Avaliação do padrão alimentar, do consumo de frutose e do estado nutricional de pacientes com doença hepática gordurosa não alcoólica (DHGNA)

Introdução: A Doença Hepática Gordurosa não Alcoólica (DHGNA) é atribuída a múltiplos fatores, configurando-se como a manifestação hepática da Síndrome Metabólica (SM). A epidemia da DHGNA tem sido associada às alterações do estilo de vida, com adoção de padrões alimentares ocidentais, baseados em produtos processados e ricos em açúcares adicionados, fontes de frutose. A frutose pode ser obtida a partir de fontes alimentares naturais, quando intrínseca aos alimentos, ou livre, obtida por processamentos industriais. Objetivos: Avaliar o consumo alimentar de frutose total, in natura e livre de pacientes com DHGNA e associá-lo ao grau de fibrose, ao perfil metabólico e ao risco cardiovascular. Metodologia: Estudo transversal com pacientes ambulatoriais diagnosticados previamente com DHGNA, atendidos no Hospital de Clínicas de Porto Alegre (HCPA). Os pacientes foram classificados segundo seu risco de progressão para a DHGNA e passaram por avaliação clínica, dietética, antropométrica e funcional. Os alimentos e bebidas informados nos Registros Alimentares (RA’s) de três dias foram classificados conforme o nível de processamento (in natura, ingredientes culinários, minimamente processados, processados e ultraprocessados) de acordo com o Sistema NOVA. Resultados: Foram avaliados 128 pacientes, dos quais 63 tinham esteatose, 44 esteatohepatite (EHNA) e 21 cirrose. A idade média foi 54,0 ± 11,9 anos, 72,7% eram mulheres e IMC de 32,6 ± 5,4 Kg/m². A ingestão total de frutose (FT) foi de 21,6g, sendo 14,8g de frutose in natura (FN) e 6,8g de frutose livre (FL). O consumo de frutose total, in natura e livre não diferiu entre os pacientes com esteatose, EHNA e cirrose (p-valores 0,140; 0,101; 0,739, respectivamente). A ingestão de frutose de fontes distintas não justifica a fibrose hepática conforme NAFLD score, devido ao baixo poder de correlação encontrado (r² = 0,009) para FT; (r² = 0,040) para FN e (r² = 0,051) para FL. Os pacientes apresentavam elevado risco cardiometabólico, devido à prevalência de 78,0% de risco intermediário a alto de fibrose hepática; 96,8% com alterada relação cintura-estatura (RCE), 79,7% com SM, 65,6% com FAM reduzida, 70,3% com obesidade sarcopênica. Conclusões: O padrão alimentar dos pacientes ambulatoriais com DHGNA no HCPA parece apresentar composição dietética distinta à maioria dos estudos, baseado majoritariamente em alimentos minimamente processados, com baixo consumo de frutose. Nenhuma associação foi encontrada entre a ingestão de frutose e o risco de fibrose hepática.Introduction: Non-Alcoholic Fatty Liver Disease (NAFLD) is attributed to multiple factors, which is considered the liver manifestation of Metabolic Syndrome (MetS). NAFLD has been linked to lifestyle changes, with adoption of Western dietary patterns based on processed products, rich in added sugars, sources of fructose. The fructose origin can be from different sources, natural/ intrinsic to food, or added, obtained by industrial processing. Objectives: Evaluate whether the dietary intake of fructose from different food sources (added and natural) is or not associated with distinct cardiovascular risk, hepatic, and metabolic profiles, in patients with NAFLD. Methodology: Cross-sectional study with NAFLD outpatients who attended the Hospital de Clínicas de Porto Alegre (HCPA). Patients were classified according to their risk for progression of NAFLD and underwent clinical, dietary, anthropometric and functional evaluation. The foods and beverages reported in the 3-day-diet-record were classified by their processing level (unprocessed, processed culinary ingredients, minimally processed, processed and ultra-processed) according to the NOVA classification. Results: 128 patients were evaluated, of which 63 had steatosis, 44 steatohepatitis (NASH) and 21 cirrhosis. The mean age was 54.0 ± 11.9 years, 72.7% were women, and BMI 32.6 ± 5.4 kg/m². Total fructose (TF) intake was 21.6g, natural fructose (NF) 14.8g and added fructose (AF) 6.8g. Total, natural and added fructose intakes not differ in patients with steatosis, steatohepatitis and cirrhosis (p-values 0.140; 0.101; 0.739, respectively). Fructose intake from different sources does not justify hepatic fibrosis according NAFLD score, in view of the low correlation power found (r² = 0.009) for TF; (r² = 0.040) for NF and (r² = 0.051) for AF. Patients presented elevated cardiometabolic risk due to the prevalence of 78.0% intermediate/ high risk of hepatic fibrosis; 96.8% over waist-height ratio (WHtR), 79.7% of metabolic syndrome (MetS), 65.6% low hand grip strength and 70.3% had sarcopenic obesity. Conclusions: Dietary pattern of NAFLD outpatients from HCPA showed a distinct dietary composition, based mostly on minimally processed foods with low fructose intake. No association was found between fructose intake and risk of hepatic fibrosis

Effect of probiotic supplementation in nonalcoholic steatohepatitis patients : PROBILIVER TRIAL protocol

Background: Recently factors in the relationship between gut microbiota, obesity, diabetes and the metabolic syndrome have been suggested in the development and progression of nonalcoholic steatohepatitis (NASH). In this sense, this work aims to evaluate the effects of probiotic supplementation on intestinal microbiota modulation, degree of hepatic steatosis and fibrosis, inflammation, gut permeability, and body composition. Methods: This double-blind, randomized clinical trial will include adult outpatients with a diagnosis of NASH confirmed by biopsy with or without transient elastography. All patients will undergo a complete anamnesis to investigate their alcohol consumption, previous history, medications, nutritional assessment (dietary intake and body composition), sarcopenia, physical activity level and physical and functional capacity, cardiovascular risk, biochemical parameters for assessment of inflammatory status, lipid profile, hepatic function, gut permeability, and assessment of microbiota. These procedures will be performed at baseline and repeated after 24 weeks (at the end of the study). Through the process of randomization, patients will be allocated to receive treatment A or treatment B. Both patients and researchers involved will be blinded (double-blind study). The intervention consists of treatment with a probiotic mix (Lactobacillus acidophillus + Bifidobacterium lactis + Lactobacillus rhamnosus + Lactobacillus paracasei, 1 x 109 CFU for each) and the placebo which is identical in all its characteristics and packaging. Patients will be instructed to consume two sachets/day during 24 weeks and to report any symptoms or side effects related to the use of the sachets. Adherence control will be carried out through the patient’s notes on a form provided, and also by checking the number of sachets used. Discussion: The final results of study will be analyzed and disseminated in 2020

How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

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INTRODUÇÃO: A esteatose caracteriza-se pelo acúmulo de triglicerídeos sob a forma de gotículas lipídicas no fígado. Esta condição, quando associada à ausência de consumo ou à ingestão de quantidades insignificativas de álcool, é denominada Doença Hepática Gordurosa não Alcoólica (DHGNA). As lesões hepáticas decorrentes da DHGNA podem ser classificadas em esteatose simples, esteatohepatite não alcoólica (EHNA), cirrose e carcinoma hepatocelular (CHC). O Índice de Massa Corporal (IMC) elevado e o aumento da obesidade visceral são fatores de risco comumente documentados nesta população. OBJETIVOS: Avaliar e associar o perfil nutricional quanto ao grau de fibrose, ao perfil metabólico e à resistência insulínica em pacientes com DHGNA. MÉTODOS: Estudo transversal com coleta de dados retrospectiva e prospectiva apresentando dados parciais referentes a 68 pacientes ambulatoriais de um total de 123 sujeitos, com diagnóstico prévio de esteatose hepática, atendidos no Hospital de Clínicas de Porto Alegre (HCPA). Os pacientes foram classificados segundo seu risco de progressão da DHGNA e passaram por avaliação clínica, dietética, antropométrica e funcional. RESULTADOS: Dentre os sujeitos da pesquisa, houve prevalência do gênero feminino (76,5%), de etnia branca (89,7%), com doenças crônicas não transmissíveis (54,4% com DM 2, 63,2% com HAS, 63,6% com dislipidemia, 82,5% com Síndrome Metabólica). O perfil encontrado foi de pacientes com elevado grau de fibrose (96,2%), dos quais 20,9% com cirrose hepática, 89,4% com sobrepeso/ obesidade e 84,5% com elevada medida de circunferência da cintura e valores médios de FAM reduzidos. CONCLUSÃO: Conclui-se, até o presente momento, que os pacientes assistidos no ambulatório de DHGNA no HCPA têm a doença em grau avançado, o que se reflete em um pior perfil nutricional devido à elevada prevalência de excesso de peso, aos elevados valores de IMC e de CC; todavia, crê-se que uma abordagem de tratamento para intervenção do estilo de vida, incluindo o acompanhamento nutricional, é imprescindível para retardar ou evitar a sua progressão.INTRODUCTION: Steatosis is characterized by the accumulation of triglycerides in the form of lipid droplets in the liver. This condition, when associated with the absence of consumption or the ingestion of insignificant amounts of alcohol, is denominated Fatty Non-Alcoholic Liver Disease (NAFLD). Hepatic lesions resulting from NAFLD can be classified as simple steatosis, non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC). High Body Mass Index (BMI) and increased visceral obesity are commonly documented risk factors in this population. OBJECTIVES: To evaluate and to associate the nutritional profile in relation to the degree of fibrosis, metabolic profile and insulin resistance in patients with NAFLD. METHODS: A cross-sectional study with retrospective and prospective data collection, presenting partial data from 68 outpatients, in a total of 123 individuals, with previous diagnosis of hepatic steatosis, attended at the Hospital de Clínicas de Porto Alegre (HCPA). The patients were classified according to their risk of NAFLD progression and underwent clinical, dietary, anthropometric and functional evaluation. RESULTS: Among the subjects of this research there was a prevalence of the female gender (76.5%), white ethnicity (89.7%), chronic noncommunicable diseases (54.4% with type 2 diabetes mellitus – T2DM, 63.2% with systemic arterial hypertension – SAH, 63.6% with dyslipidemia, 82.5% with metabolic syndrome). The profile found was of patients with a high degree of fibrosis (96.2%), of which 20.9% had hepatic cirrhosis, 89.4% with overweight/obesity, 84.5% with high waist circumference (WC) and reduced hand grip strength values. CONCLUSION: To date, it is concluded that patients seen at the NAFLD outpatient clinic at HCPA have the disease to an advanced degree, which is reflected in a poorer nutritional profile due to the high prevalence of overweight, high BMI and WC; however, it is believed that a treatment approach to lifestyle intervention along with nutritional monitoring is essential to delay or prevent its progression

Avaliação do padrão alimentar, do consumo de frutose e do estado nutricional de pacientes com doença hepática gordurosa não alcoólica (DHGNA)

Introdução: A Doença Hepática Gordurosa não Alcoólica (DHGNA) é atribuída a múltiplos fatores, configurando-se como a manifestação hepática da Síndrome Metabólica (SM). A epidemia da DHGNA tem sido associada às alterações do estilo de vida, com adoção de padrões alimentares ocidentais, baseados em produtos processados e ricos em açúcares adicionados, fontes de frutose. A frutose pode ser obtida a partir de fontes alimentares naturais, quando intrínseca aos alimentos, ou livre, obtida por processamentos industriais. Objetivos: Avaliar o consumo alimentar de frutose total, in natura e livre de pacientes com DHGNA e associá-lo ao grau de fibrose, ao perfil metabólico e ao risco cardiovascular. Metodologia: Estudo transversal com pacientes ambulatoriais diagnosticados previamente com DHGNA, atendidos no Hospital de Clínicas de Porto Alegre (HCPA). Os pacientes foram classificados segundo seu risco de progressão para a DHGNA e passaram por avaliação clínica, dietética, antropométrica e funcional. Os alimentos e bebidas informados nos Registros Alimentares (RA’s) de três dias foram classificados conforme o nível de processamento (in natura, ingredientes culinários, minimamente processados, processados e ultraprocessados) de acordo com o Sistema NOVA. Resultados: Foram avaliados 128 pacientes, dos quais 63 tinham esteatose, 44 esteatohepatite (EHNA) e 21 cirrose. A idade média foi 54,0 ± 11,9 anos, 72,7% eram mulheres e IMC de 32,6 ± 5,4 Kg/m². A ingestão total de frutose (FT) foi de 21,6g, sendo 14,8g de frutose in natura (FN) e 6,8g de frutose livre (FL). O consumo de frutose total, in natura e livre não diferiu entre os pacientes com esteatose, EHNA e cirrose (p-valores 0,140; 0,101; 0,739, respectivamente). A ingestão de frutose de fontes distintas não justifica a fibrose hepática conforme NAFLD score, devido ao baixo poder de correlação encontrado (r² = 0,009) para FT; (r² = 0,040) para FN e (r² = 0,051) para FL. Os pacientes apresentavam elevado risco cardiometabólico, devido à prevalência de 78,0% de risco intermediário a alto de fibrose hepática; 96,8% com alterada relação cintura-estatura (RCE), 79,7% com SM, 65,6% com FAM reduzida, 70,3% com obesidade sarcopênica. Conclusões: O padrão alimentar dos pacientes ambulatoriais com DHGNA no HCPA parece apresentar composição dietética distinta à maioria dos estudos, baseado majoritariamente em alimentos minimamente processados, com baixo consumo de frutose. Nenhuma associação foi encontrada entre a ingestão de frutose e o risco de fibrose hepática.Introduction: Non-Alcoholic Fatty Liver Disease (NAFLD) is attributed to multiple factors, which is considered the liver manifestation of Metabolic Syndrome (MetS). NAFLD has been linked to lifestyle changes, with adoption of Western dietary patterns based on processed products, rich in added sugars, sources of fructose. The fructose origin can be from different sources, natural/ intrinsic to food, or added, obtained by industrial processing. Objectives: Evaluate whether the dietary intake of fructose from different food sources (added and natural) is or not associated with distinct cardiovascular risk, hepatic, and metabolic profiles, in patients with NAFLD. Methodology: Cross-sectional study with NAFLD outpatients who attended the Hospital de Clínicas de Porto Alegre (HCPA). Patients were classified according to their risk for progression of NAFLD and underwent clinical, dietary, anthropometric and functional evaluation. The foods and beverages reported in the 3-day-diet-record were classified by their processing level (unprocessed, processed culinary ingredients, minimally processed, processed and ultra-processed) according to the NOVA classification. Results: 128 patients were evaluated, of which 63 had steatosis, 44 steatohepatitis (NASH) and 21 cirrhosis. The mean age was 54.0 ± 11.9 years, 72.7% were women, and BMI 32.6 ± 5.4 kg/m². Total fructose (TF) intake was 21.6g, natural fructose (NF) 14.8g and added fructose (AF) 6.8g. Total, natural and added fructose intakes not differ in patients with steatosis, steatohepatitis and cirrhosis (p-values 0.140; 0.101; 0.739, respectively). Fructose intake from different sources does not justify hepatic fibrosis according NAFLD score, in view of the low correlation power found (r² = 0.009) for TF; (r² = 0.040) for NF and (r² = 0.051) for AF. Patients presented elevated cardiometabolic risk due to the prevalence of 78.0% intermediate/ high risk of hepatic fibrosis; 96.8% over waist-height ratio (WHtR), 79.7% of metabolic syndrome (MetS), 65.6% low hand grip strength and 70.3% had sarcopenic obesity. Conclusions: Dietary pattern of NAFLD outpatients from HCPA showed a distinct dietary composition, based mostly on minimally processed foods with low fructose intake. No association was found between fructose intake and risk of hepatic fibrosis

Impact of Sarcopenia on the Severity of the Liver Damage in Patients With Non-alcoholic Fatty Liver Disease

International audienceAn extensive body of the literature shows a strong interrelationship between the pathogenic pathways of non-alcoholic fatty liver disease (NAFLD) and sarcopenia through the muscle-liver-adipose tissue axis. NAFLD is one of the leading causes of chronic liver diseases (CLD) affecting more than one-quarter of the general population worldwide. The disease severity spectrum ranges from simple steatosis to non-alcoholic steatohepatitis (NASH), cirrhosis, and its complications: end-stage chronic liver disease and hepatocellular carcinoma. Sarcopenia, defined as a progressive loss of the skeletal muscle mass, reduces physical performances, is associated with metabolic dysfunction and, possibly, has a causative role in NAFLD pathogenesis. Muscle mass is a key determinant of the whole-body insulin-mediated glucose metabolism and impacts fatty liver oxidation and energy homeostasis. These mechanisms drive the accumulation of ectopic fat both in the liver (steatosis, fatty liver) and in the muscle (myosteatosis). Myosteatosis rather than the muscle mass per se , seems to be closely associated with the severity of the liver injury. Sarcopenic obesity is a recently described entity which associates both sarcopenia and obesity and may trigger worse clinical outcomes including hepatic fibrosis progression and musculoskeletal disabilities. Furthermore, the muscle-liver-adipose tissue axis has a pivotal role in changes of the body composition, resulting in a distinct clinical phenotype that enables the identification of the “sarcopenic NAFLD phenotype.” This review aims to bring some light into the complex relationship between sarcopenia and NAFLD and critically discuss the key mechanisms linking NAFLD to sarcopenia, as well as some of the clinical consequences associated with the coexistence of these two entities: the impact of body composition phenotypes on muscle morphology, the concept of sarcopenic obesity, the relationship between sarcopenia and the severity of the liver damage and finally, the future directions and the existing gaps in the knowledge

Effect of probiotic supplementation in nonalcoholic steatohepatitis patients : PROBILIVER TRIAL protocol

Background: Recently factors in the relationship between gut microbiota, obesity, diabetes and the metabolic syndrome have been suggested in the development and progression of nonalcoholic steatohepatitis (NASH). In this sense, this work aims to evaluate the effects of probiotic supplementation on intestinal microbiota modulation, degree of hepatic steatosis and fibrosis, inflammation, gut permeability, and body composition. Methods: This double-blind, randomized clinical trial will include adult outpatients with a diagnosis of NASH confirmed by biopsy with or without transient elastography. All patients will undergo a complete anamnesis to investigate their alcohol consumption, previous history, medications, nutritional assessment (dietary intake and body composition), sarcopenia, physical activity level and physical and functional capacity, cardiovascular risk, biochemical parameters for assessment of inflammatory status, lipid profile, hepatic function, gut permeability, and assessment of microbiota. These procedures will be performed at baseline and repeated after 24 weeks (at the end of the study). Through the process of randomization, patients will be allocated to receive treatment A or treatment B. Both patients and researchers involved will be blinded (double-blind study). The intervention consists of treatment with a probiotic mix (Lactobacillus acidophillus + Bifidobacterium lactis + Lactobacillus rhamnosus + Lactobacillus paracasei, 1 x 109 CFU for each) and the placebo which is identical in all its characteristics and packaging. Patients will be instructed to consume two sachets/day during 24 weeks and to report any symptoms or side effects related to the use of the sachets. Adherence control will be carried out through the patient’s notes on a form provided, and also by checking the number of sachets used. Discussion: The final results of study will be analyzed and disseminated in 2020