OBJECTIVE:We assessed the impact of medical weight management (MWM; lifestyle modification ± obesity medications) on major adverse cardiovascular events (MACE) compared to metabolic and bariatric surgery (MBS) and usual care (UC). METHODS:We retrospectively analyzed electronic health records of adults with body mass index (BMI) ≥35 kg/m² and type 2 diabetes mellitus (T2D) at an academic health center from 2010 to 2021. The MWM group was propensity score matched on common confounders 1:1 (versus MBS) and 1:5 (versus UC). The primary outcome was a six-component MACE (all-cause mortality, coronary artery events, cerebrovascular events, heart failure, atrial fibrillation, and nephropathy).  Results: Among 2,100 patients (300 MWM, 300 MBS, and 1,500 UC), baseline characteristics were similar among groups. During a median 3.2-year follow-up (range 0-11), the adjusted hazard ratio (aHR) for MACE for MWM versus MBS was 1.61 (0.98-2.65, p=0.06); for MBS versus UC, aHR 0.66 (0.43-1.02, p=0.06); and there was no difference in MWM versus UC, aHR 1.07 (0.77-1.49, p=0.68). CONCLUSIONS:No statistically significant differences in MACE risk were found between those receiving MWM versus UC; there was a trend towards fewer MACE events in those receiving MBS. These findings must be validated in future studies, given that more effective weight loss medications (e.g., semaglutide, tirzepatide) were not available.

Understanding factors that increase risk of both mortality and specific measures of morbidity after duodenal switch (DS) is important in deciding to offer this weight loss operation. Artificial neural networks (ANN) are computational deep learning approaches that model complex interactions among input factors to optimally predict an outcome. Here, a comprehensive national database is examined for patient factors associated with poor outcomes, while comparing the performance of multivariate logistic regression and ANN models in predicting these outcomes. 2907 DS patients from the 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were assessed for patient factors associated with the previously validated composite endpoint of 30-day postoperative reintervention, reoperation, readmission, or mortality using bivariate analysis. Variables associated (P ≤ 0.05) with the endpoint were imputed in a multivariate logistic regression model and a three-node ANN with 20

Introduction Hepatic encephalopathy (HE) is a common complication of cirrhosis and a common reason for hospital admission. We aimed to determine whether expert consultation from gastroenterology (GI) leads to better clinical outcomes for inpatients with HE. Methods A retrospective review was performed of all adult patients (age ≥ 18) admitted with HE to a tertiary care hospital between January 2013 and April 2018. Patients who received a GI consult were compared to patients who did not receive a GI consult (No consult group). The primary outcome was hospital length of stay (LOS); secondary outcomes were rates of 30-day hospital readmission and 90-day mortality. Multivariate analysis was conducted to adjust for known confounders. Results Four hundred and twenty-five patients (814 encounters) were included in the study; of these, 236 patients had received a GI consultation for HE. Patients in the GI consult group were younger (mean age 55 vs 58 years, p= 0.02) and had higher Model For End-Stage Liver Disease-sodium (MELD-Na) score (mean MELD-Na 23.5 vs 17.5, p<0.01) compared to patients who did not receive GI consultation. The precipitants of HE were significantly different between the groups: there was more spontaneous bacterial peritonitis (SBP) and GI bleeding (GIB) in the GI consult group and more lactulose non-adherence in the no consult group. There was no difference in the etiology of liver disease between the two groups. Median LOS for the GI consult group was six days vs three days in the no consult group (p<0.01); the incidence rate ratio was 1.79 (95%CI 1.59-2.02, p<0.01) on multivariate analysis. There was no difference in 30-day readmission or 90-day mortality between the two groups. Conclusion GI consultation for patients with HE admitted to a hospital medicine service may be associated with longer LOS. In selected patients admitted with HE, GI consultation may not be necessary to achieve good clinical outcomes.

Background. The effect of nonalcoholic steatohepatitis (NASH) on mortality or major adverse cardiovascular events (MACE) in non-liver solid organ transplant recipients (NL-SOT) is unknown.Methods. Using a retrospective design, adult NL-SOT recipients who had biopsy-proven NASH were compared NL-SOT recipients with normal liver function tests and imaging; propensity matched at a 1:10 ratio on the following: age, sex, race, transplant year, transplant organ, smoking status, and diabetes status. Both deceased and living donor recipients were included; heart and liver transplant patients were excluded. Primary outcome was incidence of all-cause mortality and MACE (a composite outcome of coronary artery disease, ischemic stroke, and peripheral arterial disease).Results. Seven patients (3 kidney and 4 lung transplants) had biopsy-proven NASH and 70 patients without NASH, both groups were predominantly male (53%-57%), White (86%-91%), and overweight (mean body mass index similar to 26). The majority of patients were on calcineurin inhibitors (>= 85%), antimetabolites (>= 97%), and prednisone (>= 50%). Survival analysis showed that NASH patients had a higher risk of death (hazard ratio [HR], 3.24; 95% confidence interval [CI], 1.26-8.33, P = 0.02). NASH did not affect the risk of death-censored graft failure (HR, 1.08; 95% CI, 0.14-8.67; P = .94) or the risk of MACE (HR, 1.03; 95% CI, 0.23-4.62; P = .97).Conclusions. In NL-SOT recipients, NASH is significantly associated with mortality but not with MACE.

This mini-review reports the current research and arguments for extending the inclusion criteria to offer bariatric surgery in the treatment of class 1 obesity (body-mass index of 30–35 kg/m2) and obesity-related comorbidities. Recent studies have described the benefit of bariatric surgery in the treatment and resolution of obesity-related comorbidities in patients with class 1 obesity, notably, type 2 diabetes. Bariatric surgery cremains the single most effective intervention to effectively reduce excess weight and ameliorate metabolic comorbidities. Patients with class 1 obesity have largely been excluded from bariatric surgery due to longstanding guidelines. As societal recommendations for bariatric surgery candidacy have recently broadened, this mini-review examines the most common currently offered bariatric procedures, guidelines and indications, procedure selection, outcomes of notable random control trials and observational studies, safety and cost considerations, as well as medical management and endobariatrics specifically in the context of treating patients with class 1 obesity.

Roux-en-Y gastric bypass (RYGB) can precipitate protein-calorie malnutrition and micronutrient deficiencies. Sonographically guided endoscopic reversal (ER) via deployment of a stent from the gastric pouch to the remnant stomach in RYGB anatomy has emerged as a novel option for increasing both intestinal transit time and absorptive surface area. In this investigation, short-term nutritional outcomes after ER of a RYGB in patients (age ≥ 18) with severe protein-calorie malnutrition from a single academic health center in Minneapolis, Minnesota over a seven-year period (2015-2021) were retrospectively reviewed pre-procedurally, and at six and twelve months post-procedurally. 17 patients underwent ER for severe protein-calorie malnutrition, or dependence on tube feeds (TF) or total parenteral nutrition (TPN). At 6 months post-ER, two patients were no longer malnourished and only on oral nutrition; three patients were liberated from TPN. Laboratory markers of protein-calorie malnutrition, renal function, and micronutrients were not significantly different at six- or twelve-month follow-up (P > 0.05). In all patients, access to the gastric remnant was maintained via stent placement through the gastric pouch or proximal Roux limb throughout the study period and no complications were noted after ER. Despite the small sample size, this investigation revealed that ER of RYGB may prevent progressive deleterious weight loss, and worsening macro- and micro-nutrient deficiencies, though improvement in weight and nutritional parameters was not observed. Overall, ER was found to be a nuanced and safe, advanced technique useful for when remnant access is desired in RYGB patients.

Observational studies, from multiple countries, repeatedly demonstrate an association between obesity and severe COVID-19, which is defined as need for hospitalization, intensive care unit admission, invasive mechanical ventilation (IMV) or death. Meta-analysis of studies from China, USA, and France show odds ratio (OR) of 2.31 (95% CI 1.3-4.1) for obesity and severe COVID-19. Other studies show OR of 12.1 (95% CI 3.25-45.1) for mortality and OR of 7.36 (95% CI 1.63-33.14) for need for IMV for patients with body mass index (BMI) ≥ 35 kg/m2. Obesity is the only modifiable risk factor that is not routinely treated but treatment can lead to improvement in visceral adiposity, insulin sensitivity, and mortality risk. Increasing the awareness of the association between obesity and COVID-19 risk in the general population and medical community may serve as the impetus to make obesity identification and management a higher priority.

Introduction: Roux-en-Y Gastric Bypass (RYGB) is a restrictive and malabsorptive surgical procedure for weight loss that can lead to nutritional deficiencies. Despite the importance of continued nutritional supplementation after the procedure, patients are often lost to follow up which can result in severe nutritional deficiencies and related complications: dermatitis, hypercoagulability, and immunodeficiency. Case Description/Methods: Here we describe a 36-year-old female with past medical history of obesity treated with RYGB 17 years earlier with loss of outpatient follow-up, non-alcoholic steatohepatitis, and recent unprovoked pulmonary embolism treated with six months of anticoagulation, who was admitted for evaluation of subacute abdominal pain, nausea, vomiting, and multiple cutaneous symptoms. She exhibited a diffuse painful rash involving the perioral skin, palms, soles, trunk, extremities, and intertriginous regions, livedo reticularis of bilateral upper extremities, angular cheilitis, glossitis, bilateral conjunctival injection, alopecia and bilateral lower extremity edema. Computed tomography scan of the abdomen showed diffuse colonic wall thickening, and colonoscopy with biopsy showed atrophy of the terminal ileum with increased intraepithelial lymphocytes and plasma cells. Notably, the patient was found to have severe nutritional deficiencies (vitamin A, multiple B vitamins, D, E, zinc, copper, calcium, essential fatty acids). Punch biopsy was consistent with nutritional deficiency dermatitis, which correlated with the clinical presentation of acquired acrodermatitis enteropathica (zinc deficiency) and other nutritional deficiencies. Her hospital course was complicated with arterial embolism to her right foot resulting in critical limb ischemia, treated with catheter-directed alteplase and intravenous heparin. On hospital day 11, she developed septic shock and acute respiratory failure and was started on broad spectrum antimicrobials, vasopressors, and mechanical ventilation but expired within 24 hours of decompensation. Autopsy revealed disseminated Cryptococcus Neoformans. Discussion: This case illustrates the importance of ongoing – at least annual -- follow-up post RYGB for nutritional monitoring. Nutritional deficiency should be promptly and aggressively treated. In select cases of severe recalcitrant malnutrition, RYGB can be reversed surgically or endoscopically.Figure 1.: Acquired Acrodermatitis Enteropathica.

Background: SARS-CoV-2 (COVID-19) disease causes significant morbidity and mortality through increased inflammation and thrombosis. Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are states of chronic inflammation and indicate advanced metabolic disease. Objective: The purpose of this observational study was to characterize the risk of hospitalization for COVID-19 in patients with NAFLD/NASH and evaluate the mitigating effect of various metabolic treatments. Setting: Retrospective analysis of electronic medical record data of 26,896 adults from a 12-hospital Midwest healthcare system with a positive COVID-19 polymerase chain reaction (PCR) test from March 1, 2020, to January 26, 2021. Methods: Variable selection was guided by the least absolute shrinkage and selection operator (LASSO) method, and multiple imputation was used to account for missing data. Multivariable logistic regression and competing risk models were used to assess the odds of being hospitalized within 45 days of a COVID-19 diagnosis. Analysis assessed the risk of hospitalization among patients with a prescription for metformin and statin use within the 3 months prior to the COVID-19 PCR result, history of home glucagon-like peptide 1 receptor agonist (GLP-1 RA) use, and history of metabolic and bariatric surgery (MBS). Interactions were assessed by sex and race. Results: A history of NAFLD/NASH was associated with increased odds of admission for COVID-19 (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.57-2.26; P < .001) and mortality (OR, 1.96; 95% CI, 1.45-2.67; P < .001). Each additional year of having NAFLD/NASH was associated with a significant increased risk of being hospitalized for COVID-19 (OR, 1.24; 95% CI, 1.14-1.35; P < .001). NAFLD/NASH increased the risk of hospitalization in men, but not women, and increased the risk of hospitalization in all multiracial/multiethnic subgroups. Medication treatments for metabolic syndrome were associated with significantly reduced risk of admission (OR, .81; 95% CI, .67-.99; P < .001 for home metformin use; OR, .71; 95% CI, .65-.83; P < .001 for home statin use). MBS was associated with a significant decreased risk of admission (OR, .48; 95% CI, .33-.69; P < .001). Conclusions: NAFLD/NASH is a significant risk factor for hospitalization for COVID-19 and ap-pears to account for risk attributed to obesity. Other significant risks include factors associated with socioeconomic status and other co-morbidities, such as history of venous thromboembolism. Treatments for metabolic disease mitigated risks from NAFLD/NASH. More research is needed to confirm the risk associated with visceral adiposity, and patients should be screened for and informed of treatments for metabolic syndrome. (C) 2021 Published by Elsevier Inc. on behalf of American Society for Bariatric Surgery.

Background: Covid-19 disease causes significant morbidity and mortality through increase inflammation and thrombosis. Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are states of chronic inflammation and indicate advanced metabolic disease. We sought to understand the risk of hospitalization for Covid-19 associated with NAFLD/NASH. Methods: Retrospective analysis of electronic medical record data of 6,700 adults with a positive SARS-CoV-2 PCR from March 1, 2020 to Aug 25, 2020. Logistic regression and competing risk were used to assess odds of being hospitalized. Additional adjustment was added to assess risk of hospitalization among patients with a prescription for metformin use within the 3 months prior to the SARS-CoV-2 PCR result, history of home glucagon-like-peptide 1 receptor agonist (GLP-1 RA) use, and history of metabolic and bariatric surgery (MBS). Interactions were assessed by gender and race. Results: A history of NAFLD/NASH was associated with increased odds of admission for Covid-19: logistic regression OR 2.04 (1.55, 2.96, p<0.01), competing risks OR 1.43 (1.09-1.88, p<0.01); and each additional year of having NAFLD/NASH was associated with a significant increased risk of being hospitalized for Covid-19, OR 1.86 (1.43-2.42, p<0.01). After controlling for NAFLD/NASH, persons with obesity had decreased odds of hospitalization for Covid-19, OR 0.41 (0.34-0.49, p<0.01). NAFLD/NASH increased risk of hospitalization in men and women, and in all racial/ethnic subgroups. Mediation treatments for metabolic syndrome were associated with non-significant reduced risk of admission: OR 0.42 (0.18-1.01, p=0.05) for home metformin use and OR 0.40 (0.14-1.17, p=0.10) for home GLP-1RA use. MBS was associated with a significant decreased risk of admission: OR 0.22 (0.05-0.98, p<0.05). Conclusions: NAFLD/NASH is a significant risk factor for hospitalization for Covid-19, and appears to account for risk attributed to obesity. Treatments for metabolic disease mitigated risks from NAFLD/NASH. More research is needed to confirm risk associated with visceral adiposity, and patients should be screened for and informed of treatments for metabolic syndrome.

Background: Prolonged sedentary time is associated with adverse health outcomes, after controlling for the role of moderate-to-vigorous physical activity. We previously reported on a four-week randomized trial using a sitstand desk (SSD) intervention that decreased sedentary time at work without changing activity level during non-work hours. Purpose: The purpose of this study was to measure the impact of the SSD on sitting time and activity level one year after the original intervention. Methods: A pre-post design was used where the control period from the original study was regarded as "pre" and the measurements made in the follow-up study as "post" The follow-up study was conducted in the same office workers over a two-week period in June 2013. Results: Fifteen out of the 23 participants took part in the follow-up study. Self-reported sitting time during work-hours was decreased by 22% (95% CI: 15% to 29%; p < 0.001), replaced almost entirely by standing. Activity measured by Gruve accelerometer during work-hours were significantly higher in the one-year followup period compared to baseline (+ 24,748 AU/h; 95% CI: 7150 to 42,347; p < 0.01). Sedentary time during work-hours was decreased by 0.77 min per work-hour (95% CI: 1.88 to 0.33 min/h; p = 0.17). Qualitative findings through focus group sessions suggested the workers had overall favorable experiences with the SSDs without negatively impacting productivity. Conclusion: One year following the original intervention, participants continue to have increased activity and decreased sedentary time at work with the use of SSDs.

PURPOSE: The purpose of this study was to investigate the association of changes in occupational sitting time and self-rated quality of life (QOL) in adult sedentary office workers undergoing a sedentary behavior intervention. METHODS: Data were derived from the ongoing study ‘Stand & Move at Work’, a group randomized trial aimed at reducing employee sedentary time through individual, environmental, and policy level changes. Physical functioning and mental health QOL scores were assessed with the SF- 12 questionnaire. Sitting time (min/day) throughout the work day was assessed by the activPal accelerometer/inclinometer with seven days of continuous wear. Work logs were used to isolate sitting minutes at work. These measures were assessed at baseline and at the three month time-point during the intervention. Change over time was computed for all variables by subtracting the individual 3-month value from the baseline value. The correlations between change in sitting time and changes in physical functioning and mental health were estimated by Pearson’s correlation coefficient. RESULTS: A total of 344 men and women were available for these analyses, of whom 24% were male and the average age was 45 +/- 11 yr. The mean baseline sitting time was 70 +/- 16% of the workday. Change in sitting time was inversely correlated with the physical functioning score (r=-0.13, p <0.05), whereas sitting time was not associated with the mental health score (r=-.042, p = 0.44). CONCLUSIONS: Decreases in sitting time were associated with improvement in self-reported physical functioning quality of life but not in mental health quality of life. Longer term results over 12 months of intervention and comparisons between the two different intervention arms may shed more light on the robustness and interpretation of the possible link between sitting time and quality of life domains.

BackgroundSedentary time has been shown to have deleterious effects on health. Today's workforce spends most of the day sitting. The objective of this study was to evaluate the effect of workplace interventions to decrease sedentary time on cardiometabolic risk factors.MethodsSedentary office workers (n=127; ages 22‐64; BMI=28.5±6.1 kg/m2) were recruited from three Minnesota employers and randomized to one of four intervention groups for 6 months: 1) Control, 2) Move (蠅30 min of light activity during the workday), 3) Stand (standing 蠅50% of the workday using a sit‐stand workstation), or 4) Stand+Move (combined Stand and Move). A 'metabolic risk score' (MRS) was calculated at baseline and 6 months using the following cardiometabolic risk factors: blood pressure, fasting blood glucose, log of fasting triglycerides, and HDL‐cholesterol. A z‐score was computed for each risk factor for each subject [(subject value – sample mean)/sample SD]. The MRS was derived by summing the z‐scores (HDL‐z subtracted).ResultsThere was a significant intervention effect on MRS (pConclusionsSit‐stand workstations combined with an intervention to increase light physical activity at work may be an effective tool to improve cardiometabolic risk.image

Prolonged sedentary time (ST) is associated with adverse health outcomes, while decreasing ST improves health outcomes. The use of sit-stand desks (SSDs) in workplaces has been proposed as a means of reducing ST. The purpose of this study was to gain knowledge about participants' experience and perceptions of a workplace intervention involving the introduction of SSDs. Focus groups and interviews were conducted with 28 study participants who used SSDs for 4 weeks. Data were analyzed using a grounded theory approach. Participants reported a high level of satisfaction with the SSDs and 96% chose to use them permanently. Participants experienced greater energy and alertness at work and reported increased face-to-face interaction with coworkers. Lack of work-surface space was the most significant problem with the use of SSDs. There was no perception of decreased productivity or reduced workplace privacy among participants.

BACKGROUND:The objective of this study was to estimate the mean difference in energy expenditure (EE) in healthy adults between playing active video games (AVGs) compared with traditional video games (TVGs) or rest. METHODS:A systematic search was conducted on Ovid MEDLINE, Web of Knowledge, and Academic Search Premier between 1998 and April 2012 for relevant keywords, yielding 15 studies. EE and heart rate (HR) data were extracted, and random effects meta-analysis was performed. RESULTS:EE during AVG play was 1.81 (95% CI, 1.29-2.34; I² = 94.2%) kcal/kg/hr higher, or about 108 kcal higher per hour for a 60-kg person, compared with TVG play. Mean HR was 21 (95% CI, 13.7-28.3; I² = 93.4%) beats higher per minute during AVG play compared with TVG play. There was wide variation in the EE and HR estimates across studies because different games were evaluated. Overall metabolic equivalent associated with AVG play was 2.62 (95% CI, 2.25-3.00; I² = 99.2%), equivalent to a light activity level. Most studies had low risk of bias due to proper study design and use of indirect calorimetry to measure EE. CONCLUSION:AVGs may be used to replace sedentary screen time (eg, television watching or TVG play) with light activity in healthy adults.