Increasing dietary fiber intake for type 2 diabetes mellitus management: A systematic review

BACKGROUND Type 2 diabetes is a chronic,non-communicable disease with a substantial global impact,affecting a significant number of individuals.Its etiology is closely tied to imbalanced dietary practices and sedentary lifestyles.Conversely,increasing die-tary fiber(DF)intake has consistently demonstrated health benefits in numerous studies,including improvements in glycemic control and weight management.AIM To investigate the efficacy of DF interventions in the management of type 2 diabetes mellitus(T2DM).METHODS A systematic literature review was conducted to explore the association between DF intake and the management of T2DM.Following the inclusion and exclusion criteria,a total of 26 studies were included in this review.RESULTS The main strategies implied to increased DF intake were:High DF diet plus acarbose(2 studies);DF supplements(14 studies);and high DF diets(10 studies).Overall,most studies indicated that increased DF intake resulted in im-provements in glycemic control and weight management in T2DM patients.CONCLUSION DF represents a valuable strategy in the treatment of type 2 diabetes,improving health outcomes.DF intake offers the potential to improve quality of life and reduce complications and mortality associated with diabetes.Likewise,through supplements or enriched foods,DF contributes significantly to the control of several markers such as HbA1c,blood glucose,triglycerides,low-density lipoprotein,and body weight.

Protective effect of long-chain polyunsaturated fatty acids on hepatorenal syndrome in rats

BACKGROUND Hepatorenal syndrome(HRS)is the most prevalent form of acute kidney injury in cirrhotic patients.It is characterized by reduced renal blood flow and represents the most severe complication in cirrhotic patients with advanced disease.Previous research has indicated that antioxidants can delay the onset of a hyperdynamic circulatory state in cirrhosis and improve renal function in HRS patients.Regular omega-3 supplementation has significantly reduced the risk of liver disease.This supplementation could represent an additional therapy for individuals with HRS.AIM To evaluated the antioxidant effect of omega-3 polyunsaturated fatty acid supplementation on the kidneys of cirrhotic rats.METHODS Secondary biliary cirrhosis was induced in rats by biliary duct ligation(BDL)for 28 d.We used 24 male Wistar rats divided into the following groups:I(control);II(treated with omega-3,1 g/kg of body weight);III(BDL treated with omega-3,1 g/kg of body weight);and IV(BDL without treatment).The animals were killed by overdose of anesthetic;the kidneys were dissected,removed,frozen in liquid nitrogen,and stored in a freezer at-80℃for later analysis.We evaluated oxidative stress,nitric oxide(NO)metabolites,DNA damage by the comet assay,cell viability test,and apoptosis in the kidneys.Data were analyzed by one-way analysis of variance,and means were compared using the Tukey test,with P≤0.05.RESULTS Omega-3 significantly decreased the production of reactive oxygen species(P<0.001)and lipoperoxidation in the kidneys of cirrhotic rats treated with omega-3(P<0.001).The activity of the antioxidant enzymes superoxide dismutase and catalase increased in the BDL+omega-3 group compared to the BDL group(P<0.01).NO production,DNA damage,and caspase-9 cleavage decreased significantly in the omega-3-treated BDL group.There was an increase in mitochondrial electrochemical potential(P<0.001)in BDL treated with omega-3 compared to BDL.No changes in the cell survival index in HRS with omega-3 compared to the control group(P>0.05)were observed.CONCLUSION The study demonstrates that omega-3 can protect cellular integrity and function by increasing antioxidant enzymes,inhibiting the formation of free radicals,and reducing apoptosis.

Liver transplantation and alcoholic liver disease:History,controversies,and considerations

Alcohol consumption accounts for 3.8% of annual global mortality worldwide, and the majority of these deaths are due to alcoholic liver disease(ALD), mainly alcoholic cirrhosis. ALD is one of the most common indications for liver transplantation(LT). However, it remains a complicated topic on both medical and ethical grounds, as it is seen by many as a "self-inflicted disease". One of the strongest ethical arguments against LT for ALD is the probability of relapse. However, ALD remains a common indication for LT worldwide. For a patient to be placed on an LT waiting list, 6 mo of abstinence must have been achieved for most LT centers. However, this "6-mo rule" is an arbitrary threshold and has never been shown to affect survival, sobriety, or other outcomes. Recent studies have shown similar survival rates among individuals who undergo LT for ALD and those who undergo LT for other chronic causes of end-stage liver disease. There are specific factors that should be addressed when evaluating LT patients with ALD because these patients commonly have a high prevalence of multisystem alcohol-related changes. Risk factors for relapse include the presence of anxiety or depressive disorders, short pre-LT duration of sobriety, and lack of social support. Identification of risk factors and strengthening of the social support system may decrease relapse among these patients. Family counseling for LT candidates is highly encouraged to prevent alcohol consumption relapse. Relapse has been associated with unique histopathological changes, graft damage, graft loss, and even decreased survival in some studies. Research has demonstrated the importance of a multidisciplinary evaluation of LT candidates. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Abstinence is the cornerstone of ALD therapy. Psychotherapies, including 12-step facilitation therapy, cognitive-behavioral therapy, and motivational enhancement therapy, help support abstinence. Nutritional therapy helps to reverse muscle wasting, weight loss, vitamin deficiencies, and trace element deficiencies associated with ALD. For muscular recovery, supervised physical activity has been shown to lead to a gain in muscle mass and improvement of functional activity. Early LT for acute alcoholic hepatitis has been the subject of recent clinical studies, with encouraging results in highly selected patients. The survival rates after LT for ALD are comparable to those of patients who underwent LT for other indications. Patients that undergo LT for ALD and survive over 5 years have a higher risk of cardiorespiratory disease, cerebrovascular events, and de novo malignancy.

Nutritional evaluation in cirrhosis: Emphasis on the phase angle

Protein-calorie malnutrition (PCM) is a common condition in cirrhotic patients, leading to a worse prognosis, complications, poor quality of life and lower survival rates. Among ways of assessing nutritional status, there are anthropometric methods such as the evaluation of the triceps skinfold, the arm circumference, the arm muscle circumference and the body mass index, and non-anthropometric methods such as the subjective global assessment, the handgrip strength of non-dominant hand, and the bioelectrical impedance analysis (BIA). PCM is frequently under-diagnosed in clinical settings in patients with cirrhosis due to the limitations of nutritional evaluation methods in this population. BIA is a useful method, but cannot be indicated in patients with abnormal body composition. In these situations, the phase angle (PA) has been used, and can become an important tool in assessing nutritional status in any situation. The PA is superior to anthropometric methods and might be considered as a nutritional indicator in cirrhosis. The early characterization of the nutritional status in patients with cirrhosis means an early nutritional intervention, with a positive impact on patients&rsquo; overall prognosis. Among the usually accepted methods for nutritional diagnosis, the PA provides information in a quick and objective manner.

Diet as an epigenetic factor in inflammatory bowel disease

Inflammatory bowel disease(IBD)has as a main characteristic the exacerbation of the immune system against enterocytes,compromising the individual’s intestinal microbiota.This inflammatory cascade causes several nutritional deficiencies,which further compromise immunological functioning and,as a result,worsen the prognosis.This vicious cycle can be interrupted as the patient’s dietary pattern meets their needs according to their clinical condition,acting directly on the inflammatory process of IBD through the interaction of food,intestinal microbiota,and epigenome.Specific nutritional intervention for IBD has a crucial role in preventing and managing disease activity.This review addresses epigenetic modifications through dietary compounds as a mechanism for modulating the intestinal microbiota of patients with IBD.

Bioelectrical impedance vector analysis evaluates cellularity and hydration in cirrhotic patients

BACKGROUND Malnutrition in cirrhotic patients is correlated with mortality and a better response to liver transplantation.However,recovery of the nutritional status in these patients is a challenge due to the difficulty in establishing a reliable nutritional diagnosis.The bioelectrical impedance vector analysis(BIVA)method appears as a feasible tool in clinical practice to define the physiological state of cirrhotic patients by assessing hydration and body cellularity.AIM To evaluate body composition in cirrhotic patients using BIVA.METHODS This retrospective cross-sectional study was carried out by following cirrhotic outpatients at a hospital in Porto Alegre,Brazil.A tetrapolar bioelectrical impedance analysis device was used to evaluate cellularity and hydration and to perform the BIVA.The BIVA graphic was elaborated by software and for statistical analysis a significance level of 5%(P≤0.05)was considered.RESULTS One hundred and ninety patients,61.1%males,with a mean age of 56.6±11.0 years,were evaluated.Of these,56.3%had Child-Turcotte-Pugh(CTP)A score,and the prevalent etiology was hepatitis C virus(47.4%).The patients were classified according to cellularity and hydration by the quadrants and ellipses of the BIVA method,quadrant 1(47.9%);quadrant 2(18.9%);quadrant 3(14.2%);and quadrant 4(18.9%).Those classified in quadrant 1 and 2 had a higher phase angle compared to those in quadrants 3 and 4(P<0.001).Quadrant 2 patients had a lower average age than the other groups.The association with CTP score showed that patients in quadrant 2 had a higher proportion of CTP A,and those in quadrant 4 had a higher proportion of CTP C(P<0.052).CONCLUSION The BIVA method allows identification of the cellularity and hydration status of cirrhotic patients,and its association with clinical factors determines the disease severity,age and prognostic index.

Melatonin restores zinc levels,activates the Keap1/Nrf2 pathway,and modulates endoplasmic reticular stress and HSP in rats with chronic hepatotoxicity

BACKGROUND Melatonin(MLT)is a potent antioxidant molecule that is shown to have a beneficial effect in various pathological situations,due to its action against free radicals.AIM To evaluate the effect of MLT on carbon tetrachloride(CCl_(4))induced liver injury in rats in terms of oxidative stress,reticular stress,and cell damage.METHODS Twenty male Wistar rats(230-250 g)were divided into four groups:Control rats,rats treated with MLT alone,rats treated with CCl_(4)alone,and rats treated with CCl_(4)plus MLT.CCl_(4)was administered as follows:Ten doses every 5 d,ten every 4 d,and seven every 3 d.MLT was administered intraperitoneally at a dose of 20 mg/kg from the 10th wk to the end of the experiment(16th wk).RESULTS MLT was able to reduce the release of liver enzymes in the bloodstream and to decrease oxidative stress in CCl_(4)treated rats by decreasing the level of thiobarbituric acid reactive substances and increasing superoxide dismutase activity,with a lower reduction in serum zinc levels,guaranteeing a reduction in liver damage;additionally,it increased the expression of nuclear factor(erythroid-derived 2)-like 2 and decreased the expression of Kelch-like ECH-associated protein 1.MLT also decreased the expression of the proteins associated with endoplasmic reticulum stress,i.e.,glucose-regulated protein 78 and activating transcription factor 6,as well as of heat shock factor 1 and heat shock protein 70.CONCLUSION MLT has a hepatoprotective effect in an experimental model of CCl_(4)-induced liver injury,since it reduces oxidative stress,restores zinc levels,and modulates endoplasmic reticulum stress.

Resting energy expenditure in cirrhotic patients with and without hepatocellular carcinoma

BACKGROUND The diagnosis of malnutrition in patients with independent hepatocellular carcinoma(HCC)varies from 20%to 50%,is related to important complications and has a direct impact on the prognosis.Determination of the resting energy expenditure(REE)has become an important parameter in this population,as it allows therapeutic adjustments to recover their nutritional status.The REE in cirrhosis,with and without HCC,is not clearly defined,and requires the identification and definition of the best nutritional approach.AIM To evaluate the REE of patients with cirrhosis,with and without HCC.METHODS This is a prospective observational study evaluating the REE of 118 patients,33 with cirrhosis and hepatocellular carcinoma and a control group of 85 patients with cirrhosis without HCC,using indirect calorimetry(IC),bioimpedance,and predictive formulas.RESULTS The REE determined by IC in cirrhotic patients with HCC was 1643±364 and in those without HCC was 1526±277(P=0.064).The REE value as assessed by bioimpedance was 1529±501 for those with HCC and 1660±385 for those without HCC(P=0.136).When comparing the values of REE determined by IC and predictive formulas in cirrhotics with HCC,it was observed that only the formulas of the Food and Agriculture Organization(FAO)/World Health Organization(WHO)(1985)and Cunningham(1980)presented values similar to those determined by IC.When comparing the REE values determined by IC and predictive formulas in cirrhotics without HCC,it was observed that the formulas of Schofield(1985),FAO/WHO(1985),WHO(2000),Institute of Medicine(IOM)(2005)and Katch and McArdie(1996)presented values similar to those determined by IC.CONCLUSION The FAO/WHO formula(1985)could be used for cirrhotic patients with or without HCC;as it is the one with the values closest to those obtained by IC in these cirrhotic patients.

Relationship between phase angle,steatosis,and liver fibrosis in patients coinfected with human immunodeficiency virus/hepatitis C virus

BACKGROUND Malnutrition,lipodystrophy,and dyslipidemia are prevalent characteristics in patients with human immunodeficiency virus(HIV)infection with or without previous treatment.Such a clinical condition can lead to the hypothesis of the presence of hepatic steatosis with possible progression to fibrosis and the risk of hepatocellular carcinoma.Notably,a low phase angle(PA),evaluated by bioelectrical impedance analysis(BIA),is an independent prognostic marker of clinical progression and survival in HIV-infected patients.AIM To evaluate the relationship between PA and body composition with steatosis and hepatic fibrosis in HIV/hepatitis C virus(HCV)-coinfected patients.METHODS A retrospective observational study by convenience sampling of coinfected HIV/HCV patients,in which all patients underwent transient elastography(Fibroscan)and BIA evaluation.Student’s t test was used for group comparisons,and Spearman’s or Pearson’s correlation test was used when appropriate.The significance level was set at 5%,and analyses were performed using SPSS version 21.0.RESULTS Forty-three patients who received antiretroviral therapy met the inclusion criteria,and 23(53.5%)were under treatment with protease inhibitors(PIs).There was no difference in PA between those who used PIs and those who did not(P=0.635).There was no correlation between fibrosis grade and PA(P=0.355)or lean mass(P=0.378).There was a significant inverse correlation between the controlled attenuation parameter(CAP)and lean mass(P=0.378),positive correlation between PA and lean mass(P=0.378),and negative correlation between PA and fatty mass(P=0.378),although the CAP and PA were not correlated.When evaluated by sex,no significant correlations were found.CONCLUSION PA determines the muscle function of HIV/HCV-coinfected patients,and the CAP values reinforce the association with lean mass,suggesting that patients require early nutritional interventions.

Phase angle and non-alcoholic fatty liver disease before and after bariatric surgery

BACKGROUND Obesity is a global health problem that is continuing to increase in the young population.In Brazil,the frequency of obesity in 2018 was 19.8%.Several comorbidities are directly associated with obesity,such as non-alcoholic fatty liver disease(NAFLD),which is considered the most common liver disorder in Western countries and affects up to 46%of adults.Bariatric surgery is effective in treating obesity and can improve NAFLD;however,the effect of bariatric surgery on body composition,phase angle(PA),and improving NAFLD needs to be further studied.AIM To analyze the PA in the postoperative period of bariatric surgery and to correlate it with changes in body composition and liver disease.METHODS This study is a retrospective cohort study of the analysis of the medical records of patients undergoing bariatric surgery in a reference center of a teaching hospital in Porto Alegre over a 2-year period.Patients older than 18 years whose record contained all information relevant to the study were included.The data analyzed were body composition and PA through electrical bioimpedance and NAFLD through liver biopsy in the pre-and postoperative period.The level of significance adopted for the statistical analyses was 5%.RESULTS We evaluated 379 patients with preoperative data.Regarding PA,169 patients were analyzed,and 33 patients had liver biopsy pre-and postoperatively with NAFLD information.In total,79.4%were female,with a mean age of 39.1±10.6 years.The average body mass index(BMI)was 45.9±7.5 kg/m².The PA showed a mean of 5.8±0.62°in the preoperative period and a significant reduction in the postoperative period.A postoperative reduction in body composition data(skeletal muscle mass,fat percentage,fat mass,body cell mass,BMI and visceral fat area)was shown as well.Regarding liver disease,all patients presented a reduction in the degrees and stages of liver disease in the postoperative period,and some had no degree of liver disease at all.CONCLUSION PA decreased after bariatric surgery,with a direct correlation with weight loss and changes in body composition.The decrease in PA was not correlated with the improvement in NAFLD.

Assessment of resting energy expenditure in patients with cirrhosis

BACKGROUND Malnutrition affects 20%to 50%of patients with cirrhosis.It may be associated with serious complications and has a direct impact on prognosis.Resting energy expenditure(REE)is an important parameter to guide the optimization of therapy and recovery of nutritional status in patients with cirrhosis.However,the REE of patients with cirrhosis is still unclear,casting doubt upon the optimal nutritional management approach.AIM To identify the best method that predicts the REE of cirrhotic patients,using indirect calorimetry(IC)as the gold standard.METHODS An observational study was performed on 90 patients with cirrhosis.REE was assessed by IC,bioelectrical impedance analysis(BIA),and predictive formulas,which were compared using Bland-Altman plots and the Student’s t-test.RESULTS REE values measured by IC(1607.72±257.4 kcal)differed significantly from those determined by all other methods(BIA:1790.48±352.1 kcal;Harris&Benedict equation:2373.54±254.9 kcal;IOM equation:1648.95±185.6 kcal;Cunningham equation:1764.29±246.2 kcal),except the Food and Agriculture Organization of the United Nations,World Health Organization,and United Nations University(FAO/WHO/UNU)(1616.07±214.6 kcal)and McArdle(1611.30±241.8 kcal)equations.We found no significant association when comparing IC and 24-h dietary recall among different Child-Pugh classes of cirrhosis.CONCLUSION The IOM and FAO/WHO/UNU equations have the best agreement with the CI.These results indicate a possibility of different tools for the clinical practice on cirrhotic patients.

Role of the phase angle in the prognosis of the cirrhotic patient:15 years of follow-up

BACKGROUND In 2019,cirrhosis accounted for 2.4%of global deaths.The projection for 2030 is an increase in this index.In recent years,hospitalization costs have escalated by 36%for compensated cirrhosis and 24%for decompensated cirrhosis.Therefore,it is necessary to identify a tool capable of predicting the mortality of these patients according to their clinical condition and consequently extending their survival time.Different studies have shown that the phase angle(PA)can be a feasible method in clinical practice,with the potential to guide assertive patient management in the therapeutic of chronic liver disease.AIM To evaluate the prognostic role of PA in cirrhotic patients over a 15-year followup period.METHODS Retrospective cohort study with 129 cirrhotic patients of both sexes over 18 years old.Diagnosis of cirrhosis by liver biopsy.The first year of data collection was 2007,and data regarding outcomes was collected in 2023.Data were gathered from medical records,such as esophageal varices(EV),EV bleeding,ascites,spontaneous bacterial peritonitis(SBP),encephalopathy,laboratory findings and PA.The cut-off value for the PA was 5.4°,a value described in 2012 by Fernandes et al for 129 patients evaluated in this study and the cut-off points for the Brazilian population presented in percentiles(P),as described by Mattiello et al.The mortality was assessed using the PA percentile through Kaplan-Meier curves and multivariate binary logistic regression models.RESULTS Patients were divided into two groups according to the PA 5.4th(PA>5.4°,n=40;PA≤5.4°,n=89)PA percentile(<P50,n=56;≥P50 n=73).The percentile classification was more accurate in identifying long-term deaths than the 5.4ºPA.Patients with<P50 had a higher number of relevant complications such as ascites,SBP,liver encephalopathy and HCC.PA is strongly correlated with serum albumin(P<0.001),International Normalized Ratio(P=0.01),total bilirubin(P=0.02)and direct bilirubin(P=0.003).PA is correlated with survival time(P<0.001)and length of stay(P=0.02).Logistic regression analysis shows that an increase of 1°in PA enlarges the cirrhotic patient's chance of survival by 17.7%.CONCLUSION PA is a good predictor of morbidity and mortality for cirrhotic patients.The PA by percentile showed greater sensitivity in predicting mortality compared to the cut-off point of 5.4º.

Machine learning approaches using blood biomarkers in nonalcoholic fatty liver diseases

The prevalence of nonalcoholic fatty liver disease(NAFLD)is an important public health concern.Early diagnosis of NAFLD and potential progression to nonalcoholic steatohepatitis(NASH),could reduce the further advance of the disease,and improve patient outcomes.Aiming to support patient diagnostic and predict specific outcomes,the interest in artificial intelligence(AI)methods in hepatology has dramatically increased,especially with the application of lessinvasive biomarkers.In this review,our objective was twofold:Firstly,we presented the most frequent blood biomarkers in NAFLD and NASH and secondly,we reviewed recent literature regarding the use of machine learning(ML)methods to predict NAFLD and NASH in large cohorts.Strikingly,these studies provide insights into ML application in NAFLD patients'prognostics and ranked blood biomarkers are able to provide a recognizable signature allowing cost-effective NAFLD prediction and also differentiating NASH patients.Future studies should consider the limitations in the current literature and expand the application of these algorithms in different populations,fortifying an already promising tool in medical science.

Physiology and health assessment,risk balance,and model for endstage liver disease scores:Postoperative outcome of liver transplantation

BACKGROUND Liver transplantation aims to increase the survival of patients with end-stage liver diseases and improve their quality of life.The number of organs available for transplantation is lower than the demand.To provide fair organ distribution,predictive mortality scores have been developed.AIM To compare the Acute Physiology and Chronic Health Evaluation IV(APACHE IV),balance of risk(BAR),and model for end-stage liver disease(MELD)scores as predictors of mortality.METHODS Retrospective cohort study,which included 283 adult patients in the postoperative period of deceased donor liver transplantation from 2014 to 2018.RESULTS The transplant recipients were mainly male,with a mean age of 58.1 years.Donors were mostly male,with a mean age of 41.6 years.The median cold ischemia time was 3.1 hours,and the median intensive care unit stay was 5 days.For APACHE IV,a mean of 59.6 was found,BAR 10.7,and MELD 24.2.The 28-day mortality rate was 9.5%,and at 90 days,it was 3.5%.The 28-day mortality prediction for APACHE IV was very good[area under the curve(AUC):0.85,P<0.001,95%CI:0.76-0.94],P<0.001,BAR(AUC:0.70,P<0.001,95%CI:0.58–0.81),and MELD(AUC:0.66,P<0.006,95%CI:0.55-0.78),P<0.008.At 90 days,the data for APACHE IV were very good(AUC:0.80,P<0.001,95%CI:0.71–0.90)and moderate for BAR and MELD,respectively,(AUC:0.66,P<0.004,95%CI:0.55–0.77),(AUC:0.62,P<0.026,95%CI:0.51–0.72).All showed good discrimination between deaths and survivors.As for the best value for liver transplantation,it was significant only for APACHE IV(P<0.001).CONCLUSION The APACHE IV assessment score was more accurate than BAR and MELD in predicting mortality in deceased donor liver transplant recipients.