Enteral Nutrition Therapy: Historical Perspective, Utilization, and Complications.

PURPOSE OF REVIEW: Enteral nutrition (EN) therapy can provide vital nutrition support for patients with various medical conditions as long as it is indicated and supported by ethical reasoning. This review seeks to offer a detailed account of the history of EN development, highlighting key milestones and recent advances in the field. Additionally, it covers common complications associated with EN and their management. RECENT FINDINGS: After years of research and development, we have reached newer generations of enteral feeding formulations, more options for enteral tubes and connectors, and a better understanding of EN therapy challenges. Given the availability of many different formulas, selecting a feeding formula with the best evidence for specific indications for enteral feeding is recommended. Initiation of enteral feeding with standard polymeric formula remains the standard of care. Transition to small-bore connectors remains suboptimal. Evidence-based practices should be followed to recognize and reduce possible enteral feeding complications early.

Discharged on Enteral Nutrition: What Now? The Poor State of Outpatient Support for Patients on Enteral Nutrition Support.

PURPOSE OF REVIEW: While the use of enteral nutrition (EN) has increased, and more medical centers have developed inpatient programs to address the unique needs of these patients, our collective experience at a few large institutions indicates that there is very little systemic support for patients after discharge. Here, we discuss what we have observed to be some of the barriers to providing outpatient follow up care, summarize the impact we have seen on patients, and propose some possible solutions. RECENT FINDINGS: We have observed and identified some of the root causes to include financial barriers; uncoordinated care transitions; high complexity of care, including medication management; and diffuse leadership to a multidisciplinary problem. Systematic support for outpatient care for patients discharged on enteral nutrition is rare and limited, due to many root causes. There are a few tools and tips that we have summarized here for individual providers, and a few promising methods in development, but a systematic approach is in great need.

Effectiveness of anti-obesity medications approved for long-term use in a multidisciplinary weight management program: a multi-center clinical experience.

BACKGROUND AND AIMS: Randomized clinical trials have proven the efficacy and safety of Food and Drug Administration (FDA) approved anti-obesity medications (AOMs) for long-term use. It is unclear whether these outcomes can be replicated in real-world clinical practice where clinical complexities arise. The aim of this study was to evaluate the effectiveness and side effects of these medications in real-world multidisciplinary clinical practice settings. METHODS: We reviewed the electronic medical records (EMR) of patients with obesity who were prescribed an FDA-approved AOM for long-term use in academic and community multidisciplinary weight loss programs between January 2016 and January 2020. INTERVENTION: We assessed percentage total body weight loss (%TBWL), metabolic outcomes, and side effect profile up to 24 months after AOM initiation. RESULTS: The full cohort consisted of 304 patients (76% women, 95.2% White, median age of 50 years old [IQR, 39-58]). The median follow-up time was 9.1 months [IQR, 4.2-14.1] with a median number of 3 visits [IQR, 2-4]. The most prescribed medication was phentermine/topiramate extended-release (ER) (51%), followed by liraglutide (26.3%), bupropion/naltrexone sustained-release (SR) (16.5%), and lorcaserin (6.2%). %TBWL was 5.0%, 6.8%, 9.3%, 10.3%, and 10.5% at 3, 6, 12, 18, and 24 months. 60.2% of the entire cohort achieved at least 5% TBWL. Overall, phentermine/topiramate-ER had the most robust weight loss response during follow-up, with the highest %TBWL at 12 months of 12.0%. Adverse events were reported in 22.4% of patients. Only 9% of patients discontinued the medication due to side effects. CONCLUSIONS: AOMs resulted in significant long-term weight loss, that was comparable to outcomes previously reported in clinical trials.

Dietitian Involvement Improves Consumption of Oral Nutrition Supplements in Hospitalized Patients.

Hospitalized patients are at an increased risk of malnutrition due to multiple factors including, but not limited to, acute and chronic diseases especially those affecting gastrointestinal tract, surgery, appetite, and frequent nil per os while undergoing diagnostic workup. Because of this, guidelines suggest the use of oral nutritional supplements (ONS) in hospitalized patients to reduce the risk of malnutrition and its complications. The current report aims to highlights key findings from a cross-sectional survey of 99 hospitalized patients who were at risk for or diagnosed with malnutrition and prescribed ONS. Data regarding ONS prescriber information as well as number ordered and consumed were collected. Of the 2.4 ± 1.5 supplements ordered per person each day, only 1.3 ± 1.1 were consumed, and there was 48% wastage of prescribed ONS. However, dietitian involvement was associated with significant reduction in wastage. Given the need and benefit, it is imperative for the nutrition community to further explore best practices to improve ONS consumption.

Efficacy and Safety of Endoscopic Balloon Placement for Weight Loss in Patients With Cirrhosis Awaiting Liver Transplantation.

The efficacy and safety of a fluid-filled intragastric balloon (IGB) for weight loss in patients with cirrhosis on the liver transplantation (LT) waiting list is unknown. We enrolled stable compensated patients with body mass index >35 kg/m2 and on the waiting list for IGB placement endoscopically for a maximum of 6 months. A total of 8 patients (7 men) aged mean ± SD, 56 ± 4.6 years with Model for End-Stage Liver Disease-sodium (MELD-Na) scores 14.1 ± 3.4 experienced weight reduction (146 ± 22.2 kg versus 127 ± 21.6 kg [P = 0.005] with IGB in place and 130 ± 24.6 kg [P = 0.014] at 6 months), with a total body weight loss of 12.2% ± 8.8% with IGBs in place and 10.9% ± 8.9% at 6 months. Body fat decreased from 48.6% ± 5.8% to 40.6% ± 6.4% (P = 0.001) and lean mass increased from 51.3% ± 6% to 59.4% ± 6.4% (P = 0.001). No change in MELD-Na scores occurred (P = 0.770). Early balloon retrieval was attributed to accommodative symptoms (n = 2) and liver decompensation (n = 1). Mallory Weiss tears (n = 3), but no portal hypertensive bleeding, occurred. Liver decompensation and/or hepatocellular carcinoma (HCC) developed in 3 patients. A total of 4 patients with LT ± sleeve gastrectomy maintained overall weight loss. Of 4 patients who did not receive transplants, 2 experienced weight regain. IGB results in short-term weight loss in patients with cirrhosis awaiting LT, with body fat loss without lean mass loss. Adverse effects were common. Decompensation and HCC did occur, with uncertainty of the relation to weight loss, and thus careful patient selection and close follow-up are required.

Growing use of home enteral nutrition: a great tool in nutrition practice toolbox.

PURPOSE OF REVIEW: Home enteral nutrition (HEN) is a well-established practical nutrition therapy tool that is typically managed by an interdisciplinary team. Prevalence of HEN is increasing across the globe given significant evidence for utility, feasibility, efficacy, safety, and reliability of HEN in helping patients meeting their nutrition needs. The current review highlights the growing use of HEN in the context of what is novel in the field including trends in HEN practice with regards to tubes and connectors, feeding formula and real food blends, and common complications. The review also highlights that the use of HEN is expected to expand further over coming years emphasizing the need for national consensus recommendations and guidelines for HEN management. RECENT FINDINGS: The growing use of HEN has always been parallel to adoption of holistic definitions and concept of malnutrition in clinical nutrition practice and more understanding of the need for malnutrition risk stratification, meeting unmet needs in practice and addressing challenges that lead to suboptimal enteral nutrition. SUMMARY: Research and advancements in technology as well as in tube feeding formula industry have led to the development of more solutions and have helped identify and implement best HEN practices.

Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study.

BACKGROUND AND AIMS: Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort. METHODS: Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months. RESULTS: Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation. CONCLUSIONS: R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options.

Processed Foods - Getting Back to The Basics.

PURPOSE OF REVIEW: Real-world data suggested that more than half of daily energy intake is coming from processed and ultra-processed foods in most western countries. This high consumption of processed foods is of concern, given laboratory and epidemiological studies' findings that prove overwhelming harms of processed foods on human health. RECENT FINDINGS: Data demonstrate that consumption of processed foods is increasing with more reports linking ultra-processed foods to various medical conditions; namely, obesity, metabolic syndrome, atherosclerotic cardiovascular diseases, and certain types of cancer. Scientific community's understanding of the mechanisms and substances by which processed foods are affecting human health is expanding. Holistic approach to the current critical situation is advisable and requires collaborative public health strategies. The current review describes recent classification of processed foods and highlights the pertinent findings in the relationship between processed foods and health. It also outlines key clinical data relevant to the topic.

When Pandemics Collide: the Interplay of Obesity and COVID-19.

PURPOSE OF REVIEW: The COVID-19 pandemic has been associated with significant morbidity and mortality worldwide. In addition to those with advanced age and co-morbidities such as heart disease or cancer, obese individuals have also had very high rates of hospitalization, critical illness, need for ventilator support, as well as mortality. A number of factors associated with obesity have led to devastating consequences as these two pandemics have interacted. RECENT FINDINGS: Obese individuals through a combination of structural and cellular level changes have greater risk of ischemic heart disease, diabetes, cancer, and respiratory disease, which are themselves risk-factors for acquiring COVID-19 disease. These structural changes also result in increased intra-abdominal and intra-thoracic pressure as well as a restrictive lung physiology that leads to reduction in total lung capacity, functional residual capacity, and increase in airway hyper-reactivity. Adipose tissue is also impacted in obese individuals leading to local as well as systemic inflammation, which can contribute to increased release of free fatty acids and systemic insulin resistance. Additionally, angiotensin-converting enzyme 2 and dipeptidyl peptidase 4, which act as receptors for SARS-CoV-2 are also significantly increased in obese individuals. The present manuscript reviews these structural, immune, and molecular changes associated with obesity that make obese individuals more vulnerable to acquiring severe COVID-19 and more challenging to manage associated complications.

Using quality improvement to increase the awareness of obesity among endometrial cancer patients.

OBJECTIVE: To increase discussion about obesity and endometrial cancer and referrals to weight loss clinic in patients with newly diagnosed low-risk endometrial cancer. METHODS: A multidisciplinary team used a quality improvement methodology to increase patient awareness about obesity and endometrial cancer. Target population included patients <80 years old with a body mass index ≥30 kg/m2 who underwent surgery at our institution and had a final diagnosis of complex hyperplasia or stage I, grade 1-2 endometrioid endometrial cancer. A toolkit was developed for the intervention. Clinical characteristics, discussion about obesity, and referrals to a weight loss clinic were abstracted for a historic and intervention cohort. Data for the two cohorts were compared using chi-square, Fisher's exact test, and t-test. RESULTS: 54 patients from the historic cohort and 53 from the intervention cohort met inclusion criteria. Clinical characteristics were balanced between the groups. Discussion about obesity increased from 11.1% (6/54) to 79.2% (42/53) after implementing the toolkit (p<0.001). Referrals to the weight loss clinic also increased from 3.7% (2/54) to 26.4% (14/53) after implementing the toolkit (p=0.001), but in both groups only 50% of those referred actually attended the weight loss clinic. No clinical characteristics were identified as associated with being more likely to have documented conversations or referrals. CONCLUSIONS: A multidisciplinary quality-improvement project can be used to increase discussion about obesity and referral to a weight loss clinic in patients with low-risk endometrial cancer. Increasing patient awareness of the connection between obesity and endometrial cancer may have implications on the long-term health of endometrial cancer survivors.

Single Fluid-Filled Intragastric Balloon Safe and Effective for Inducing Weight Loss in a Real-World Population.

BACKGROUND & AIMS: The Orbera intragastric balloon (OIB) is a single fluid-filled intragastric balloon approved for the induction of weight loss and treatment of obesity. However, little is known about the effectiveness and safety of the OIB outside clinical trials, and since approval, the Food and Drug Administration has issued warnings to health care providers about risk of balloon hyperinflation requiring early removal, pancreatitis, and death. We analyzed data on patients who have received the OIB since its approval to determine its safety, effectiveness, and tolerance in real-world clinical settings. METHODS: We performed a postregulatory approval study of the safety and efficacy of the OIB, and factors associated with intolerance and response. We collected data from the Mayo Clinic's database of patient demographics, outcomes of OIB placement (weight loss, weight-related comorbidities), technical aspects of insertion and removal, and adverse events associated with the device and/or procedure, from 8 centers (3 academic, 5 private, 4 surgeons, and 4 gastroenterologists). Our final analysis comprised 321 patients (mean age, 48.1 ± 11.9 y; 80% female; baseline body mass index, 37.6 ± 6.9). Exploratory multivariable linear and logistic regression analyses were performed to identify predictors of success and early balloon removal. Primary effectiveness outcomes were percentage of total body weight lost at 3, 6, and 9 months. Primary and secondary safety outcomes were rates of early balloon removal, periprocedural complications, dehydration episodes requiring intravenous infusion, balloon migration, balloon deflation or hyperinflation, pancreatitis, or other complications. RESULTS: Four patients had contraindications for placement at the time of endoscopy. The balloon was safely removed in all instances with an early removal rate (before 6 months) in 16.7% of patients, at a median of 8 weeks after placement (range, 1-6 mo). Use of selective serotonin or serotonin-norepinephrine re-uptake inhibitors at the time of balloon placement was associated with increased odds of removal before 6 months (odds ratio, 3.92; 95% CI, 1.24-12.41). Total body weight lost at 3 months was 8.5% ± 4.9% (n = 204), at 6 months was 11.8% ± 7.5% (n = 199), and at 9 months was 13.3% ± 10% (n = 47). At 6 months, total body weight losses of 5%, 10%, and 15% were achieved by 88%, 62%, and 31% of patients, respectively. Number of follow-up visits and weight loss at 3 months were associated with increased weight loss at 6 months (ß = 0.5 and 1.2, respectively) (P < .05). Mean levels of cholesterol, triglycerides, low-density lipoprotein, and hemoglobin A1c, as well as systolic and diastolic blood pressure, were significantly improved at 6 months after OIB placement (P < .05). CONCLUSIONS: In an analysis of a database of patients who received endoscopic placement of the OIB, we found it to be safe, effective at inducing weight loss, and to reduce obesity-related comorbidities in a real-world clinical population. Rates of early removal (before 8 weeks) did not differ significantly between clinical trials and the real-world population, but were affected by use of medications.

Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis.

BACKGROUND AND AIMS: Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature. METHODS: Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used. RESULTS: 130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18 months after TORe was 9.31 ± 6.7 kg (N = 84), 7.75 ± 8.4  kg (N = 70), 8 ± 8.8 kg (N = 46) (p < 0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12 months was 8.4 kg (95% CI 6.5-10.3) with no significant heterogeneity across included studies (p = 0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported. CONCLUSION: When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

Endoscopic Sleeve Gastroplasty Alters Gastric Physiology and Induces Loss of Body Weight in Obese Individuals.

BACKGROUND & AIMS: Although bariatric surgery is the most effective therapy for obesity, only a small proportion of candidates undergo this surgery. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that reduces the size of the gastric reservoir. We investigated its durability and effects on body weight and gastrointestinal function in a prospective study of obese individuals. METHODS: Twenty-five obese individuals (21 female; mean body mass index, 35.5 ± 2.6 kg/m2; mean age, 47.6 ± 10 years) underwent ESG with endoluminal creation of a sleeve along the gastric lesser curve from September 2012 through March 2015 at the Mayo Clinic in Rochester, Minnesota. Subjects were followed for a median period of 9 months. We measured changes in body weight and recorded adverse events; patients were assessed by endoscopy after 3 months. Four participants underwent pre-ESG and post-ESG analyses to measure solid and liquid gastric emptying, satiation (meal tolerance), and fasting and postprandial levels of insulin, glucose, and gut hormones. RESULTS: Subjects had lost 53% ± 17%, 56% ± 23%, 54% ± 40%, and 45% ± 41% of excess body weight at 6, 9, 12, and 20 months, respectively, after the procedure (P < .01). Endoscopy at 3 months showed intact gastroplasty in all subjects. After ESG, physiological analyses of 4 participants showed a decrease by 59% in caloric consumption to reach maximum fullness (P = .003), slowing of gastric emptying of solids (P = .03), and a trend toward increased insulin sensitivity (P = .06). Three patients had serious adverse events (a perigastric inflammatory collection, a pulmonary embolism, and a small pneumothorax) but made full recoveries with no need for surgical interventions. No further serious adverse events occurred after the technique was adjusted. CONCLUSIONS: ESG delays gastric emptying, induces early satiation, and significantly reduces body weight. ESG could be an alternative to bariatric surgery for selected patients with obesity. ClincialTrials.gov number: NCT 01682733.

Phenotypes of Obesity: How it Impacts Management.

PURPOSE OF REVIEW: The worldwide prevalence of obesity is increasing. Obesity is strongly associated with many chronic health conditions that have been shown to improve with weight loss. However, counseling patients on weight loss can be challenging. Identifying specific aspects of weight management may personalize the conversation about weight loss and better address the individual patient's health goals and perceived barriers to change. RECENT FINDINGS: Physical and behavioral phenotypes are being identified to better tailor treatment recommendations, given lack of efficacy of currently available interventions. The current review provides a summary of the evidence behind the management of several recognized clinical phenotypes, to include body fat distribution (e.g., central obesity), muscle mass (e.g., sarcopenic obesity of the elderly), and problematic eating behaviors (e.g., cravings). Identifying specific aspects of weight management may personalize the conversation about weight loss and better address the individual patient's health goals and perceived barriers to change.

Designation of obesity as a disease: lessons learned from alcohol and tobacco.

Obesity is a leading cause of preventable death in the USA. The American Medical Association recently recognized obesity as meeting the definition of a chronic disease. This declaration had the intention of improving screening and long-term treatment and is historically similar to the designation of tobacco and alcohol dependence as a chronic disease. Nevertheless, it has ignited a nationwide debate in both academia and public opinion. The current article reviews the implications of treating obesity as a chronic disease, comparing the similarities in pathophysiology of obesity and other addictions, and discusses the pros and cons of this designation as it pertains to health care workers and patients.

Preoperative duration of type 2 diabetes mellitus and remission after Roux-en-Y gastric bypass: A single center long-term cohort study.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has demonstrated excellent glycemic control and type 2 diabetes mellitus (T2DM) remission for patients with obesity and T2DM. Duration of T2DM is a consistent negative predictor of remission after RYGB. However, the exact timing to offer surgical intervention during the course of the disease is not well elucidated. MATERIAL AND METHODS: We performed a retrospective cohort study between 2008-2020 to establish the exact association between duration of T2DM and remission after RYGB. We divided our cohort into quartiles of preoperative disease duration to quantify the change in remission rates for each year of delay between T2DM diagnosis and RYGB. We also compared the average time to remission and changes in glycemic control parameters. RESULTS: A total of 519 patients (67.2% female; age 53.4±10.7 y; BMI 46.6±8.4 kg/m2) with a follow-up period of 6.6±3.8 years were included. Remission was demonstrated in 51% of patients. Longer duration of T2DM was a significant negative predictor of remission with an estimated decrease in remission rates of 7% for each year of delay ([OR=0.931 (95% CI 0.892-0.971)]; P<0.001). Compared to patients with <3 years of T2DM, remission decreased by 37% for patients with 3-6 years, 64% for those with 7-12 years and 81% for patients with more than 12 years (P<0.001). Half of the patients reached T2DM remission after 0.5 and 1.1 years respectively for the first and second quartiles, while patients in the other quartiles never reached 50% remission. Lastly, we noted an overall improvement in all glycemic control parameters for all quartiles at last follow-up. CONCLUSION: Patients with a recent history of T2DM who undergo early RYGB experience significantly higher and earlier T2DM remission compared to patients with a prolonged history of preoperative T2DM, suggesting potential benefit of early surgical intervention to manage patients with obesity and T2DM.