Ongoing Weight Loss Research Articles

Lasting Symptoms After Esophageal Resection (LASER): European Multicenter Cross-sectional Study.

To identify the most prevalent symptoms and those with greatest impact upon health-related quality of life (HRQOL) among esophageal cancer survivors. Long-term symptom burden after esophagectomy, and associations with HRQOL, are poorly understood. Between 2010 and 2016, patients from 20 European Centers who underwent esophageal cancer surgery, and were disease-free at least 1 year postoperatively were asked to complete LASER, EORTC-QLQ-C30, and QLQ-OG25 questionnaires. Specific symptom questionnaire items that were associated with poor HRQOL as identified by EORTC QLQ-C30 and QLQ-OG25 were identified by multivariable regression analysis and combined to form a tool. A total of 876 of 1081 invited patients responded to the questionnaire, giving a response rate of 81%. Of these, 66.9% stated in the last 6 months they had symptoms associated with their esophagectomy. Ongoing weight loss was reported by 10.4% of patients, and only 13.8% returned to work with the same activities.Three LASER symptoms were correlated with poor HRQOL on multivariable analysis; pain on scars on chest (odds ratio (OR) 1.27; 95% CI 0.97-1.65), low mood (OR 1.42; 95% CI 1.15-1.77) and reduced energy or activity tolerance (OR 1.37; 95% CI 1.18-1.59). The areas under the curves for the development and validation datasets were 0.81 ± 0.02 and 0.82 ± 0.09 respectively. Two-thirds of patients experience significant symptoms more than 1 year after surgery. The 3 key symptoms associated with poor HRQOL identified in this study should be further validated, and could be used in clinical practice to identify patients who require increased support.

A111 SEVERE FAT MALABSORPTION IN A PATIENT POST ILEAL POUCH ANAL ANASTAMOSIS: A RARE PRESENTATION OF MICROSCOPIC ENTERITIS

Abstract Background Microscopic enteritis (ME) is a rare enteropathy characterized by malabsorptive diarrhea and lymphocytic infiltration +/- collagen deposition in the subepithelial layer of the small bowel. Its etiology is unclear. Aims To elucidate a rare cause of fat malabsorption and vitamin deficiency in a patient with ulcerative colitis and an ileoanal pouch. Methods A 74 yo male with a prior IPAA was referred to Internal Medicine in August 2018 for a 36 kg weight loss over 18 months and >16 bowel movements (BM) per day (baseline 6, no history of pouchitis). Celiac serology and infectious workup were negative. Medical management and nutritional supplements did not result in weight gain or improvement of diarrhea. He was admitted in June 2019 with ongoing weight loss, AKI, and signs of fat-soluble vitamin deficiency. A 72-hour fecal fat analysis showed an average fecal weight of 2100 g/d (ref <250 g/d), and excretion of 70% of daily fat intake (ref <7%). His fecal elastase (FE) was 147 µg/g, consistent with moderate pancreatic insufficiency (PI) with mild atrophy on CT. EGD and pouch endoscopy were macroscopically normal, with histological findings of intraepithelial lymphocytosis and mild villous blunting in the duodenum and afferent limb. CT enterography excluded small bowel abnormalities. He was started on pancreatic enzyme replacement and discharged. He returned with worsening diarrhea and AKI. He was treated with supportive care and sent home. In the ensuing 3 weeks, he had up to 24 BM per day and 4 kg of weight loss. He returned in August 2019 with AKI, lack of PO intake and worsened nutritional status. Re-examination of duodenal biopsies from June 2019 revealed an added finding of focal subepithelial collagen thickening. Budesonide was started. Results On budesonide, his symptoms improved within days. BMs decreased to baseline, and his ability to sustain PO intake improved. At his 4-week follow-up visit, BMs were stable with a 6 kg weight gain and no ensuing laboratory abnormalities. Conclusions ME is a rare enteropathy that presents with malabsorption. Fat-soluble vitamin deficiencies can develop with widespread physiological disruption of the mucosal surface. This patient was a diagnostic challenge. His steatorrhea and reduced FE levels led clinicians down a diagnostic pathway of PI. FE is the most common test used in the diagnosis of PI. Levels <200 µg/g are abnormal. Specificity is highest in chronic pancreatitis; however, this decreases in the presence of mucosal atrophy (i.e. IBD and diffuse small bowel disease). Thus, FE could not delineate the cause of steatorrhea in our patient. We can surmise that he likely has diffuse disease that was underestimated on duodenal biopsy. This is supported by his response to budesonide. This case highlights the heterogeneity of clinical presentations of ME. Awareness can reduce patient morbidity. Funding Agencies None

Body Mass Index at Presentation of Inflammatory Bowel Disease in Children.

PurposeThe evidence for an association between inflammatory bowel disease (IBD) and obesity is conflicting. Therefore, we set out to review the body mass index (BMI) at presentation of IBD to understand if the rise of the obesity rate in the general population, lead to an increase of obesity in patients with IBD at the time of diagnosis.MethodsRetrospective review of all patients with IBD seen at Children's Hospital and Medical Center from January 1st 2010 to December 31st 2014. From the initial visit and endoscopy, we obtained: age; sex; BMI; disease phenotype; disease severity.ResultsWe had a total of 95 patients, 35 patients were excluded due to incomplete data or referral being made after diagnosis was made. 28 were males and 32 were females, Age range was 2–17 years. A 37 had Crohn's disease, 19 ulcerative colitis, and 4 indeterminate colitis. Disease severity in 19 cases was mild, 29 moderate and 12 severe. BMI distribution was as follows—obese (5.0%), overweight (6.7%), normal weight (65.0%), mild malnutrition (8.3%), moderate malnutrition (15.0%), severe malnutrition (1.7%).ConclusionOur data is consistent with other series. Showing most children had a normal BMI, regardless of disease severity or phenotypes. One confounding factor is the possibility of delay in referral to GI. This could mean some obese children may fall in the normal BMI range at the time of diagnosis due to ongoing weight loss. Future studies should include prospective cohort studies, comparing incidence of IBD in obese and non-obese patients, severity at presentation, duration of symptoms, and clinical outcomes.

O161 LASTING SYMPTOMS AFTER ESOPHAGEAL RESECTION (LASER) – EUROPEAN MULTI-CENTER CROSS-SECTIONAL STUDY

Abstract Aim Long-term functional outcomes and the associations to health-related quality of life (HRQOL) after esophagectomy is largely unknown. LASER is a multi-center European study aimed to identify the most prevalent symptoms, and those with the greatest impact upon HRQOL among patients surviving more than one-year after esophagectomy for cancer, and to develop a clinically relevant symptom-based tool to measure HRQOL. Background & Methods Between 2010 and 2016, patients from 20 European Centers who underwent esophagectomy for esophageal cancer, and were disease-free at least one year postoperatively were invited to complete the LASER questionnaire, EORTC-QLQ30 and OG25. Specific symptom questionnaire items that were associated with a poor HRQOL as identified by EORTC-QLQC30 and OG25 were identified by multivariable linear and logistic regression analysis and combined to form a tool, which was tested using receiver operating characteristics curve analysis. Results A total of 876 of 1081 invited patients responded to the questionnaire, giving a response rate of 81%. Of these, 66.9% stated in the last 6 months they had had symptoms associated with their esophagectomy and 52.4% of patients had sought medical treatment for their symptoms. Ongoing weight loss was reported by 10.4% of patients while 32.4% were struggling to maintain their body weight, and 18.8% of patients required supplemental oral nutrition. Only 13.8% of patients had returned to work with the same activities as before. Three LASER symptoms in multivariate analysis were correlated with poor HRQOL; pain on scars on chest (Odds ratio (OR) 1.27; 95% CI 0.97-1.65), low mood (OR 1.42; 95% CI 1.15-1.77) and reduced energy or activity tolerance (OR 1.37; 95% CI 1.18-1.59). The areas under the curves for the development and validation datasets were 0.81±0.02 and 0.82±0.09 respectively. Conclusions Two-thirds of patients experience symptoms related to their esophagectomy more than one year after surgery. The three key symptoms associated with poor HRQOL identified in this study should be further validated, and could be used in clinical practice to identify patients who require increased long-term term support.

722P - It’s not only about weight loss: Tackling pancreatic cancer-associated cachexia

BackgroundCachexia affects 70-80% patients with pancreatic adenocarcinoma (PA). Systemic inflammation is a key feature of this multifactorial syndrome of unintended weight loss (WL). Despite being often described, cancer-associated cachexia (CAC) remains poorly understood and rarely recognized in clinical settings, therefore an unmet need. This study aims to acknowledge the effect of CAC in PA patients and to study the impact of WL, body mass index (BMI) and other available biomarkers (BM) on survival. MethodsRetrospective analysis of PA patients treated in our institution between 2013 - 2018. Patients were categorized at baseline as having CAC if 1 of 2 criteria were met: WL>5% from previous stable weight; BMI < 20kg/ m2 and ongoing WL>2%. Serum hemoglobin, c-reactive protein (CRP), albumin, inflammation-based score (Glasgow Prognostic Score mGPS), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) and cancer specific antigen CA 19-9 were assessed at baseline and at 3-month. Data analysis with descriptive statistics, t-test, chi-square test, cox regression and log-rank test were performed with StataIC. Results95 eligible patients (median age 72 [46;98], 60% female) were reviewed. At baseline, cachectic patients (CP) (74%), when compared to non-CP, had higher CA 19-9 (p=0,047), more advanced disease (p=0,001) lower BMI (p=0,016), worse performance status (p=0,016) and mean WL of 13,8 ± 6,7 (%) (p=0,001). Also, NLR>3,5 (p=0,001), PLR>150 (p=0,018) and hypoalbuminemia (p=0,004) were all statistically associated to CP. Median overall survival (OS) of non-CP was 19,13 months versus 5,03 months in CP (HR 2,69 95% CI 1,58-4,59, p=0,001). In the latter, at baseline, higher CA 19.9 (HR 1,0 95% CI 1,01-1,021, p=0,015), higher CRP (HR 1,21 95% CI 1,06-1,39, p=0,006) and PLR>150 (HR 2,45; 95% CI 1,09-5,54, p=0,031) were independent predictors of worst OS. In non-CP, normal baseline albumin (HR 0,04 95CI 0,02-0,72, p=0,029) was an independent predictor of better OS. ConclusionsA better understanding of CAC in PA might improve outcomes for PA patients. Our study suggests that a prompt identification of prognostic BM may lead to a better standardized management of CAC and that nutritional parameters can be optimized, with impact on prognosis. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Effectiveness of Online Aftercare Programs Following Intragastric Balloon Placement for Obesity Is Similar to Traditional Follow-up: a Large Propensity Matched US Multicenter Study.

The combination of intragastric balloons (IGB) with comprehensive lifestyle and behavioral changes is critical for ongoing weight loss. Many community and rural practices do not have access to robust obesity resources, limiting the use of IGBs. Online aftercare programs were developed in response to this need, delivering lifestyle coaching to maximize effectiveness. How these programs compare to traditional follow-up is currently unknown. Using propensity scoring(PS) methods, two large prospective databases of patients undergoing IGB therapy were compared to estimate the difference in percent total body weight loss (%TBWL) between groups while identifying predictors of response. Seven hundred fifty-eight unique patients across 78 different participating practices (online n = 437; clinical registry n = 321) was analyzed. The mean %TBWL at balloon removal was 11% ± 6.9 with an estimated treatment difference (ETD) between online and traditional follow-up of - 1.5% TBWL (95% CI - 3-0.4%; p = 0.125). Three months post-balloon removal, the combined %TBWL was 12.2% ± 8.3 with an ETD of only 1% TBWL (95%CI -3-3%; p = 0.08). On multivariable linear regression, each incremental follow-up was associated with increased %TBWL (β = 0.6% p = 0.002). Online IGB aftercare programs provide similar weight loss compared with traditional programs. Increased lifestyle coaching whether in person or remotely is associated with more %TBWL at removal and during follow-up. Close follow-up for clinical symptoms is still warranted.

SAT-096 Later Timing of Energy Intake Associates with Higher Fat Mass in Adults with Overweight and Obesity

Background Emerging literature suggests that later timing of energy intake and sleep are related to obesity (1-3). However, few studies have assessed both meal and sleep timing in adults with obesity, and it is not clear whether eating later in the day is associated with shorter sleep duration or higher adiposity. Understanding whether temporal feeding and sleep patterns are associated with body composition will help in the design of novel weight loss and maintenance interventions aimed at altering the timing of lifestyle behaviors. Methods Thirty-two overweight and obese adults (90% female sex, age 36.4±6.4 years, and BMI=33.4±5.5 kg/m2) were recruited to participate in an ongoing weight loss trial comparing daily caloric restriction to time-restricted feeding. Participants simultaneously wore an activPAL accelerometer on the thigh and an Actiwatch on the non-dominant wrist for 7 days in a free-living environment to assess waking sedentary behavior and nighttime sleep, respectively. A cell phone application (MealLogger) was used to photograph and timestamp all caloric events during the 7-day period to determine daily feeding duration, which was verified using a continuous glucose monitor. Assessments were performed at baseline and will be repeated at 12 weeks following completion of the weight loss intervention. Correlation analyses were performed on baseline data to determine associations among the duration and timing of daily energy intake and sleep. Results are reported as mean±SD. Results On average, participants consumed energy over 11.0±1.9 hours during the day and slept for 7.2±0.7 hours at night. The clock time of the last caloric event averaged 7:54pm ± 93 min. Later meal timing (midpoint of the feeding window) was positively correlated with later sleep timing (midpoint of the sleep window, r = 0.67, P = <0.0001) but did not impact sleep duration. A later feeding midpoint correlated with higher BMI (r = 0.49, P = 0.005) and fat mass (r = 0.55, P = 0.001). Conclusions We used a novel set of methods to show that individuals with overweight and obesity may be eating later into the day. In addition, later meal timing was associated with higher BMI and fat mass. Future studies are needed to compare the timing of energy intake and sleep in normal weight versus obese individuals. These findings support ongoing studies by our group investigating whether restricting energy intake to the early part of the day lowers obesity risk. References (1) McHill et al., Am J Clin Nutr. 2017 Nov;106(5):1213-1219. (2) Baron et al., Obesity (Silver Spring). 2011 Jul;19(7):1374-81. (3) Garaulet, Gomez-Abellan, Physiol Behav. 2014 Jul;134:44-50. Sources of Research Support: This research has received funding from the NIH

AB020. S3B-6. Nutrition care in patients with cancer

: Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Malnutrition, anorexia, and cachexia are a common finding in patients with cancer. They become more evident with tumor growth and spread. These mechanisms can involve primary tumor or damage by specific treatment such as anticancer therapies (surgery, chemotherapy, radiotherapy) also in cancers that usually are not directly responsible for nutritional and metabolic status alterations. Cancer cachexia is defined as a multifactorial syndrome characterized by an ongoing loss of skeletal muscle mass that cannot be fully reversed by the conventional nutritional support and leads to progressive functional impairment. It is common among patients with cancer who often experience marked unintentional weight loss, sarcopenia, anemia, anorexia, and fatigue. The pathophysiology is characterized by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism. The metabolic changes seen are distinctly different from starvation, reduced caloric intake, or from tumor burden alone. Patients with upper gastrointestinal, head and neck, and lung cancer are among the most severely affected by cancer cachexia. Cancer cachexia has detrimental effects on quality of life (QOL), performance status, and physical function. Cachexia is defined as >5% involuntary weight loss over the preceding 6 months or a body mass index (BMI) <20 kg/m2 and ongoing weight loss >2% or signs of sarcopenia and ongoing weight loss >2%. Sarcopenia has been defined by a variety of assessment tools, including mid-arm muscle area or circumference, appendicular skeletal muscle index determined by dual-energy X-ray absorptiometry, lumber skeletal muscle index determined by oncological computerized tomography, or whole-body fat-free mass index without bone determined by bioelectrical impedance. The use of optimized nutrition intervention programs such as dietitian consults, periodic monitoring, appropriate nutrition supplements, and feeding tube placements as needed throughout the treatment period markedly improves treatment tolerance and outcomes in head and neck cancer patients. The procedures of nutritional interventions were included in climbing order as followings: dietary adaptations or changes, oral supplements, enteral feeding through a feeding tube and parenteral nutrition. Recently, nutrient support, such as omega-3 rich food components, has attracted attention as a potential anti-tumor immunonutrition therapy. As cancer cachexia is a multifactorial process, the treatment approach should be multi-targeted. Further large prospective studies are needed to investigate whether immune enhanced oral nutritional supplements, enriched by a variety of micronutrients, are a beneficial intervention for the metabolic disturbances induced by cachexia.

Rationale for novel intermittent dieting strategies to attenuate adaptive responses to energy restriction.

Eating patterns involving intermittent energy restriction (IER) include 'intermittent fasting' where energy intake is severely restricted for several 'fasting' days per week, with 'refeeding' days (involving greater energy intake than during fasting days) at other times. Intermittent fasting does not improve weight loss compared to continuous energy restriction (CER), where energy intake is restricted every day. We hypothesize that weight loss from IER could be improved if refeeding phases involved restoration of energy balance (i.e. not ongoing energy restriction, as during intermittent fasting). There is some evidence in adults with overweight or obesity showing that maintenance of a lower weight may attenuate (completely or partially) some of the adaptive responses to energy restriction that oppose ongoing weight loss. Other studies show some adaptive responses persist unabated for years after weight loss. Only five randomized controlled trials in adults with overweight or obesity have compared CER with IER interventions that achieved energy balance (or absence of energy restriction) during refeeding phases. Two reported greater weight loss than CER, whereas three reported similar weight loss between interventions. While inconclusive, it is possible that achieving energy balance (i.e. avoiding energy restriction or energy excess) during refeeding phases may be important in realizing the potential of IER.

Impact of preoperative cachexia on postoperative length of stay in elderly patients with gastrointestinal cancer.

The aim of the present study was to investigate the impact of preoperative cachexia on postoperative length of stay (LOS) in elderly patients with gastrointestinal cancer. This prospective cohort study enrolled 98 patients (≥60 y of age) with gastric or colorectal cancer who were scheduled to undergo curative surgery and were categorized as either having cachexia or as being in a non-cachexia group. The definition of cachexia was patients with >5% loss of stable body weight over the previous 6 mo, a body mass index (BMI) <20 kg/m2 and ongoing weight loss >2%, or sarcopenia and ongoing weight loss >2%. Multivariable Poisson regression analysis was performed with postoperative LOS as the dependent variable and the presence of cachexia as the independent variable, and age, sex, Eastern Cooperative Oncology Group performance status, education, cancer type, clinical stage, surgical approach, and the Charlson Comorbidity Index as confounding variables. Twenty-two patients (22.4%) were diagnosed with cachexia. Postoperative LOS was 17.1 ± 8.7 d in the non-cachexia group and 20.6 ± 10.8 d in the cachexia group. Multivariable Poisson analysis showed that preoperative cachexia was significantly associated with prolonged postoperative LOS after adjustment (2.41 d; 95% confidence interval, 0.28to4.55; P = 0.027). Our results suggested that preoperative cachexia prolongs postoperative LOS in elderly patients with gastrointestinal cancer, implying that cachexia should be assessed and treated before surgery.

A Case Tough to Swallow: Esophageal Intramural Pseudodiverticulosis

Esophageal intramural pseudodiverticulosis (EIP) is a rare condition characterized by multiple small outpouchings protruding from the esophageal lumen to the outer wall. The pseudodiverticula represent dilated excretory ducts of deep esophageal mucosal glands. The most common symptom is dysphagia with esophageal stricture formation. In this case, we present a 62 year-old lady who suffered from dysphagia and unintentional weight loss, and was diagnosed to have EIP by esophagogram and esophagogastroduodenoscopy (EGD) which improved after dilatational therapy. A 62 year old female with a history of liver cirrhosis, chronic pancreatitis, and gastroesophageal reflux disease presented with nausea, vomiting, and melena. Social history was significant for smoking (25 pack/yr.), and chronic alcoholism. Initial exam revealed a thin, malnourished woman in overall poor health who endorsed dysphagia with regurgitation of solid food, and ongoing unintentional weight loss. Her labs exhibited an AST (71u/L), ALT (122 u/L), and Hgb (5.6 g/dL). EGD and colonoscopy were planned to workup her anemia, and dysphagia. EGD, displayed severe stenosis in the proximal esophagus that was dilated with 8 mm TTS (Through the Scope) dilator. Subsequently, she was sent for esophagram which displayed numerous submucosal collections of contrast in the upper portion of the esophagus, consistent with EIP. Repeat EGD showed benign esophageal stenosis with pseudodiverticula in the upper third of the esophagus. The stenosis was dilated with 24 and 27 Fr dilators leading to resolution of her dysphagia, and on follow up she is tolerating a full diet. EIP is a rare condition with approximately 200 cases reported world-wide. Two mechanisms of proposed injury predominate; excretory ductal obstruction secondary to inflammation, and submucosal fibrosis caused by chronic irritation. Reports have shown the risks of developing EIP are higher in those who have coexisting disease such as esophageal candidiasis, diabetes mellitus, or corrosive injury. One study found a statistically significant difference between prevalence of EIP in patients with esophageal cancer (4.5%) and of those without cancer (0.09%). Given more than 80% of patients with EIP experience stenosis and dysphagia, endoscopic dilation has proven to alleviate symptoms longterm. Our case expands the potential causes of dysphagia, and emphasizes the importance of ruling out potentially serious underlying causes associated with EIP.

Opinions and practices of healthcare professionals on assessment of disease associated malnutrition in children: Results from an international survey

Lack of consensus on clinical indicators for the assessment of pediatric disease associated malnutrition (DAM) may explain its under-recognition in clinical practice. This study surveyed the opinions of health professionals (HP) on clinical indicators of DAM and barriers impeding routine nutritional screening in children. Web-based questionnaire survey (April 2013-August 2015) in Australia, Belgium, Israel, Spain, The Netherlands, Turkey and UK. There were 937 questionnaires returned via local professional associations, of which 693 respondents fulfilled the inclusion criteria and were included in the final analysis; 315 pediatric gastroenterologists and 378 pediatric dieticians. The most important clinical indicators of DAM were ongoing weight loss (80.4%), increased energy/nutrient losses (73.0%), suboptimal energy/macronutrient intake (68.6%), a high nutritional risk condition (67.2%) and increased energy/nutrient requirements (66.2%). These findings were consistent across countries and professions. The most common approach to screen for DAM was assessment of weight changes (85%), followed by the usage of growth charts (77-80%). Common perceived barriers for routine nutritional screening/assessment were low staff awareness (47.5%), no local policy or guidelines (33.4%) and lack of time to screen (33.4%). HP who routinely assess and treat children with DAM identified ongoing weight loss, increased losses, increased requirements, low intake and high nutritional risk conditions as the most important clinical indicators of DAM. These clinical indicators should now serve as a basis to form clinical-based criteria for the identification of DAM in routine clinical practice. Low awareness, lack of guidelines or local policy and lack of resources were the most important barriers of routine screening.

Predictive factors of weight regain following laparoscopic Roux-en-Y gastric bypass.

Strategies to address weight recidivism following Roux-en-Y gastric bypass (RYGB) could be developed if patients at risk were identified in advance. This study aimed to determine factors that predict weight regain. Retrospective review was performed of patients who underwent laparoscopic RYGB at a single institution over 10years. Group-based modeling was used to estimate trajectories of weight regain after nadir and stratify patients based on percent weight change (%WC). Three trajectories were identified from 586 patients: 121 had ongoing weight loss, 343 were weight stable, and 122 regained weight. Male sex (p = 0.020) and white race (p < 0.001) were associated with stable weight or weight regain. Being from a neighborhood of socioeconomic advantage (p = 0.035) was associated with weight regain. Patients with weight regain experienced improved percent weight loss (%WL) at nadir (p < 0.001) and ΔBMI (p = 0.002), yet they had higher weight and BMI and lower %WL and ΔBMI than the other two groups during long-term follow-up. On multivariate analyses, those who regained weight were more likely from socioeconomically advantaged neighborhoods (OR 1.82, CI 1.18-2.79). Several patient-related characteristics predicted an increased likelihood of weight regain. Further studies are needed to elucidate how these factors contribute to weight recidivism following bariatric surgery.

Is it Celiac Disease or CVID-Associated “Celiac-Like Disease”?

Common Variable Immunodeficiency (CVID) is the most common primary immunodeficiency in adults. Gastrointestinal (GI) symptoms are common in CVID patients, and up to 50% of patients have chronic diarrhea with malabsorption. CVID is commonly associated with intestinal villous atrophy mimicking Celiac Disease (CD). The prevalence of true CD in CVID remains unknown. We present a case of gluten-free diet (GFD) responsive CD in a patient with CVID. A 67 year old Caucasian female with long standing history of CVID on IgG replacement therapy, chronic kidney disease, and severe iron deficiency presented for evaluation of persistent nausea, anorexia, weight loss and non-healing chronic leg ulcer. She underwent EGD after initial anti tissue transglutaminase (anti-TTG) was found to be 17 U/mL, which showed marked villous blunting and mild lymphocytic infiltration with inflammatory pathology. Enteral access was obtained for nutritional supplementation in a setting of ongoing weight loss. An EGD 1 month after high fidelity enteral GFD showed resolution of inflammatory changes and improvement in villous blunting. (Table 1) The ensuing 3 months of strict diet adherence resulted in removal of the feeding tube with resolution of anorexia and nausea, as well as a 35 pound weight gain with return to healthy baseline weight. A dramatic improvement in her chronic leg wound was observed that had previously been resistant to all therapies. Anti-TTG levels at 4 month mark improved to 8 U/mL. Common variable immunodeficiency (CVID) with an estimated prevalence of 1/100,000 to 1/50,000 is the most common symptomatic primary antibody deficient syndrome. Up to 50% of CVID patients have chronic diarrhea with malabsorption. CVID is commonly associated with intestinal villous atrophy mimicking Celiac Disease (CD). Due to unreliable antibody testing and inconsistent response to GFD making a diagnosis of CD in CVID remains a challenge. Based on a few recent studies, the only criterion to confirm CD in CVID population is histological response to GFD. Our patient had significant improvement in symptoms and showed a histological response with GFD. CVID and CD can co-exist, hence a high level of clinical suspicion is warranted to diagnose CD in the CVID population.Table: Table. Sequential Duodenal Bulb Biopsies

Effect of a mobile app intervention on vegetable consumption in overweight adults: a randomized controlled trial

BackgroundMobile applications (apps) have been heralded as transformative tools to deliver behavioral health interventions at scale, but few have been tested in rigorous randomized controlled trials. We tested the effect of a mobile app to increase vegetable consumption among overweight adults attempting weight loss maintenance.MethodsOverweight adults (n=135) aged 18–50 years with BMI=28–40 kg/m2 near Stanford, CA were recruited from an ongoing 12-month weight loss trial (parent trial) and randomly assigned to either the stand-alone, theory-based Vegethon mobile app (enabling goal setting, self-monitoring, and feedback and using “process motivators” including fun, surprise, choice, control, social comparison, and competition) or a wait-listed control condition. The primary outcome was daily vegetables servings, measured by an adapted Harvard food frequency questionnaire (FFQ) 8 weeks post-randomization. Daily vegetable servings from 24-hour dietary recalls, administered by trained, certified, and blinded interviewers 5 weeks post-randomization, was included as a secondary outcome. All analyses were conducted according to principles of intention-to-treat.ResultsDaily vegetable consumption was significantly greater in the intervention versus control condition for both measures (adjusted mean difference: 2.0 servings; 95% CI: 0.1, 3.8, p=0.04 for FFQ; and 1.0 servings; 95% CI: 0.2, 1.9; p=0.02 for 24-hour recalls). Baseline vegetable consumption was a significant moderator of intervention effects (p=0.002) in which effects increased as baseline consumption increased.ConclusionsThese results demonstrate the efficacy of a mobile app to increase vegetable consumption among overweight adults. Theory-based mobile interventions may present a low-cost, scalable, and effective approach to improving dietary behaviors and preventing associated chronic diseases.Trial registrationClinicalTrials.gov NCT01826591. Registered 27 March 2013.

Mobile Technology for Vegetable Consumption: A Randomized Controlled Pilot Study in Overweight Adults.

BackgroundMobile apps present a potentially cost-effective tool for delivering behavior change interventions at scale, but no known studies have tested the efficacy of apps as a tool to specifically increase vegetable consumption among overweight adults.ObjectiveThe purpose of this pilot study was to assess the initial efficacy and user acceptability of a theory-driven mobile app to increase vegetable consumption.MethodsA total of 17 overweight adults aged 42.0 (SD 7.3) years with a body mass index (BMI) of 32.0 (SD 3.5) kg/m2 were randomized to the use of Vegethon (a fully automated theory-driven mobile app enabling self-monitoring of vegetable consumption, goal setting, feedback, and social comparison) or a wait-listed control condition. All participants were recruited from an ongoing 12-month weight loss trial (parent trial). Researchers who performed data analysis were blinded to condition assignment. The primary outcome measure was daily vegetable consumption, assessed using an adapted version of the validated Harvard Food Frequency Questionnaire administered at baseline and 12 weeks after randomization. An analysis of covariance was used to assess differences in 12-week vegetable consumption between intervention and control conditions, controlling for baseline. App usability and satisfaction were measured via a 21-item post-intervention questionnaire.ResultsUsing intention-to-treat analyses, all enrolled participants (intervention: 8; control: 9) were analyzed. Of the 8 participants randomized to the intervention, 5 downloaded the app and logged their vegetable consumption a mean of 0.7 (SD 0.9) times per day, 2 downloaded the app but did not use it, and 1 never downloaded it. Consumption of vegetables was significantly greater among the intervention versus control condition at the end of the 12-week pilot study (adjusted mean difference: 7.4 servings; 95% CI 1.4-13.5; P=.02). Among secondary outcomes defined a priori, there was significantly greater consumption of green leafy vegetables, cruciferous vegetables, and dark yellow vegetables (adjusted mean difference: 2.6, 1.6, and 0.8 servings; 95% CI 0.1-5.0, 0.1-3.2, and 0.3-1.4; P=.04, P=.04, and P=.004, respectively). Participants reported positive experiences with the app, including strong agreement with the statements “I have found Vegethon easy to use” and “I would recommend Vegethon to a friend” (mean 4.6 (SD 0.6) and 4.2 (SD 0.8), respectively, (on a 5-point scale).ConclusionsVegethon demonstrated initial efficacy and user acceptability. A mobile app intervention may be useful for increasing vegetable consumption among overweight adults. The small sample size prevented precise estimates of effect sizes. Given the improved health outcomes associated with increases in vegetable consumption, these findings indicate the need for larger, longer-term evaluations of Vegethon and similar technologies among overweight adults and other suitable target groups.Trial RegistrationClinicalTrials.gov NCT01826591; https://clinicaltrials.gov/ct2/show/NCT01826591 (Archived by WebCite at http://www.webcitation.org/6hYDw2AOB)

Chronic CNS oxytocin signaling preferentially induces fat loss in high-fat diet-fed rats by enhancing satiety responses and increasing lipid utilization.

Based largely on a number of short-term administration studies, growing evidence suggests that central oxytocin is important in the regulation of energy balance. The goal of the current work is to determine whether long-term third ventricular (3V) infusion of oxytocin into the central nervous system (CNS) is effective for obesity prevention and/or treatment in rat models. We found that chronic 3V oxytocin infusion between 21 and 26 days by osmotic minipumps both reduced weight gain associated with the progression of high-fat diet (HFD)-induced obesity and elicited a sustained reduction of fat mass with no decrease of lean mass in rats with established diet-induced obesity. We further demonstrated that these chronic oxytocin effects result from 1) maintenance of energy expenditure at preintervention levels despite ongoing weight loss, 2) a reduction in respiratory quotient, consistent with increased fat oxidation, and 3) an enhanced satiety response to cholecystokinin-8 and associated decrease of meal size. These weight-reducing effects persisted for approximately 10 days after termination of 3V oxytocin administration and occurred independently of whether sucrose was added to the HFD. We conclude that long-term 3V administration of oxytocin to rats can both prevent and treat diet-induced obesity.

Cardiac changes in anorexia nervosa.

Introduction Anorexia nervosa is an eating disorder, which is associated with many different medical complications as a result of the weight loss and malnutrition that characterise this illness. It has the highest mortality rate of any psychiatric disorder. A large portion of deaths are attributable to the cardiac abnormalities that ensue as a result of the malnutrition associated with anorexia nervosa. In this review, the cardiac complications of anorexia nervosa will be discussed. A comprehensive literature review on cardiac changes in anorexia nervosa was carried out. There are structural, functional, and rhythm-type changes that occur in patients with anorexia nervosa. These become progressively significant as ongoing weight loss occurs. Cardiac changes are inherent to anorexia nervosa and they become more life-threatening and serious as the anorexia nervosa becomes increasingly severe. Weight restoration and attention to these cardiac changes are crucial for a successful treatment outcome.

Cancer Cachexia: One Step Ahead

Cachexia is one of the most common manifestations in advanced cancer patients, but too often it remains under- recognized and under-treated. Starvation is not the same of cachexia. Cachexia is defined by "weight loss >5% over past 6 months in absence of simple starvation or the combination of ongoing weight loss>2% with BMI <20 or sarcopenia". The pathogenesis of cancer cachexia is not fully understood, but inflammation and an increased catabolic response to a number of cancer-related factors seem to represent the basis of any assumption. Early diagnosis of a pre-cachectic or cachectic state is a key moment for the treatment of this complex syndrome, in order to guarantee an adequate food intake and suitable exercise and to interfere with the inflammatory processes that are typical of cachexia. Therefore, one of the main aims is to identify those patients most likely to develop the syndrome early. A multimodality baseline approach to cancer cachexia addresses reversible clinical contributory factors. There are currently no medicinal products that have a proven efficacy in the medical approach to cancer cachexia. Recently, anamorelin, a synthetic orally active ghrelin receptor agonist, showed promising results, but the best approach to cancer cachexia probably remains an early multimodal interventions consisting in nutritional intervention, exercise and rehabilitation program, and multi-target drug therapies. This review summarizes what we know and what still need to know about cancer cachexia syndrome.

Comparing Two Classifications of Cancer Cachexia and Their Association with Survival in Patients with Unresected Pancreatic Cancer

There is no universally accepted definition of cancer cachexia. Two classifications have been proposed; the 3-factor classification requiring ≥2 of 3 factors; weight loss ≥10%, food intake ≤1500 kcal/day, and C-reactive protein ≥10 mg/l, and the consensus classification requiring weight loss >5% the past 6 mo, or body mass index <20 kg/m2 or sarcopenia, both with ongoing weight loss >2%. Precachexia is the initial stage of the cachexia trajectory, identified by weight loss ≤5%, anorexia and metabolic change. We examined the consistency between the 2 classifications, and their association with survival in a palliative cohort of 45 (25 men, median age of 72 yr, range 35–89) unresected pancreatic cancer patients. Computed tomography images were used to determine sarcopenia. Height/weight/C-reactive protein and survival were extracted from medical records. Food intake was self-reported. The agreement for cachexia and noncachexia was 78% across classifications. Survival was poorer in cachexia compared to noncachexia (3-factor classification, P = 0.0052; consensus classification, P = 0.056; when precachexia was included in the consensus classification, P = 0.027). Both classifications showed a trend toward lower median survival (P < 0.05) with the presence of cachexia. In conclusion, the two classifications showed good overall agreement in defining cachectic pancreatic cancer patients, and cachexia was associated with poorer survival according to both.