and physiotherapy after transplantation merits further investigation.

Background Reduced nutritional intake in care-dependent patients is a risk factor for malnutrition. The prevalence of malnutrition has been extensively reported, but there is little empirical data on the prevalence of the underlying causes of reduced oral intake and the extent of nursing interventions that address malnutrition. Objectives To report the prevalence of problems that potentially led to decreased nutritional intake. To investigate the association between these problems and body mass index (BMI). To investigate the association between increased care dependency and BMI. To document nutrition-related interventions. Design Cross-sectional multicentre study. Setting A total of 15 hospitals (H) and 76 nursing homes (NH) in Germany were included. Participants A total of 2930 hospital patients and 5521 nursing home residents were included in the study. The mean age was 66.6±16.7 years (in H) and 84.9±9.8 years (in NH); 14.7% (in H) and 50.4% (in NH) were almost or completely care dependent. A BMI≤20kg/m 2 was found in 8.5% (in H) and 16.7% (in NH). Results Most hospital patients were eating and drinking independently (72.2%), whereas 58.4% of the nursing home residents needed assistance. Major problems in hospitals were polypharmacy (18.6%), loss of appetite (14.6%) and pain (7.8%); in nursing home common problems were functional problems of the upper extremities (17%), loss of appetite (15.5%) and polypharmacy (15.5%). Patients with a high level of care dependency had higher rates of BMI≤20kg/m 2 . In both settings (H and NH), BMI≤20kg/m 2 was significantly associated with loss of appetite (odds ratio (OR) 2.6, 95%CI 1.9–3.5 and OR 7.0, 95%CI 5.9–8.3), nausea (OR 2.1, 95%CI 1.3–3.3 and OR 2.8, 95%CI 1.9–4.1), chewing problems (OR 2.1, 95%CI 1.2–3.4 and OR 2.5, 95%CI 2.1–3.1) and swallowing problems (OR 2.3, 95%CI 1.4–3.6 and OR 2.3, 95%CI 1.9–2.8). Nutrition-related nursing interventions were employed more frequently in nursing homes than in hospitals. Conclusion A high care dependency in general and in terms of eating and drinking should be addressed in daily care to ensure sufficient nutritional intake. Additional problems, such as loss of appetite, should also be addressed with suitable interventions to prevent malnutrition. Nutrition-related interventions need to be increased in German health care facilities.

BACKGROUND & AIMS: Recognition and treatment of undernutrition in hospitalized patients are not often a priority in clinical practice. OBJECTIVES: We investigated how the nutritional risk of patients is determined and whether such assessment influences daily nutritional care across Europe and in Israeli hospitals. METHODS: 1217 units from 325 hospitals in 25 countries with 21,007 patients participated in a longitudinal survey "nutritionDay" 2007/2008 undertaken in Europe and Israel. Screening practice, the type of tools used and whether energy requirements and intake are assessed and monitored were surveyed using standardized questionnaires. RESULTS: Fifty-two percent (range 21-73%) of the units in the different regions reported a screening routine which was most often performed with locally developed methods and less often with national tools, the Nutrition Risk Screening-2002, or the Malnutrition Universal Screening Tool. Twenty-seven percent of the patients were subjectively classified as being "at nutritional risk", with substantial differences existing between regions. Independent factors influencing the classification of nutritional risk included age, BMI

Summary Introduction The impedance vector produced by an alternating current in the bioimpedance analysis can be seen as a standardised test of cellular mass and function since reactance is believed to reflect the mass and integrity of cell membranes. This study investigated the association between resistance and reactance normalised for height ( R / H and Xc/ H ), and muscle function as assessed by hand grip strength. Methods 363 patients (172 male, 191 female) from Berlin and Copenhagen were included in the analysis. Whole body impedance was determined by BIA 2000M (Berlin) or EFG2.0 (Copenhagen). Hand grip strength was measured with Digimax electronic hand dynamometer (Berlin) or Jamar dynamometer (Copenhagen). The general linear model was used to assess the association between R / H , Xc/ H and hand grip strength. Results We observed a significant association between the impedance parameters R / H and Xc/ H and hand grip strength after adjusting for confounding variables (hand grip strength=−36.9−0.063×R/H+0.573×Xc/H+40.7×Height+0.115×Weight−0.09×Age+3.41 (gender=male)+1.87 (Centre Berlin); Weight: P =0.04, all other coefficients: P r 2 =0.708). Conclusions The impedance parameters R / H and Xc/ H are related to hand grip strength and might therefore be used as a cooperation-independent method to reproducibly assess muscle function.