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Background Self-imposed food restrictions are common in patients with inflammatory bowel disease (IBD) because oftheir erroneous belief of the role of food in disease worsening and, recently, eating disorders have alsobeen described. Orthorexia nervosa is characterized by the obsession of eating healthy and natural foods.Only a few studies have assessed orthorexia in patients with digestive disease and there are no studies inIBD. The aim of this study is to assess the risk of orthorexia in patients with IBD. Methods 158 consecutive subjects were prospectively recruited from February to October 2022 in a tertiary referralcenter: 113 patients with IBD and 45 healthy controls. The cohort of IBD patients consisted of 74 patientson biologic drugs, 28 patients on conventional therapy, and 12 patients admitted to the ward for diseaseflares. Demographic and clinical data were collected, and the ORTO-15 questionnaire, validated by Doniniet al., was used to assess the risk of orthorexia. Results Patients with IBD had a prevalence of orthorexia of 77%, significantly higher than the 47% observed in thecontrol group (p Conclusion Our study showed that most patients with IBD has a risk of orthorexia and that this is associated with alower BMI and a history of previous surgery for IBD. Further research is warranted to evaluate the clinicalimpact of orthorexia in patients with IBD and its relationship with the avoidant restrictive food intakedisorder (ARFID) or other eating disorder. Evidence based counselling by a qualified dietician is stronglywarranted in IBD clinics.

Background Diet is receiving growing attention as a key environmental factor involved in the pathogenesis of Inflammatory Bowel Disease (IBD). Dietary components have a relevant role in triggering symptoms from the patients’perspective, but there is a gap between patients’ and doctors’ beliefs. Every patient has collected his or her own list of prohibited foods and reports a clinical benefit from avoiding such foods. Elimination of nutrients can lead to nutritional deficiencies and impact on style and quality of life. The aim of this study is to identify frequently avoided foods in a Mediterranean cohort of patients with IBD. Methods Consecutive patients with IBD attending our tertiary center for infusion of biologics or for follow-up visits were enrolled. Demographics and disease characteristics UC or CD) were recorded in a dedicated database. A questionnaire investigated food avoided and reasons for dietary changes, if self-driven or advised by doctors or other healthcare professionals. Results 167 patients agreed to participate in the study. Eighty-one patients (48.8%) had UC, 86 (51.5%) had CD. Mean age was 48.6 ± 16 (range 18–77 years), 57.5% were males. Patients were in clinical remission or with mild activity. Most patients, about 80%, and especially patients with CD avoided certain foods considered as triggers, and this avoidance was usually practiced in both exacerbations of the disease and remission periods. This occurred upon medical advice in a minority of patients, especially for vegetable avoidance (13.2%). Foods more frequently avoided were spicy foods, seasoned foods, fried foods, milk and dairy products, carbonated drinks, spirits, vegetables, legumes, and whole grain bread. Processed meat was avoided in about 6.6% (only in 1.8% upon medical advice) and coffee in 12.6%. A lactose-free diet was advised by the treating physicians only in 14.3% of patients. 4 patients were on a glutenfree diet because of a self-reported gluten sensitivity. The role of other healthcare professionals (dietitician, nurses) was marginal in their food choices. Conclusion Most of the patients set diet on self-experience and give up many foods. Our results are comparable with those of previous studies. Spicy foods, seasoned and fried foods, carbonated drinks, and dairy products are on top of the list. Legumes and vegetables, the cornerstones of the Mediterranean diet, are also avoided even though the evidence that dietary fibers can induce relapse is lacking. The benefit reported could be related to the effect on IBS-related symptoms frequent in IBD in remission. Further studies and a greater involvement of doctors in providing dietary recommendations are warranted.

Background: Diet has a relevant role in triggering symptoms in inflammatory bowel disease (IBD) from the patients’ perspective, but there is gap the between patients’ and doctors’ perceptions. Few studies have addressed this topic. The aim of this study was to evaluate food habits and nutrition knowledge in a homogeneous cohort of patients with IBD from southern Italy. Methods: 167 consecutive patients with IBD were recruited. The survey was based on the administration of a semi-structured questionnaire assessing demographics, disease features, dietary behavior, and food intolerance. Results: The majority of patients did not consider food a cause of their disease. However more than 80% changed their diet after the diagnosis and most report an improvement in symptoms. Spiced and seasoned foods, dairy products, vegetables, and fruit were often avoided. A dairy-free diet was adopted by 33.7%. Food choices were based on self-experience and not on medical counselling. Dietary modifications deeply impact on lifestyle. Conclusions: Most of the patients with IBD set diet and lifestyle on self-experience and give up many foods. This has an impact on psychosocial functioning and can lead to nutritional deficiencies. High quality studies are warranted to assess evidence-based dietary strategies and develop patient-targeted dietary recommendations.

Background & Aims: In patients with hepatitis C virus (HCV)-related advanced cirrhosis, the effects of sustained virological response (SVR) by direct antiviral agents (DAAs) on decompensation and liver deaths are less clearcut, since up to 30% of patients do not improve, and no predictors of outcome have been identified. We used 13C-aminopyrine breath test (ABT) to assess whether its changes can predict liver-related outcomes after DAA treatment in patients with HCV cirrhosis. Methods: Fifty consecutive patients with HCV cirrhosis were enrolled. Patients were included if they had Child A cirrhosis at risk for decompensation – defined as Child A6 (N=22, 44%) or previous decompensation (N=7, 14%) – or Child B cirrhosis (N=21, 42%) eligible for DAA-based antiviral therapy. ABT was performed at baseline and 12weeks after the end of antiviral therapy. Patients received sofosbuvir-based regimens. Results: Aminopyrine breath test was available for all 50 patients at baseline. The 120’ cumulative dose was directly associated at regression analysis only with albumin levels (P=.001). ABT was available at follow-up week 12 for 41 patients (FUW12), all with SVR, and followed for a median of 25.2months (range 12.2-32.1months). Lower Ʌ ABT – defined as changes of 120’ cumulative dose from FUW12 to baseline – (HR 0.97, 95% CI 0.94-0.99; P=.02) and FUW12 hepatic encephalopathy (HR 19.0, 95% CI 1.16-310.3; P=.03) were the only independent predictors of liver events/death at multivariate Cox regression analysis. The AUC of Ʌ ABT was good (0.87, 95% CI 0.75-0.97), with a delta ≥0% well discriminating patients at lower vs patients at higher risk of liver-related events/death (P&nbsp

Indirect methods to predict the presence of esophageal varices (EV) in patients with cirrhosis are not sensitive enough to be used as a surrogate for endoscopy. We tested the effectiveness of liver stiffness measurement (LSM) by transient elastography and the presence of insulin resistance (IR), a marker associated with fibrosis progression, in the noninvasive prediction of portal hypertension. One hundred four consecutive patients with newly diagnosed Child A hepatitis C virus (HCV) cirrhosis underwent upper gastrointestinal endoscopy to search for EV. Clinical, anthropometric, biochemical, ultrasonographic, and metabolic features, including IR by the homeostasis model assessment (HOMA), and LSM by transient elastography, were recorded at the time of endoscopy. EVs were detected in 63 of 104 patients (60%). In 10 patients (16%), the EVs were medium-large (≥F2). By multivariate analysis, the presence of EVs was independently associated with a low platelet count/spleen diameter ratio (OR, 0.998; 95% CI, 0.996-0.999) and a high HOMA-IR score (OR, 1.296; 95%CI, 1.018-1.649), not with LSM (OR, 1.009; 95%CI, 0.951-1.070). It is noteworthy that nine of ten patients with medium-large EVs had a platelet/spleen ratio of less than 792 or an HOMA-IR of greater than 3.5. The independent association between low platelet count/spleen diameter ratio (OR, 0.998; 95%CI, 0.996-1.000), high HOMA-IR score (OR, 1.373; 95%CI, 1.014-1.859) and presence of EV was confirmed in the subgroup of 77 nondiabetic subjects. Conclusions: In patients with Child A HCV cirrhosis, two simple, easy-to-get tests, namely the platelet/spleen ratio and insulin resistance measured by HOMA-IR, regardless of the presence of diabetes, significantly predict the presence of EV, outweighing the contribution given by transient elastography. (HEPATOLOGY 2009;49:195-203)

Indirect methods for predicting the presence of esophageal varices (EV) in cirrhotic patients are not sensitive enough to be used as a surrogate for endoscopy. We tested the effectiveness of liver stiffness measurement (LSM) by transient elastography (TE) and the presence of insulin resistance (IR), a marker associated with fibrosis progression, in the non-invasive prediction of portal hypertension. One hundred and four consecutive patients with newly diagnosed Child A HCV cirrhosis underwent upper GI endoscopy to search for EV. Clinical, anthropometric, biochemical, ultrasonographic and metabolic features, including IR by the homeostasis model assessment (HOMA), and LSM by TE, were recorded at the time of endoscopy. EV were detected in 63 of 104 patients (60%). In 10 patients (16%) the EV were medium-large (≥ F2). By multivariate analysis presence of EV was independently associated with a low platelet count/spleen diameter ratio (OR 0.998; 95% CI; 0.996-0.999) and with a high HOMA score (OR 1.296; 95%CI; 1.018-1.649) but not with LSM (OR 1.009; 95%CI; 0.951-1.070). It is noteworthy that 9/10 patients with medium-large EV had a platelet/spleen ratio of < 792 and/or a HOMA of > 3.5. The independent association between low platelet/spleen ratio (OR 0.998; 95%CI; 0.996-1.000), high HOMA score (OR 1.373; 95%CI; 1.014-1.859) and presence of EV was confirmed in the sub-group of 77 non-diabetic subjects. Conclusions: In patients with Child A HCV cirrhosis, a low platelet/spleen ratio and a high HOMA score, regardless of diabetes, are the strongest independent predictors of the presence of EV. In this specific setting LSM seems not contribute to the diagnosis of portal hypertension.

Retinol-binding protein 4 (RBP4) is an adipocytokine associated with insulin resistance. We tested serum levels of RB4 to assess its link with steatosis in patients with genotype 1 (G1) chronic hepatitis C (CHC) or non-alcoholic fatty liver disease (NAFLD). Non-diabetic patients with CHC (n=143) or NAFLD (n=37) were evaluated by liver biopsy and anthropometric and metabolic measurements, including insulin resistance by the homeostasis model assessment (HOMA). Biopsies were scored by Scheuer classification for CHC, and Kleiner for NAFLD. Steatosis was tested as a continuous variable and graded as absent-mild

Background & Aims: Unhealthy food intake, specifically fructose, has been associated with metabolic alterations and with the severity of liver fibrosis in patients with non-alcoholic fatty liver disease. In a cohort of patients with genotype 1 chronic hepatitis C (G1 CHC), we tested the association of fructose intake with the severity of liver histology. Methods: Anthropometric and metabolic factors, including waist circumference (WC), waist-to-hip ratio (WHR), dorso-cervical lipohypertrophy and HOMA were assessed in 147 consecutive biopsy-proven G1 CHC patients. Food intake, namely industrial and fruit fructose, was investigated by a three-day structured interview and a computed database. All biopsies were scored by an experienced pathologist for staging and grading (Scheuer classification), and graded for steatosis, which was considered moderate-severe if P20%. Features of non-alcoholic steatohepatitis (NASH) in CHC were also assessed (Bedossa classification). Results: Mean daily intake of total, industrial and fruit fructose was 18.0 ± 8.7 g, 6.0 ± 4.7 g, and 11.9 ± 7.2 g, respectively. Intake of industrial, not fruit fructose, was independently associated with higher WHR (p = 0.02) and hypercaloric diet (p

Background Genotype 1 (G1) hepatitis C virus (HCV) is associated with insulin resistance (IR) and its clearance seems to improve insulin sensitivity. We aimed to evaluate the time course of IR in response to antiviral therapy in non-diabetic, non-cirrhotic G1 HCV patients and to assess the effect of metabolic factors on sustained virological response (SVR). Methods A total of 83 consecutive treatment-naive G1 chronic hepatitis C (CHC) patients were evaluated by anthropometric and metabolic measurements, including IR using the homeostasis model assessment (HOMA). Patients were considered to have IR if HOMA was >2.7. All cases had a liver biopsy scored for staging, grading and steatosis. Anthropometric parameters and HOMA were re-evaluated at the end of antiviral therapy and at follow-up. Results SVR was achieved in 46 (55.4%) patients. By logistic regression, female gender (odds ratio [OR] 0.132, 95% confidence interval [CI] 0.33–0.529), γ-glutamyltransferase >50 IU (OR 0.217, 95% CI 0.066–0.720) and presence of steatosis (OR 0.134, 95% CI 0.028–0.654) were independent negative predictors of SVR, whereas low-density lipoprotein cholesterol >107 IU (OR 6.671, 95% CI 1.164–11.577) was a positive predictor of SVR. The proportion of patients with IR significantly decreased ( P=0.02) during antiviral therapy and at follow-up in patients achieving SVR. A similar trend, even if not significant, was observed in relapsers and non-responders. Conclusions In non-diabetic G1 HCV patients undergoing antiviral therapy, IR improved in all patients, independently of virological outcome. HCV viral clearance was an additional factor in IR improvement. Female gender, hepatic steatosis and other metabolic parameters, but not IR, were identified as negative predictors of SVR in this study.

Retinol-binding protein 4 (RBP4) is an adipocytokine associated with insulin resistance (IR). We tested serum levels of RBP4 to assess its link with steatosis in patients with genotype 1 chronic hepatitis C (CHC) or nonalcoholic fatty liver disease (NAFLD). Nondiabetic patients with CHC (n = 143) or NAFLD (n = 37) were evaluated by liver biopsy and anthropometric and metabolic measurements, including IR by the homeostasis model assessment. Biopsies were scored by Scheuer classification for CHC, and Kleiner for NAFLD. Steatosis was tested as a continuous variable and graded as absent-mild or =30%. Thirty nondiabetic, nonobese blood donors served as controls. RBP4 levels were measured by a human competitive enzyme-linked immunosorbent assay kit (AdipoGen). Mean values of RBP4 were similar in NAFLD and CHC (35.3 +/- 9.3 microg/L versus 36.8 +/- 17.6; P = 0.47, respectively), and both were significantly higher than in controls (28.9 +/- 12.1; P = 0.02 and P = 0.01, respectively). RBP4 was higher in CHC patients with steatosis than in NAFLD (42.1 +/- 19.7 versus 35.2 +/- 9.3; P = 0.04). By linear regression, RBP4 was independently linked to steatosis only (P = 0.008) in CHC, and to elevated body mass index (P = 0.01) and low grading (P = 0.04) in NAFLD. By linear regression, steatosis was independently linked to homeostasis model assessment score (P = 0.03) and high RBP4 (P = 0.003) in CHC. By logistic regression, RBP4 was the only variable independently associated with moderate-severe steatosis in CHC (odds ratio, 1.045; 95% confidence interval, 1.020 to 1.070; P = 0.0004), whereas waist circumference was associated with moderate-severe steatosis in NAFLD (odds ratio, 1.095; 95% confidence interval, 1.007 to 1.192; P = 0.03). CONCLUSION: In nondiabetic, nonobese patients with genotype 1 CHC, serum RBP4 levels might be the expression of a virus-linked pathway to steatosis, largely unrelated to IR.

Background and Aims: Many foreign-born persons in the U.S. are at high risk of chronic hepatitis B (HBV) and C (HCV) infections, yet are not aware of their infection, and lack healthcare coverage or linkage to care. Methods: A unique partnership, the Hepatitis Outreach Network, combines the expertise and resources of the Mount Sinai School of Medicine, the NYC Department of Health and Mental Hygiene, and community-based organizations, to provide education, screening and link to care in communities with high prevalence of chronic viral hepatitis. Comprehensive HBV and HCV screening identifies infected patients, who then receive further evaluation from either local or Mount Sinai physicians, combined with patient-navigators who organize follow-up visits. Results: Of 1603 persons screened, 76 had HBV and 75 had HCV. Importantly, screening for HCV based on traditional risk factors would have missed 67% of those who tested positive. Of the 76 persons with HCV infection, 49 (64%) received a medical evaluation (26 with local providers and 23 at Mount Sinai). Of the 49 HCVinfected persons evaluated, treatment was recommended in 11 and begun in 8 (73%). Of the 76 persons with HBV infection, 43 (57%) received a medical evaluation (31 with local providers and 12 at Mount Sinai). Of the 43 HBV-infected persons evaluated, treatment was recommended and begun in 5 (100%). Conclusion: Hepatitis Outreach Network has successfully established novel proof of concept for identifying HBV and HCV infections in foreign-born persons through use of several unique elements that effectively link them to care.