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Pedersen RB, Fraulund MM, Chabanova E, Holm LA, Hansen T, Thomsen HS, Holm JC, Fonvig CE. Nonpharmacological Childhood Obesity Management in Denmark Reduces Steatotic Liver Disease and Obesity. Child Obes 2025; 21:392-401. [PMID: 39841082 DOI: 10.1089/chi.2024.0287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2025]
Abstract
Background: Steatotic liver disease (SLD) represents a multisystem disease and is a common complication of childhood obesity. We studied fat content at the abdominal level (liver, subcutaneous, and visceral) and the response to childhood obesity management. Methods: In this retrospective longitudinal study, 8-18-year-olds with a body mass index (BMI) z-score above 1.28 (corresponding to a BMI above the 90th percentile), as a proxy for obesity, were offered person-centered, family-oriented obesity management in a hospital setting and in a magnetic resonance (MR) scan. Liver fat content (LFC) was assessed by MR spectroscopy, whereas subcutaneous adipose tissue and visceral adipose tissue (VAT) were assessed by MR imaging. We conducted nonparametric tests to evaluate baseline-to-follow-up changes and comparisons between participants with and without an MR assessment. Additionally, a logistic regression model examined the association between changes in LFC and BMI z-score. Results: The study group comprised 1002 children and adolescents (52% females) with an MR assessment at baseline. The median age was 13.0 years, the median BMI was 28.4, and the BMI z-score was 2.90. At baseline, 378 (38%) exhibited SLD defined by an LFC above 1.5%. Among the 322 with a follow-up MR scan, 76% of the patients with SLD reduced their LFC. BMI z-score and VAT (both p < 0.001) were reduced during intervention. Conclusions: SLD is highly prevalent (38%) in children and adolescents with obesity. A chronic care obesity management model reduced the fat content in the liver, the visceral fat, and the degree of obesity.
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Affiliation(s)
- Rebecca Berg Pedersen
- Department of Pediactrics, The Children's Obesity Clinic, Accredited European Centre for Obesity Management, Copenhagen University Hospital Holbæk, Holbæk, Denmark
| | - Maria Martens Fraulund
- Department of Pediactrics, The Children's Obesity Clinic, Accredited European Centre for Obesity Management, Copenhagen University Hospital Holbæk, Holbæk, Denmark
| | | | - Louise Aas Holm
- Department of Pediactrics, The Children's Obesity Clinic, Accredited European Centre for Obesity Management, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- Faculty of Health and Medical Sciences, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Torben Hansen
- Faculty of Health and Medical Sciences, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Henrik S Thomsen
- Department of Radiology, Herlev and Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens-Christian Holm
- Department of Pediactrics, The Children's Obesity Clinic, Accredited European Centre for Obesity Management, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- Faculty of Health and Medical Sciences, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cilius Esmann Fonvig
- Department of Pediactrics, The Children's Obesity Clinic, Accredited European Centre for Obesity Management, Copenhagen University Hospital Holbæk, Holbæk, Denmark
- Faculty of Health and Medical Sciences, Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Omaña-Guzmán I, Rosas-Diaz M, Martínez-López YE, Perez-Navarro LM, Diaz-Badillo A, Alanis A, Bustamante A, Castillo-Ruiz O, Del Toro-Cisneros N, Esquivel-Hernandez DA, Garcia-Villalobos G, Garibay-Nieto N, Garcia-Oropesa EM, Hernandez-Martinez JC, Lopez-Sosa EB, Maldonado C, Martinez D, Membreno J, Moctezuma-Chavez OO, Munguia-Cisneros CX, Nava-González EJ, Perales-Torres AL, Pérez-García A, Rivera-Marrero H, Valdez A, Vázquez-Chávez AA, Ramirez-Pfeiffer C, Carter KV, Tapia B, Vela L, Lopez-Alvarenga JC. Strategic interventions in clinical randomized trials for metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity in the pediatric population: a systematic review with meta-analysis and bibliometric analysis. BMC Med 2024; 22:548. [PMID: 39574069 PMCID: PMC11580631 DOI: 10.1186/s12916-024-03744-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 10/31/2024] [Indexed: 11/25/2024] Open
Abstract
BACKGROUND Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), is a prevalent hepatic condition linked to metabolic alterations. It gradually causes liver damage and potentially progresses to cirrhosis. Despite its significance, research, especially in the pediatric population, is limited, leading to contradictory findings in diagnosis and treatment. This meta-analysis aims to synthesize existing literature on therapeutic interventions for MASLD in children and adolescents. METHODS A comprehensive search of randomized controlled clinical trials yielded 634 entries from PubMed, Scopus, and Web of Science up to 2023. Interventions included medications, behavioral modifications, dietary changes, probiotics, supplements, surgical procedures, or combinations. The analysis focused on studies with treatment duration of at least 3 months, employing a random-effects REML meta-analysis model. Treatment effects on anthropometric measurements and biochemical components were examined and adjusted for heterogeneity factors analysis. A bibliometric analysis for insights into research contributors was performed. RESULTS The systematic review incorporated 31 clinical trials, with 24 meeting criteria for meta-analysis. These comprised 3 medication studies, 20 with supplements, 4 focusing on lifestyle, and 4 centered on diets. Significant overall treatment effects were observed for ALT, AST, BMI, and HOMA-IR mainly by supplements and lifestyle. Meta-regression identified age, BMI changes, and treatment duration as factors modifying ALT concentrations. Bibliometric analysis involving 31 linked studies highlighted contributions from 13 countries, with the USA, Spain, and Chile being the most influential. CONCLUSIONS We conclude that supplementation and lifestyle changes can effectively impact ALT and AST levels, which can help address liver issues in obese children. However, the evaluation of risk bias, the high heterogeneity, and the bibliometric analysis emphasize the need for more high-quality studies and broader inclusion of diverse child populations to provide better therapeutic recommendations. TRIAL REGISTRATION PROSPERO, CRD42023393952. Registered on January 25, 2023.
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Affiliation(s)
- Isabel Omaña-Guzmán
- Pediatric Obesity Clinic and Wellness Unit, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - Marisol Rosas-Diaz
- Laboratorio de Biologia Molecular, Universidad Autónoma de Tamaulipas, Tamaulipas, Mexico
| | | | | | - Alvaro Diaz-Badillo
- Department of Health and Behavioral Sciences, Texas A&M University, San Antonio, TX, USA
| | - Anthony Alanis
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, TX, USA
| | | | | | - Noemi Del Toro-Cisneros
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de La Nutricion Salvador Zubiran, Mexico City, Mexico
| | | | | | - Nayely Garibay-Nieto
- Pediatric Obesity Clinic and Wellness Unit, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | | | | | - Elena Beatriz Lopez-Sosa
- Angiologia y Cirugía Vascular, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado de México (ISSTE), Hospital 20 de Noviembre, Mexico City, Mexico
| | - Carlos Maldonado
- Instituto Nacional de Enfermedaes Respiratorias, Mexico City, Mexico
| | - David Martinez
- Department of Biology, The University of Texas Rio Grande Valley, Edinburg, TX, USA
| | - Joshua Membreno
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, TX, USA
| | | | - Claudia X Munguia-Cisneros
- Centro Especializado de Metabolismo y Diabetes (CEDIAMET), Universidad México Americana del Norte, Tamaulipas, Mexico
| | - Edna J Nava-González
- Facultad de Salud Pública y Nutrición, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | | | - Adolfo Pérez-García
- Research Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | | | - Alisha Valdez
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, TX, USA
| | | | | | - Kathleen V Carter
- School of Medicine, The University of Texas Rio Grande Valley, Edinburg, TX, USA
| | - Beatriz Tapia
- Faculty Affairs, Asst Dean Faculty Development, The University of Texas Rio Grande Valley, Edinburg, TX, USA
- Division of Population Health & Biostatistics, School of Medicine, University of Texas Rio Grande Valley, 2102 Treasure Hills Boulevard, Edinburg, TX, 78550, USA
| | - Leonel Vela
- Division of Population Health & Biostatistics, School of Medicine, University of Texas Rio Grande Valley, 2102 Treasure Hills Boulevard, Edinburg, TX, 78550, USA
| | - Juan Carlos Lopez-Alvarenga
- Escuela de Medicina, Universidad México Americana del Norte, Reynosa, Tamaulipas, Mexico.
- Division of Population Health & Biostatistics, School of Medicine, University of Texas Rio Grande Valley, 2102 Treasure Hills Boulevard, Edinburg, TX, 78550, USA.
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Sood V, Alam S, Nagral A, Srivastava A, Deshmukh A, Bavdekar A, Acharyya BC, Geetha SM, Gupte G, Bhatia I, Tiwari K, Bharadia L, Sathiyasekaran M, Kaur P, Khanna R, Shrivastava R, Poyekar S, Pandey S, Ramakrishna SH, Kinjawadekar U, Borkar V, Sivaramakrishnan VM, Kohli R, Matthai J, Dhawan A. Practice Recommendations for Metabolic Dysfunction-Associated Steatotic Liver Disease by the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN). Indian Pediatr 2024; 61:919-934. [PMID: 39297398 DOI: 10.1007/s13312-024-3290-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Accepted: 09/03/2024] [Indexed: 01/06/2025]
Abstract
JUSTIFICATION There has been an alarming increase in metabolic dysfunction-associated steatotic liver disease (MASLD) and it is now the most common chronic liver disease worldwide, in both adult and pediatric populations. The lack of regional guidelines has hampered the formulation of national policies for prevention and management of MASLD in children. Therefore, we formulated recommendations for steatotic liver disease in children. OBJECTIVES To review the existing literature on the burden and epidemiology of pediatric MASLD and formulate recommendations for diagnostic evaluation, prevention, and management strategies. PROCESS The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international stakeholders to participate in a consensus meeting held on April 20, 2024, in Mumbai, Maharashtra, India. Various aspects of pediatric steatotic liver disease were deliberated upon and a consensus document and recommendations were formulated after several rounds of discussion. RECOMMENDATIONS Metabolic dysfunction-associated steatotic liver disease (MASLD) should be used as the preferred term in place of non-alcoholic fatty liver disease (NAFLD). There is a high prevalence of steatotic liver disease (SLD) among Indian children and adolescents, especially those who are overweight or obese. This condition may be progressive in childhood and associated with increased morbidity and mortality in adulthood. Various lifestyle, dietary, and genetic factors may predispose individuals to MASLD, including an increased intake of calorie-dense processed foods, sweetened sugar beverages, excessive screen time, higher sedentary time and lack of moderate to vigorous physical activity. MASLD is usually asymptomatic or presents with mild, non-specific symptoms and therefore, a high degree of suspicion is required for early diagnosis. MASLD is usually associated with cardiometabolic factors (hypertension, insulin resistance/diabetes mellitus, and/or dyslipidemia) and secondary causes should be excluded in all cases, particularly in the presence of red flag signs. Screening for MASLD should be considered in all obese children (body mass index or BMI ≥95th percentile) and in all overweight children (BMI ≥ 85th and <95thpercentile) with additional risk factors, such as prediabetes/diabetes, dyslipidemia, positive family history of metabolic syndrome, obstructive sleep apnea, and hypopituitarism. Abdominal ultrasound in combination with alanine aminotransferase (ALT) levels should be used as a screening test for MASLD in Indian children as per the proposed algorithm. Diet (any hypocaloric diet) and exercise (aerobic, resistance, or a combination of both; moderate to high intensity; regular in frequency) remain the cornerstones of pediatric MASLD management. Pharmacotherapy and/or endoscopic/surgical techniques for obesity should be considered as adjuncts and should be considered only after a failed adequate trial of lifestyle modifications.
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Affiliation(s)
- Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India. Correspondence to: Dr Seema Alam, Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Center and Apollo Hospital, Mumbai, Maharashtra, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Aniket Deshmukh
- Department of Pediatric Hepatology and Liver Transplant, Gleneagles Hospital, Mumbai, Maharashtra, India
| | - Ashish Bavdekar
- Department of Pediatrics, KEM Hospital and Research Centre, Pune, Maharashtra, India
| | - Bhaswati C Acharyya
- Department of Pediatric Hepatology and Gastroenterology, Institute of Child Health, Kolkata, West Bengal, India
| | - S M Geetha
- Department of Pediatric Gastroenterology, Aster Medcity, Kochi, Kerala, India
| | - Girish Gupte
- Liver Unit (Including Small Bowel Transplantation), Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Ishitaa Bhatia
- Department of Nutrition, The Nutrition Project and Wellfed Children's Nutrition Clinic, Mumbai, Maharashtra, India
| | - Kritika Tiwari
- Department of Pediatrics and Adolescent Medicine, Matushree Gomati Hospital, Mumbai, Maharashtra, India
| | - Lalit Bharadia
- Department of Pediatric Gastroenterology, Neoclinic Children Hospital, Jaipur, Rajasthan, India
| | - Malathi Sathiyasekaran
- Department of Pediatric Gastroenterology, Rainbow Children's Hospital, Chennai, Tamil Nadu, India
| | - Prabhsaran Kaur
- Department of Pediatrics, Seth G.S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rimjhim Shrivastava
- Pediatric Gastroenterology and Hepatology Clinic, Raipur, Chhattisgarh, India
| | - Samriddhi Poyekar
- Department of Gastroenterology, Jagjivan Ram Hospital, Mumbai, Maharashtra, India
| | - Snehavardhan Pandey
- Department of Pediatric Hepatology and Liver Transplantation, Sahyadri Superspeciality Hospital Pvt Ltd, Pune, Maharashtra, India
| | | | - Upendra Kinjawadekar
- Department of Pediatrics, Kamlesh Mother and Child Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Vibhor Borkar
- Department of Pediatric Hepatology and Gastroenterology, Nanavati Max Super Specialty Hospital, Mumbai, Maharashtra, India
| | | | - Rohit Kohli
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Matthai
- Department of Pediatrics, Masonic Medical Centre for Children, Coimbatore, Tamil Nadu, India
| | - Anil Dhawan
- Pediatric Liver, GI and Nutrition Centre, and Mowat Labs, King's College Hospital, London, UK
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Serbis A, Polyzos SA, Paschou SA, Siomou E, Kiortsis DN. Diet, exercise, and supplements: what is their role in the management of the metabolic dysfunction-associated steatotic liver disease in children? Endocrine 2024; 85:988-1006. [PMID: 38519764 DOI: 10.1007/s12020-024-03783-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/13/2024] [Indexed: 03/25/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as nonalcoholic fatty liver disease (NAFLD), is the main cause of chronic liver disease in children and adolescents. Indeed, epidemiological studies have shown that MASLD affects up to 40% of children with obesity. Despite the recent approval of medications that target weight loss in adolescents that could have benefits on pediatric MASLD, lifestyle interventions, such as diet and exercise, remain the mainstay of our therapeutic approach. More specifically, studies on diet alone have focused on the possible role of carbohydrate or fat restriction, albeit without a definite answer on the best approach. Weight loss after dietary intervention in children with obesity and MASLD has a beneficial effect, regardless of the diet used. In relation to the role of exercise in MASLD reversal, indirect evidence comes from studies showing that a sedentary lifestyle leading to poor fitness, and low muscle mass is associated with MASLD. However, research on the direct effect of exercise on MASLD in children is scarce. A combination of diet and exercise seems to be beneficial with several studies showing improvement in surrogate markers of MASLD, such as serum alanine aminotransferase and hepatic fat fraction, the latter evaluated with imaging studies. Several dietary supplements, such as vitamin E, probiotics, and omega-3 fatty acid supplements have also been studied in children and adolescents with MASLD, but with equivocal results. This review aims to critically present available data on the effects of lifestyle interventions, including diet, exercise, and dietary supplements, on pediatric MASLD, thus suggesting a frame for future research that could enhance our knowledge on pediatric MASLD management and optimize clinicians' approach to this vexing medical condition.
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Affiliation(s)
- Anastasios Serbis
- Department of Pediatrics, School of Medicine, University of Ioannina, Ioannina, Greece.
| | - Stergios A Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ekaterini Siomou
- Department of Pediatrics, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Dimitrios N Kiortsis
- Laboratory of Physiology, Medical School, University of Ioannina, Ioannina, Greece
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Southcombe F, Lin F, Krstic S, Sim KA, Dennis S, Lingam R, Denney-Wilson E. Targeted dietary approaches for the management of obesity and severe obesity in children and adolescents: A systematic review and meta-analysis. Clin Obes 2023; 13:e12564. [PMID: 36394356 DOI: 10.1111/cob.12564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 10/04/2022] [Accepted: 10/14/2022] [Indexed: 11/19/2022]
Abstract
There is a need for a detailed understanding of effective dietary interventions for children with obesity. This systematic review examined the effectiveness of diets of varying energy content as a component of weight treatment in children and adolescents with obesity, severe obesity and obesity-related comorbidity. A systematic search of six databases, from 2000 to 2021, for intervention studies of targeted dietary treatment for obesity in children aged 2-18 years identified 125 studies. Dietary interventions were grouped according to diet type and energy target. Risk of bias was assessed using the Effective Public Healthcare Panacea Project assessment tool. Meta-analysis examined change in body mass index (BMI) at intervention end. A broad array of diet types were effective at reducing BMI in children with obesity. When dietary types were considered by energy target, a gradient effect was observed. Very-low energy diets were most effective with a - 4.40 kg/m2 (n = 3; 95% CI -7.01 to -1.79). While dietary interventions with no specified energy target were ineffective, resulting in a BMI gain of +0.17 kg/m2 (n = 22; 95% CI 0.05 to 0.40). Practical definitions of dietary energy target in the management of obesity and severe obesity are urgently required to ensure treatment seeking children have timely access to efficacious interventions.
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Affiliation(s)
- Faye Southcombe
- Primary and Community Health, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Fang Lin
- Primary and Community Health, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Slavica Krstic
- Primary and Community Health, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Kyra A Sim
- Sydney Local Health District, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah Dennis
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Ingham Institute of Applied Medical Research, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Raghu Lingam
- Population Child Health Research Group, School of Women's and Children's Health, University of NSW, Sydney, New South Wales, Australia
| | - Elizabeth Denney-Wilson
- Sydney Local Health District, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Sandhu SA, Angel CA, Campbell KL, Hickman IJ, MacLaughlin HL. Standardised Outcome Reporting for the Nutrition Management of Complex Chronic Disease: A Rapid Review. Nutrients 2021; 13:3388. [PMID: 34684389 PMCID: PMC8538850 DOI: 10.3390/nu13103388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/18/2021] [Accepted: 09/21/2021] [Indexed: 11/05/2022] Open
Abstract
Individuals with coexisting chronic diseases or with complex chronic disease are among the most challenging and costly patients to treat, placing a growing demand on healthcare systems. Recommending effective treatments, including nutrition interventions, relies on standardised outcome reporting from randomised controlled trials (RCTs) to enable data synthesis. This rapid review sought to determine how the scope and consistency of the outcomes reported by RCTs investigating nutrition interventions for the management of complex chronic disease compared to what is recommended by the core outcome sets (COS) for individual disease states. Peer-reviewed RCTs published between January 2010 and July 2020 were systematically sourced from PubMed, CINAHL and Embase, and COS were sourced from the International Consortium for Health Outcomes Measurements (ICHOM) and the Core Outcome Measures in Effectiveness Trials (COMET) database. A total of 45 RCTs (43 studies) and 7 COS were identified. Outcomes were extracted from both the RCTs and COS and were organised using COMET Taxonomy Core Areas. A total of 66 outcomes and 439 outcome measures were reported by the RCTs. The RCTs demonstrated extensive outcome heterogeneity, with only five outcomes (5/66, 8%) being reported with relative consistency (cited by ≥50% of publications). Furthermore, the scope of the outcomes reported by studies was limited, with a notable paucity of patient-reported outcomes. Poor agreement (25%) was observed between the outcomes reported in the RCTs and those recommended by the COS. This review urges greater uptake of the existing COS and the development of a COS for complex chronic disease to be considered so that evidence can be better synthesised regarding effective nutrition interventions.
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Affiliation(s)
- Savita A Sandhu
- School of Exercise and Nutrition Sciences, Queensland University of Technology (QUT), Brisbane 4059, Australia;
| | - Chloe A Angel
- School of Exercise and Nutrition Sciences, Queensland University of Technology (QUT), Brisbane 4059, Australia;
| | - Katrina L Campbell
- Healthcare Excellence and Innovation, Metro North Hospital and Health Service, Brisbane 4029, Australia;
| | - Ingrid J Hickman
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane 4102, Australia;
- Faculty of Medicine, University of Queensland, Brisbane 4006, Australia
| | - Helen L MacLaughlin
- School of Exercise and Nutrition Sciences, Queensland University of Technology (QUT), Brisbane 4059, Australia;
- Royal Brisbane and Women’s Hospital, Brisbane 4029, Australia
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7
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Buzzetti E, Linden A, Best LM, Madden AM, Roberts D, Chase TJG, Freeman SC, Cooper NJ, Sutton AJ, Fritche D, Milne EJ, Wright K, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Lifestyle modifications for nonalcohol-related fatty liver disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD013156. [PMID: 34114650 PMCID: PMC8193812 DOI: 10.1002/14651858.cd013156.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence of nonalcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases the risks of liver cirrhosis, hepatocellular carcinoma, and requirement for liver transplantation. There is uncertainty surrounding the relative benefits and harms of various lifestyle interventions for people with NAFLD. OBJECTIVES To assess the comparative benefits and harms of different lifestyle interventions in the treatment of NAFLD through a network meta-analysis, and to generate rankings of the different lifestyle interventions according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in people with NAFLD, whatever the method of diagnosis, age, and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We planned to perform a network meta-analysis with OpenBUGS using Bayesian methods and to calculate the differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios (RaRs) with 95% credible intervals (CrIs) based on an available-participant analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. However, the data were too sparse for the clinical outcomes. We therefore performed only direct comparisons (head-to-head comparisons) with OpenBUGS using Bayesian methods. MAIN RESULTS We included a total of 59 randomised clinical trials (3631 participants) in the review. All but two trials were at high risk of bias. A total of 33 different interventions, ranging from advice to supervised exercise and special diets, or a combination of these and no additional intervention were compared in these trials. The reference treatment was no active intervention. Twenty-eight trials (1942 participants) were included in one or more comparisons. The follow-up ranged from 1 month to 24 months. The remaining trials did not report any of the outcomes of interest for this review. The follow-up period in the trials that reported clinical outcomes was 2 months to 24 months. During this short follow-up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver-related mortality were sparse. This is probably because of the very short follow-up periods. It takes a follow-up of 8 years to 28 years to detect differences in mortality between people with NAFLD and the general population. It is therefore unlikely that differences by clinical outcomes will be noted in trials with less than 5 years to 10 years of follow-up. In one trial, one participant developed an adverse event. There were no adverse events in any of the remaining participants in this trial, or in any of the remaining trials, which seemed to be directly related to the intervention. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about the effects of the lifestyle interventions compared with no additional intervention (to general public health advice) on any of the clinical outcomes after a short follow-up period of 2 months to 24 months in people with nonalcohol-related fatty liver disease. Accordingly, high-quality randomised clinical trials with adequate follow-up are needed. We propose registry-based randomised clinical trials or cohort multiple randomised clinical trials (a study design in which multiple interventions are trialed within large longitudinal cohorts of participants to gain efficiencies and align trials more closely to standard clinical practice), comparing aerobic exercise and dietary advice versus standard of care (exercise and dietary advice received as part of national health promotion). The reason for the choice of aerobic exercise and dietary advice is the impact of these interventions on indirect outcomes which may translate to clinical benefit. The outcomes in such trials should be mortality, health-related quality of life, decompensated liver cirrhosis, liver transplantation, and resource use measures including costs of intervention and decreased healthcare use after a minimum follow-up of eight years, to find meaningful differences in the clinically important outcomes.
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Affiliation(s)
- Elena Buzzetti
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Audrey Linden
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Angela M Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Thomas J G Chase
- Department of General Surgery, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | | | - Kathy Wright
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Vuille-Lessard É, Lange N, Riebensahm C, Dufour JF, Berzigotti A. Dietary Interventions in Liver Diseases: Focus on MAFLD and Cirrhosis. ACTA ACUST UNITED AC 2021. [DOI: 10.1007/s11901-021-00563-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Purpose of Review
Dietary interventions (DI) aimed at improving overweight and metabolic abnormalities in metabolic dysfunction-associated fatty liver disease (MAFLD) and at reducing malnutrition and sarcopenia in cirrhosis should become part of routine care in hepatology. This review focuses on recent advances in this field.
Recent Findings
In patients with MAFLD, a gradual reduction, respectively, of 7–10% of body weight if overweight or of 3–5% if lean, obtained by moderately reducing caloric intake, is effective to improve liver disease. Intermittent energy restriction might be an alternative to continuous energy restriction with higher adherence. Qualitative dietary adjustments should include increased intake of unprocessed foods including fruits and vegetables, whole grains, fiber, and unsaturated fatty acids (FAs), for example, through a Mediterranean diet. Refined carbohydrates (CHOs), saturated FA (SFAs), red meat, and processed meat should be limited. DI studies in HIV-infected subjects with MAFLD are very limited, and this is a field for future research. In patients with cirrhosis, DI should aim at correcting malnutrition and improving skeletal muscle mass. Daily diet contents should aim at achieving 30–35 kcal/kg of body weight, including 1.2–1.5 g/kg proteins, and oral or enteral supplementation might be used in patients unable to achieve these targets. In some studies, branched-chain amino acids (BCAAs) proved to be effective in improving muscle mass and were associated with a lower risk of hepatic encephalopathy. Obesity requires adjustment of the above-mentioned targets, and its management is challenging. Studies looking at the efficacy of DI recommended by the existing guidelines on clinical endpoints are a field for future research.
Summary
Dietary interventions are able to improve MAFLD and show potential to reduce complications in liver disease. Despite its key importance, there are many barriers limiting the implementation of DI in patients with chronic liver disease. Patients’ empowerment is crucial and should be the focus of specific educational programs. In addition, liver clinics would benefit from multidisciplinary teams involving experts in nutrition, physical exercise, primary care physicians, and psychologists when needed.
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Effects of Dietary and Lifestyle Interventions on Liver, Clinical and Metabolic Parameters in Children and Adolescents with Non-Alcoholic Fatty Liver Disease: A Systematic Review. Nutrients 2020; 12:nu12092864. [PMID: 32961669 PMCID: PMC7551480 DOI: 10.3390/nu12092864] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/31/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) affects 5.5–10.3% of children worldwide, while in obese individuals, it increases to almost 34%. Pediatric NAFLD is consistently associated with metabolic syndrome and insulin resistance. As no pharmacological agents exist for the treatment of NAFLD, lifestyle modifications remain the only therapy. However, as not all overweight/obese children have NAFLD, high-quality data, focused exclusively on NAFLD population are needed. Therefore, the present systematic review assessed the efficacy of lifestyle (diet or exercise) based on randomized controlled clinical trials (RCTs) on liver, anthropometric, glucose, and lipid parameters in children, with imaging or biopsy-proven NAFLD. In general, the results were inconclusive and therefore no specific recommendations could be drawn. In most studies, differences were derived from within group comparisons, which are known to be highly misleading. However, both low-carbohydrate and low-fat diets could benefit liver outcomes, as long as weight loss is achieved, but not necessary glucose and lipid parameters. No RCTs were found on exercise alone, as compared to no intervention on pediatric NAFLD. Concerning diet plus exercise interventions, all studies led to improvements in liver outcomes accompanied with weight loss. Resolution of NAFLD was found in considerably high percentages, while improvements were also seen in glucose but were modest in lipid parameters.
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Chiyanika C, Chan DFY, Hui SCN, So H, Deng M, Yeung DKW, Nelson EAS, Chu WCW. The relationship between pancreas steatosis and the risk of metabolic syndrome and insulin resistance in Chinese adolescents with concurrent obesity and non-alcoholic fatty liver disease. Pediatr Obes 2020; 15:e12653. [PMID: 32351030 PMCID: PMC7507143 DOI: 10.1111/ijpo.12653] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 03/17/2020] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The incidence of childhood obesity and associated comorbidities are on an increasing trend worldwide. More than 340 million children and adolescents aged between 5 and 19 years old were overweight or had obesity in 2016, from which over 124 million children and adolescents (6% of girls and 8% of boys) had obesity. OBJECTIVE To describe the relationship between pancreas steatosis, body fat and the risk of metabolic syndrome, insulin resistance in Hong Kong Chinese adolescents with both obesity and non-alcoholic fatty liver disease (NAFLD). METHODS Fifty two adolescents with obesity and NAFLD were analysed (14-18 years), stratified into fatty and non-fatty pancreas groups using chemical shift encoded MRI-pancreas proton density fat fraction ≥5%. Pancreatic, abdominal subcutaneous adipose tissue (SAT)/visceral adipose tissue (VAT) volumes, biochemical and anthropometric parameters were measured. Mann-Whitney U test, multiple linear/binary logistic regression analyses and odds ratios were used. RESULTS Fifty percent had fatty pancreas, 38% had metabolic syndrome and 81% had insulin resistance. Liver proton density fat fraction (PDFF) and VAT were independent predictors of insulin resistance (P = .006, .016). Pancreas and liver PDFF were both independent predictors of beta cells dysfunction (P = .015, .050) and metabolic syndrome (P = .021, .041). Presence of fatty pancreas in obesity was associated with insulin resistance (OR = 1.58, 95% CI = 0.39-6.4) and metabolic syndrome (OR = 1.70, 95% CI = 0.53-5.5). CONCLUSION A significant causal relationship exists between fatty pancreas, fatty liver, body fat and the risk of developing metabolic syndrome and insulin resistance. KEY POINTS Fatty pancreas is a common finding in adolescents with obesity, with a prevalence rate of 50% in this study cohort. Liver PDFF and VAT are independent predictors of insulin resistance while pancreas PDFF and liver PDFF are independent predictors of both beta cells dysfunction and metabolic syndrome. Presence of fatty pancreas at imaging should not be considered as a benign finding but rather as an imaging biomarker of emerging pancreatic metabolic and endocrine dysfunction.
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Affiliation(s)
- Chileka Chiyanika
- Department of Imaging and Interventional RadiologyThe Chinese University of Hong KongHong KongChina
| | - Dorothy F. Y. Chan
- Department of PaediatricsThe Chinese University of Hong KongHong KongChina
| | - Steve C. N. Hui
- Department of Imaging and Interventional RadiologyThe Chinese University of Hong KongHong KongChina,Russell H. Morgan Department of Radiology and Radiological ScienceThe Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Hung‐kwan So
- Department of Paediatrics and Adolescent MedicineThe University of Hong KongHong KongChina
| | - Min Deng
- Department of Imaging and Interventional RadiologyThe Chinese University of Hong KongHong KongChina
| | - David K. W. Yeung
- Department of Imaging and Interventional RadiologyThe Chinese University of Hong KongHong KongChina,Department of Clinical OncologyThe Chinese University of Hong KongHong KongChina
| | | | - Winnie C. W. Chu
- Department of Imaging and Interventional RadiologyThe Chinese University of Hong KongHong KongChina
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Leung AWY, Chan RSM, Sea MMM, Woo J. Identifying psychological predictors of adherence to a community-based lifestyle modification program for weight loss among Chinese overweight and obese adults. Nutr Res Pract 2019; 13:415-424. [PMID: 31583061 PMCID: PMC6760981 DOI: 10.4162/nrp.2019.13.5.415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/11/2019] [Accepted: 07/18/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND/OBJECTIVES Existing evidence on lifestyle modification programs for weight loss is limited by the high attrition rate of such programs. Identifying predictors of adherence to a lifestyle modification program could result in program improvement. However, little is known about behavior-specific adherence and its psychological predictors. This study aimed to examine the psychological predictors of adherence after one-month participation in a community-based lifestyle modification program among Chinese overweight and obese adults in Hong Kong. SUBJECTS/METHODS A total of 205 Chinese overweight and obese adults aged 38.9 ± 10.5 years completed the study. Data were collected at baseline and after one month using self-reported questionnaires, which assessed knowledge (self-developed scale), motivation (Treatment Self-Regulation Questionnaire), stage of change (Stage of Exercise Scale) and self-efficacy (Self-Rated Abilities for Health Practices Scale). At one month, a 4-day dietary recall and the International Physical Activity Questionnaire-Short Form were used to assess dietary and physical activity (PA) adherence. Food and PA diaries were examined to indicate self-monitoring. Program attendance was tracked between baseline and one-month follow-up. RESULTS After one month, participants reported high dietary adherence, attendance, and adherence to self-monitoring but low PA adherence. Multiple regression analyses suggested that diet self-efficacy (baseline) and nutrition knowledge (one-month change) were independent predictors of dietary adherence score at one month, whereas autonomous PA motivation (baseline) and PA self-efficacy (both baseline and one-month change) were independent predictors of PA adherence score at one month. No significant psychological predictor was identified for attendance or self-monitoring. CONCLUSIONS The results suggest that the effect of psychological factors on adherence differs between diet and PA adherence outcomes. To promote adherence, practitioners should assess self-efficacy, knowledge, and motivation at the beginning of a weight-loss program and explore behavior-specific strategies to improve knowledge and self-efficacy. The results of this study have direct implications for program improvements.
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Affiliation(s)
- Alice Wai Yi Leung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Ruth Suk Mei Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Centre for Nutritional Studies, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Mandy Man Mei Sea
- Centre for Nutritional Studies, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Jean Woo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Centre for Nutritional Studies, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Sheng-Jiang Powder Ameliorates High Fat Diet Induced Nonalcoholic Fatty Liver Disease via Inhibiting Activation of Akt/mTOR/S6 Pathway in Rats. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2018:6190254. [PMID: 30402130 PMCID: PMC6193319 DOI: 10.1155/2018/6190254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/27/2018] [Accepted: 09/24/2018] [Indexed: 02/05/2023]
Abstract
Background and Aims Nonalcoholic fatty liver disease (NAFLD) is an alarming public health problem that directly contributes to increased prevalence of liver cirrhosis and hepatic cell cancer, but without any specific pharmacological option. Sheng-jiang powder (SJP), an empirical Chinese medicine formula to treat NAFLD, showed great efficacy but the specific mechanisms have never been reported. Therefore, we performed this study to explore the effect of SJP on NAFLD and the potential mechanism. Methods NAFLD was induced by high fat diet (HFD) feeding. Rats were treated with SJP/normal saline daily for 10 weeks and all rats were euthanized after 12 weeks' feeding. Liver tissue samples were obtained for biochemistry test and pathological evaluation. Additionally, oleic acid induced LO2 cells were employed to simulate a cell model of NAFLD. Cells were subjected to western blotting for Akt, mTOR, S6, SREBP1-c, and FASN detection after coincubated with SJP, LY294002 (a selective PI3K inhibitor), or the combination for 24h. Results HFD significantly induced hepatic steatosis. Plenty of lipid droplets were observed under transmission electron microscope. The ultrastructure of liver cells showed distinct changes with obvious endoplasmic reticulum expansion, mitochondrial contraction, and cell matrix solidification. Although no difference was detected in serum hepatic enzymes and tissue proinflammatory cytokines, the tissue level of SOD and GSH-px was much lower and the pathologic injuries were much severe in HFD feeding rats. However, SJP treatment significantly attenuated the ultrastructure changes and protected rat liver against inflammatory injury. Abundant of lipid droplets and high expression of pAkt, pmTOR, pS6, and FASN were observed in oleic acid treated LO2 cells, while these changes were restored by SJP treatment. Conclusions SJP is efficient in attenuating HFD induced NAFLD in rats and this effect might be partly related to the inhibition of Akt/mTOR/S6 pathway.
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