Brief ICF Core set for Obesity [3].
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"213",leadTitle:null,fullTitle:"Environmental Management in Practice",title:"Environmental Management in Practice",subtitle:null,reviewType:"peer-reviewed",abstract:"In recent years the topic of environmental management has become very common. 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",isbn:"978-1-80356-372-5",printIsbn:"978-1-80356-371-8",pdfIsbn:"978-1-80356-373-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"1c89c2e1b5d03b90db5b13d44479baa6",bookSignature:"Dr. Ram Krishna",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11466.jpg",keywords:"Extreme Temperature Application, High Strength, Corrosion Resistance, Electron Microscopy, Microstructure, Additive Manufacturing, Titanium Matrix Composite, Load-Displacement Curves, Selective Laser Melting, Sustainable Thermomechanical Processing, Weldability, Superplasticity",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 22nd 2022",dateEndSecondStepPublish:"April 27th 2022",dateEndThirdStepPublish:"June 26th 2022",dateEndFourthStepPublish:"September 14th 2022",dateEndFifthStepPublish:"November 13th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Researcher in advanced materials and their advanced characterization techniques, Dr. Krishna completed his Ph.D. at the University of Leicester, UK, and held postdoctoral positions at the University of Manchester, UK, and North Carolina State University, US. Appointed as Associate Dean for the Industry Institute Interaction Cell at his college, he is a Fellow Member of The Institution of Engineers (India).",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"296477",title:"Dr.",name:"Ram",middleName:null,surname:"Krishna",slug:"ram-krishna",fullName:"Ram Krishna",profilePictureURL:"https://mts.intechopen.com/storage/users/296477/images/system/296477.jpg",biography:"After getting his Master's degree in Materials and Metallurgical Engineering from the Indian Institute of Technology Kanpur, Dr. Ram Krishna continued his studies at the University of Leicester in the United Kingdom, where he got his Ph.D. in 2011. He held postdoctoral positions at the University of Manchester in the United Kingdom and North Carolina State University in Raleigh, North Carolina. His knowledge includes a wide range of materials for high temperatures applications and understanding their behavior and performance through mechanical testing at high temperatures, as well as advanced characterization techniques, as evidenced by his h-index of 10 and designation as co-inventor of 13 patents. He has authored or coauthored more than 30 research papers that have appeared in journals and conference proceedings. 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Graded increase in activities of daily living (ADL) limitation was observed with increasing body weight [1]. Rehabilitation medicine approach to address the needs of a bariatric individual encompasses both ends of the management spectrum: to restore and prevent further deterioration of physical function associated or aggravated with excess body weight; as well as to enhance post-operative results with a sustainable weight management strategy.
The rehabilitation medicine approach to function can be viewed from The International Classification of Functioning, Disability and Health (ICF) concept to better understand the interactive nature of a chronic health condition such as obesity and formulate a rehabilitation plan to address physical, psychological and socio-environmental barriers to bariatric-related disability [2, 3] (Table 1). Individualisation of care from all disciplines involved in the bariatric population to produce long-term sustainable results can also be deduced by understanding the dynamics of a disease process through this concept. We shall discuss the approaches to a bariatric evaluation, rehabilitation intervention and functional outcome in two parts with special focus on prehabilitation and peri-operative rehabilitation.
Domains affected | Descriptors |
---|---|
Body function | Energy and drive function |
Weight maintenance functions | |
Activities and participation | Handling stress and other psychological demands |
Walking | |
Moving around | |
Looking after one’s health | |
Environmental factors | Products of substances for personal consumption |
Immediate family |
Brief ICF Core set for Obesity [3].
Obesity affects physical, biopsychosocial aspects of an individual’s health and function. The complex nature may require rehabilitation interventions to be carried out in various settings to accommodate for different functional goals and engaging a multidisciplinary rehabilitation team to tap into different expertise to achieve the desired functional milestones. The bariatric individual presents with unique challenges to the treating team in both functional limitations and the approaches that can be employed to address these impairments and prevent further functional deterioration. The ICF highlights the domains that are affected by excessive weight: pain, cutaneous sensation, neuromusculoskeletal issues and movement difficulties as well skin issues due to difficulty in reaching during cleaning and toileting are the most commonly impaired function and complications leading to limitation in general tasks, mobility and poorer quality of life [1]. Concurrent presence of medical comorbidities can add up to tip the individual into compromised functional independence [1]. Common comorbidities related to obesity such as osteoarthritis of the weight bearing joints and cardiopulmonary conditions impacts severely on an individual’s functional reserves. Thus, the goal for bariatric rehabilitation program should include assisting the attainment of optimal weight reduction; to address current and potential medical complications especially metabolic syndrome, CVD and MSK conditions; to address functional limitations resulting from physical disabilities and improve quality of life through improving functional independence, self-confidence and empowering self-management.
Severe obesity with multiple comorbidities requires admission to medical facilities structurally adequate to assist in supporting and assisting individuals with excess body mass to transfer and mobilise with the use of bariatric- safe lifting devices, mobility equipment and transfer aids. Ideally these rehabilitation facilities are linked to a bariatric- dedicated medical and surgical specialities [4].
The bariatric patients frequently develop medical complications that may run a protracted course [5]. Common medical complications readily noted at admission include:
Skin excoriations, rashes or ulcers in deep tissue folds with possibility of fungal infections.
Edema or fluid retention and venous congestion that causes feeling of limb heaviness or leading to diaphoresis-fluid leakage that renders the skin sensitive to shear forces, skin tears and infection.
Diabetes and respiratory problems including obesity hypoventilation syndrome or obstructive sleep apnoea.
These complications may indicate specialised nursing care or aids to protect during mobilisation. It may also preclude the use of some rehabilitation modalities i.e. hydrotherapy and priorities needs to be given to address medical conditions that delays resumption of weight bearing or therapeutic standing.
Hospitalisation-related complications that tend to occur are mainly as a result of prolonged recumbency, also known as deconditioning. While deconditioning is not exclusive to bariatric population, its effects are more pronounced as bariatric individuals face challenges for immediate resumption of upright posture especially those who were admitted acutely for medical complications such as cardiopulmonary emergencies, following falls or exacerbation of musculoskeletal conditions leading to pain on weight bearing. Deconditioning can affect both physical and psychological domains as prolonged bed rest affects nearly all body systems. Specific to bariatric population these complications may entail a prolonged stay and protracted course of recovery:
Cardiovascular system: orthostatic hypotension and reduced exercise tolerance contributed by decreased cardiac output and resting tachycardia affecting sitting up, standing, transfers and physical activity participation.
Pulmonary system: orthostatic pneumonia or atelectasis resulting in hypoxemia and reduced tolerance to physical activity may complicate obesity hypoventilation syndrome or sleep apnoea.
Haematological system: deep venous thrombosis and pulmonary embolism may occur despite no lower limb neurological deficit as abdominal mass may compress on lower limb circulation and altered blood viscosity.
Musculoskeletal system: muscle atrophy causing weakness; leading to longer periods of non-weight bearing and increasing the risk of osteoporosis, joint stiffness and worsening posture. Especially of concern is weakness of extensor muscles needed to assume or assist to an upright position.
Gastrointestinal: constipation from lack of upright posture often complicate prescription diet plans due to the bloating sensation, abdominal discomfort and possibility of spurious diarrhoea complicating personal hygiene due to poor access to the perineal region combined with postural stasis that predisposes to the development of pressure ulcers.
Endocrine: impaired insulin response with hyperglycemia; gastrostasis leading to sensation of nausea and oesophageal reflux symptoms.
The result impacts on a bariatric individual’s functional reserves in terms of muscle power, balance, and coordination, jeopardising functional performance and results in the development of psychological sequelae as a direct result of deconditioning or from the loss of function it entails. Confusion and disorientation are part of the deconditioning constellation seen earlier on the bedrest period which can culminate in clinically significant anxiety and depression once the impact of functional loss sets in as self-care, leisure activities and gainful employment becomes challenging. Reconditioning as a rehabilitation goal will be discussed further in the prehabilitation section. Given the prospect of functional deterioration that can occur at an accelerated rate in the bariatric population due to inherent difficulties in mobilisation, special attention should be given to addressing factors that negate upright sitting and to promote lower limb weight bearing in cases that permit them as soon as possible. These include identifying at risk bariatric individuals with hip and knee replacements, paralysis, amputations, contractures, osteoporosis, respiratory and cardiac conditions, and skin conditions such as pressure ulcers. Availability of bariatric mobility aids such as hoists, tilt tables, chairs or wheelchairs and walking aids greatly assist in preventing the ill effects on deconditioning and translates to better cost-efficiency to prevent such deleterious complications rather than treatment of the aforementioned complications.
Various models of bariatric rehabilitation exists to generally addresses 5 key factors: knowledge to empower action, goal-setting and self-care; beliefs surrounding causes and solutions to obesity; behavioural adaptation focusing on diet and physical activity, psychological coping strategies and adjustments of physical activity to include exercise, current functional capacity and that expected after bariatric surgery. A holistic model such as bio-psycho-social model explained via ICF helps to provide a multi-dimensional framework to evaluate the needs, identify the barriers and provide intervention or solutions to improve independence. Selection of the model to address such an individualistic experience such as function is paramount as the different considerations of the desired rehabilitation goals and outcomes of interest are given priority by different models [6]. The lack of obesity-specific outcome measures to quantify physical impairments and ADL limitations prevents stratification of bariatric individuals based on the magnitude of disability [7]. This is useful to establish as a threshold value for inpatient rehabilitation admission, and serves as an objective severity identification tool that impacts on the decision of appropriate rehabilitation setting and chart progress during rehabilitation. An example of such tool is the Obesity-related Disability Test (TSD.OC) developed by Donini et al. that aims to evaluate pertinent obesity- specific functional dimensions [8]. The main targets for bariatric rehabilitation are the cardiorespiratory, musculoskeletal and multi-systemic effects of deconditioning as described above. Strategies that reduce pain, increases strength and mobility as well as optimise functions can be delivered in various settings depending on the severity of obesity-induced disability. Inpatient rehabilitation facility offers an opportunity for more intensive rehabilitation input and caters well to bariatric clients admitted acutely for MSK or CVD that often runs a prolonged hospital stay and poorer functional recovery if left without rehabilitation input. The goals of inpatient rehabilitation are focused on attaining maximal functional independence for safe home discharge through improvements in strength, balance, and endurance coupled with initiation of CVD risk factor control and body weight reduction through dietary and physical activity prescription. An outpatient program may provide significant functional improvements in clients who can access both the centres and their lodging with appropriate means of transportation between them. This is attained by promoting increased pain-free joint range of motion, increasing muscle strength and cardiopulmonary endurance during functional activities. Concurrent efforts to optimise CVD risk factor and improve lean-to-fat mass ratio are also continued in the outpatient setting through education and individualised counselling on dietary and physical activity plan to maximise functional capacity despite excessive weight. Capodaglio et al. conducted a prospective 4-week inpatient bariatric rehabilitation with orthopaedic conditions consisting of strengthening and aerobic exercises adapted to the patient’s mobility; caloric restriction and nutritional education with psychological counselling [7]. The results exemplified that mild and severely disabled bariatric individuals with orthopaedic comorbidities can significantly experience functional improvements independent of the weight loss sustained; with the higher BMI and younger individuals showing the most functional gains. Similarly, Hanapi et al. employed an approach based on the cardiac rehabilitation model and resources for inpatient bariatric clients with CVD risk factors and orthopaedic comorbidities [9]. Employing adapted physical activity and exercise prescription, dietary modification, provision of psychological and social support, their approach successfully addressed weight, cardiometabolic profile optimisation prior to bariatric surgical intervention and conferring postoperative improvement in mood, dependency level, perceived physical and mental health during the postoperative phase with sustained functional capacity, endurance and quality of life up to 3 months post operatively.
Admission planning for an inpatient rehabilitation stay is crucial to ensure logistic requirements, staffing ratio, bariatric-compliant equipment, administrative support and a mobilisation plan is developed as part of a function-centric rehabilitation plan. By definition, bariatric individuals include individuals whose weight exceeds or appears to exceed the identified safe working loads for equipment, lacks mobility or presents with challenges in manual handling [10, 11]. Moving and handling of bariatric clients can accentuate the risks of musculoskeletal injuries and excessive spinal loading in health care workers. Planning of staff and equipment reduces the risks associated with the care of bariatric patients. Safety of patients and health care workers can be enhanced by developing a movement and handling plan as each bariatric admission often presents with unique issues that require problem solving and an understanding of equipment or patient transfer procedures. Involvement of occupational health and safety representatives as well as risk reduction efforts can minimise unplanned situations that may differ between patients due to individuals’ risks, goals and resources available. Every aspect of patient- HCW interaction should be therapeutic from rehabilitation perspective including communication. Open discussion on equipment use and transfer techniques can lead the way to more serious discussions on dietary habits, adapting lifestyles and long-term functional goals. Education on the importance of physical activity and dietary management to aid weight loss and maintain functional independence helps boost motivation and compliance [9]. Discharge planning should include not just physical preparation of the destination. Consideration should be given to post-rehabilitation functional limitations that may require physical help or adaptive equipment as functional goals attainment may require repeated cycles of rehabilitation. Potential home modifications and long-term plans for adapted physical activity, dietary maintenance, psychological support, surveillance for relapses and complications as well as plans for higher functions such as return to work and driving should be discussed with the patients and their social support.
Outpatient bariatric rehabilitation continues the inpatient gains made with focus on long-term prevention of function and weight- gain relapse. The common impairments addressed are osteoarticular pain especially of the lower back and knees as well as joint malalignment. The effects of excessive weight on systemic inflammation, joint compression and premature degenerative disease of the joint can be offset by the role of adapted physical activity which is more pronounced in this setting to maintain compliance to caloric expenditure, CVD prevention and positive psychosocial reinforcement. A combination of both aerobic, resistance and flexibility exercises adapted to individual MSK conditions working on large muscle groups alongside dietary modification has led to improvement in CV biomarkers, fat loss and skeletal muscle gains conferring enhanced functional improvements in programs that include resistance exercises [12, 13]. In comparison to diet modification intervention alone, multimodal exercises program combined with diet interventions conferred lean mass sparing effect [14]. This is also evident in a systematic review of sarcopenic obesity treatment whereby excess fat mass and reduced lean mass impairs physical performance in which weight loss attained through exercise in combination with dietary intervention is the best treatment strategy that improves metabolic consequences of excess fat mass while preserving lean muscle mass and promotes functional recovery [15]. Aerobic exercises for caloric expenditure, reducing joint pain and controlling weight which is a risk factor of osteoarthritis as well as resistance exercise for strengthening of the joint supporting musculature and cartilage health reduces obesity-related joint conditions [16, 17]. As the client returns to the community, psychological support to sustain weight loss motivation and purpose as well as addressing stigma associated with excessive weight is equally important to ensure sustained functional and weight loss gains are maintained. Chronic pain and its effect on gait, psychical activity, participation and quality of life also needs to be addressed.
In conclusion, bariatric rehabilitation addresses common medical comorbidities and obesity related MSK complications through multimodal rehabilitative and allied health interventions, including prescription exercises and diet modification to increase cardiopulmonary endurance and caloric expenditure while minimising fear of movement and joint pain. This in turn leads to progressive body weight reduction and improved comorbidities profile leading to better body composition and physical function capacity.
Bariatric individuals often present with medical comorbidities arising from obesity-related changes or complications sustained from hospitalisation- related bedrest for acute medical crises. Functional impairments evident pre-operatively should be addressed to improve postoperative results and functional independence. The concept of deconditioning is discussed above- the bariatric individual runs a higher risk of developing deconditioning due to delayed weight bearing or resumption of an upright position. This is often multifactorial: common patient related factors such as sarcopenia, kinesiophobia, osteoarticular joint pain and exertional dyspnoea; logistic issues i.e. lack bariatric-safe equipment or staffs’ lack of ergonomic awareness are among easily amenable factors [18]. Deconditioning impacts the geriatric age group more [19]. Adapted exercises have been successful to prevent multisystem deconditioning from zero-gravity environment or from prolonged bed rest [20, 21]. Hanapi et al. demonstrated a 6-weeks bariatric surgery prehabilitation [9] consisting of patient education and prescription of therapeutic exercises, dietary modification and nutritional-behavioural counselling, the use of technological advancement to facilitate early non-weight bearing aerobic and resistance exercises that had successfully prepared the bariatric patients for the demands of the surgery as well as facilitated early post-operative mobilisation that has been purported to reduce post-surgical morbidity [22, 23]. This model adapted the principles of cardiac rehabilitation in formulating the evaluation, intervention and outcomes including risk-stratifying the bariatric surgery candidates for cardiovascular risk during exercise participation, quantifying exercise capacity for exercise prescription and addressing CVD risk factors that can complicate anaesthetic and post-operative care. Priorities were given to utilising adapted physical activity and early mobilisation to translate cardiorespiratory and musculoskeletal reserve improvements into functional mobility and independence in basic activities of daily living. This model along with other bio-psycho-social approaches have shown positive impact on long term functional capacity, endurance, dietary habits, weight loss and quality of life up between 3 to 12-month post-surgery [24].
In the management of a complex, chronic condition such as obesity a multidisciplinary approach has consistently shown the best outcomes [25]. This approach however must be integrated into individual clinical complexity of each individual bariatric patient. An approach that entail evaluation with the intent to individualise treatment plan utilising multimodal treatment strategies i.e. diet, physical activity and functional rehabilitation, educational therapy, cognitive-behaviour therapy, drug therapy, and bariatric surgery will most likely ensure quality of weight loss, addressing the medical and psychiatric comorbidities together, psychosocial problems and physical disability [26]. Older bariatric patients may face a more challenging rehabilitation course due to age-related changes such as sarcopenia, muscular fatty infiltration which leads to strength reduction and diminishing exercise capacity; as well as external factors such as increased inertia from excessive mass causing imbalance, longer exposure to effects of obesity causing pronounced musculoskeletal degeneration and pain as well as more damage in the peripheral tissues [7]. Sarcopenic obesity in advanced age contributes to more dependence in ADL [27]. Muscular and mobility deterioration in combination contributes to exacerbate physiological changes associated with ageing. Thus, identification of such patients earlier prior to surgery is paramount to ensure successful outcomes following bariatric surgery.
The economics of bariatric rehabilitation can be seen from 2 angles- in respect to functional restoration and from a long-term preventive viewpoint. Bariatric individuals who have undergone rehabilitation have shown functional improvement independent of the amount of weight lost, with more pronounced improvement in function observed in the severely disabled individuals [7]. This translates to earlier weight bearing, resumption of mobility and independence in self-care which in turns minimises the risk post-operative complications. Alongside improvement in muscular strength and lean mass, individuals who have undergone rehabilitation also had controlled CVD risk profiles, joint pain and reduced sedentary time conferring protection to future CVD in this high-risk group. However, to truly understand the cost–benefit effect of bariatric rehabilitation, long term outcomes expressed in multiple domains of function are needed to allow better understanding of the effect of different rehab interventions, optimal intensity and duration to therapeutic effect.
Capacity building in an organisation that caters for bariatric rehabilitation is essential to reduce personal risks to patients and staff as well as minimise disruption of bariatric rehabilitation services. This includes developing a bariatric rehabilitation pathway, continuous staff education and training and an audit of the outcomes from the pathway. A bariatric rehabilitation pathway details the appropriate facilities, staff and equipment are available at each stage of the bariatric individuals’ rehabilitation process from admission to outpatient facilities. Although this may incur short term increase in expenditure, the long term return of investment can be quantified through better morbidity and mortality reduction of the bariatric population regardless of conservative or surgical management approach chosen to suit individual medical and functional needs.
Formulation of an individually-tailored rehabilitation program based on each bariatric patients’ clinical complexity should be the priority to holistically manage such clients using a multidisciplinary team approach. Multidisciplinary teams offer the best post-operative outcomes [28], addressing quality of weight loss, medical and psychiatric comorbidities, psychosocial problems and physical disability [29]. To ensure a smooth transition from prehabilitation through postoperative rehabilitation, the physical, biopsychosocial model continues to be relevant and emphasis should be placed on preventing surgical-related complications, secondary prevention of CVD, addressing bariatric-related disabilities, psychological and socio-environmental barriers, enhancing physical function through adapted physical activities, education on nutritional management as well as implementation of sustainable weight management strategies.
The post-bariatric surgery management will require coordinated care from a multidisciplinary team of healthcare providers starting from immediate post-op followed by long-term management. The integration of several medical specialties including clinical nutrition, endocrinology, psychiatry [1], rehabilitation medicine, as well as allied health professionals including physiotherapy, occupational therapy, and nursing should be included as part of the core management team. Each team member should provide detailed assessment of impairments, outline prevention strategies and provide solutions for disease management alongside implementation of a functional restoration program. A functional restoration program post-operatively should aim to not only achieve marked weight loss, but also prevention of weight regain, progression of obesity-associated comorbidities, restoration of physical functioning and increase health-related quality of life.
A post-op functional restoration program can be broadly grouped into two categories:
Medical
Nutritional management
Weight management
Comorbidities
Rehabilitation
Physical activity and exercise training
Psychosocial
The goal of weight loss procedures in general is to either reduce the amount of consumed calories (restrictive) per day or to alter the absorption of the fat (malabsorption) in the food one consumes. For restrictive procedures such as vertical banded gastroplasty (VBG) or laparoscopic adjustable gastric banding (LAGB), that has no malabsorption effect, the volume of food intake will be reduced overall, hence, some nutritional deficiencies may occur. Malabsorptive surgeries such as or biliopancreatic diversion (BPD), gastric sleeve (GS) or Roux-en-Y gastric bypass (RYGB) causes alterations in the intestinal tract and creates challenges in maintaining healthy levels of nutrients including proteins, vitamins and minerals as well as reduction in the absorption of calcium and iron [30].
Management of these potential nutritional deficiencies is therefore paramount for patients undergoing bariatric surgery and strategies should be employed to compensate for food reduction or food intolerance to reduce the risk for clinically important nutritional deficiencies. Signs and symptoms of protein deficiency such as hair loss, fatigue and leg swelling should be monitored. Heber et al. recommended the nutritional management should include: an average of 60 – 120 g of protein daily in all patients to maintain a lean body mass during the weight loss and for the long term to prevent protein malnutrition and its effects, and this is especially important in those treated with malabsorptive procedures to prevent protein malnutrition and its effects [28].
Long-term vitamin and mineral supplementation is recommended in all patients undergoing bariatric surgery with those who have had malabsorptive procedures requiring potentially more extensive replacement therapy to prevent nutritional deficiencies [28]. Specific signs and symptoms of common vitamin and mineral deficiencies include bone pain (calcium), fatigue (iron, vitamin B12), brittle nails (zinc), poor wound healing (vitamin E), easy bruising (vitamin K), numbness and tingling in the hands and feet (vitamin B1). Deficiencies in fat-soluble vitamins A, D, E and K is expected therefore, it is essential for patients to take specially formulated vitamins (A, D, E, and K in water-soluble form). B-complex vitamins, iron, and calcium must also be supplemented at higher than daily recommended levels, because of the impact of the gastric bypass procedure on their absorption. Due to the body’s limited ability to a absorb calcium postoperatively and the acidic environment needed for absorption, a citrated form of calcium is recommended and taken in amounts that meet or exceed daily recommended levels [30]. For maximal absorption, elemental calcium supplements should be taken in divided doses not to exceed 500 mg, three times daily [30]. Iron deficiency is also very common after malabsorptive procedures and iron-fortified foods such as leafy greens, legumes, seafood, iron-fortified grains, red meat and poultry should be consumed on a regular basis. Routine laboratory testing of the iron stores postoperatively may be required with iron supplementation either orally or parenterally administered accordingly by the healthcare provider.
Dumping syndrome may occur as a result of malabsorptive procedures such as RYGB where the food content empties into the small intestine faster than usual. Patients may experience symptoms such as abdominal cramping, nausea and vomiting due to the small intestine being unable to absorb the nutrients from food that have not been fully digested in the stomach. Reactive hypoglycaemia may also occur due to the large surge of insulin after “dumping”. Dietary changes is the mainstay of treatment for dumping syndrome. Avoidance of simple carbohydrates such as white flour and sugar, consumption of more complex carbohydrates such as whole grain and sources of protein such as fish, meat, beans, legumes and soy are recommended. Frequent loose stools is also a potential side-effect of malabsorptive procedures. It is critical that patients stay adequately hydrated to reduce the risk of dehydration. Lack of mobility may also predispose patients with regular soiling of the perineum to skin pathologies including development of pressure areas. Nutritional education is vital to the success of the surgery and prevention of complications. Regular follow-up and periodic monitoring of nutritional deficiencies postoperatively will be required for detection and correction. Lifelong supplementation of daily mineral, multivitamin and micronutrients must be considered.
Following weight loss surgery, patients may lose weight fairly rapidly at first, and then as time passes the weight loss becomes more gradual. Commonly, weight will stabilise at about 18 months after RYGB [30]. During these 18 months, weight loss can be erratic with alternating periods of significant weight loss followed by a plateau. Other than the loss of fat mass, there are many other factors that may contribute to the fluctuations in weight loss during the initial phase. This includes variations in water weight which is dependent upon the individuals’ hydration status, contents of the gastrointestinal tract, gain of muscle mass, or menstrual cycles [30].
Sustainable weight loss strategies should include tailored exercise programs with monitoring of the exercise frequency and intensity to boost metabolic rate for a more rapid weight loss. A generic exercise program with lack of progressive targeted goals may lead to weight loss plateaus. Increase in physical activity and strength training will cause slower weight loss as the fat is replaced by muscle mass, which are denser tissues. This should not be perceived as a deterrent, but rather a positive trend that will lead to a leaner frame and stronger body. The recommended nutritional plan should be adhered to diligently to ensure adequate nutrition and muscle mass is maintained. Most weight regain or plateaus in weight loss boils down to eating habits. It is recommended that a patient eat several small meals a day with the ultimate goal of eating a regular diet in smaller amounts. Binge eating, snacking or grazing should be avoided as the extra calories will add up to the weight gain.
Several anatomic factors may influence weight loss, and this include the size of the gastric pouch which may change over time with the RYGB. As it enlarges over time, it will accommodate larger meals, causing a reduction in weight loss. Anostomotic dilatation between the stomach pouch and the intestine may also occur and this allows quicker emptying of the pouch, reducing its effect on satiety and potential weight loss [30]. This is also the underlying reason why one should not drink during meals after gastric bypass as it will result in a more rapid transition of solid food from the gastric pouch, eliminating the effect on satiety resulting in ingestion of larger portions. The resultant change in anatomic structure after malabsorptive procedures such as the RYGB also alters the absorption of food with higher absorption of fats, thus reducing the benefit of the surgery [30]. Eating small meals high in protein may help mitigate this effect.
Plateaus and fluctuations in weight loss are to be expected throughout various phases post-surgery. Constant reassurance, providing patient education on the expected outcomes and exploring together the underlying causes of weight plateaus can increase understanding, avoid miscommunication, avert patient depression or frustration with the surgery. A regular exercise regimen and adherence to correct eating behaviour and nutritional intake may lead to greater outcome and a more sustainable long-term weight loss.
Frequently, patients undergoing bariatric surgery have associated comorbidities including Type 2 Diabetes Mellitus, cardiovascular disease, lipid abnormalities, fatty liver, degenerative joint disease, hypertension, gastroesophageal reflux disease, and obstructive sleep apnea with considerable impact on disability and quality of life. To reduce the likelihood of weight regain and to ensure that comorbid conditions are adequately managed, all patients should receive careful medical follow-up postoperatively. Monitoring postoperative glycaemic control should consist of achieving glycated HBA1c of 7% or less with fasting blood glucose no greater than 110 mg/dl and postprandial glucose no greater than 180 mg/dl [28]. Lipid abnormalities should be monitored and treated with lipid-lowering therapy that remain above desired goals should be continued. However due to the dramatic reductions in lipid levels, the doses of lipid-lowering drugs should be periodically evaluated [28]. Ideally, a multidisciplinary team should be in place before the operation is performed. The bariatric surgeon should be part of this comprehensive team that provides pre- and postoperative care. The inclusion of other medical specialties in the team including endocrinologists, gastroenterologists and rehabilitation physicians allow a more holistic approach for the treatment of patients with multiple comorbidities and associated impairments and disabilities.
Surgery-induced weight loss by itself was associated with a series of beneficial health effects, including increased objectively measured habitual physical activity and cardiorespiratory fitness [29]. Using a cardiac rehabilitation model is effective to cause significant improvement in bariatric individuals’ cardio-metabolic profile [31]. Hanapi et al. demonstrates the application of cardiac rehabilitation principle for post-bariatric surgery patients which include risk stratification through the use of submaximal exercise stress testing to objectively quantify the patient’s cardiovascular capacity for exercise participation, subsequent exercise prescription based on the individuals’ physical impairments and cardiovascular functioning, lifestyle modification to manage cardiovascular risk factors and translating the gains of cardiorespiratory and musculoskeletal fitness into more functional activities [9].
Postoperative exercise is imperative and remains the most important factor that can help a patient achieve long-standing and successful weight loss. Exercises can begin as early as day one postoperatively and short term and long term goals should be set early on and revised as activity and exercise capacity increases. The exercise program should incorporate muscle strengthening, physical endurance or aerobic exercises to improve cardiorespiratory fitness, balance training, functional mobility, musculoskeletal reconditioning, joint protection as well activity of daily living (ADL) training, tailored individually within the limit of patients’ cardiovascular capacity.
To sustain weight loss, effective behaviour changes towards increasing energy expenditure through occupational, leisure time and planned physical activity needs to occur alongside dietary management [32]. Physical activity can be incorporated to daily activities which helps with caloric expenditure or decreasing the amount of sitting time or sedentary leisure activities. Education on the importance of physical activities to aid weight loss and maintain functional independence helps boost motivation and compliance. This ultimately affects their level of independence, quality of life and self-efficacy [9].
In addition to loss of fat mass, there are other numerous benefits to exercise. These benefits include prevention of loss of muscle mass when losing weight rapidly after surgery, and improved overall weight loss. Exercise may also reduce a person’s appetite, increases immunity and reduces fatigue which may lead to improved self-confidence, and overall improved sense of well-being.
A substantial number of patients experience poor long-term outcomes following bariatric surgery which may be contributed by difficulty in making and sustaining changes in dietary intake and physical activity as well as post-surgery binge eating, which has also been associated with poorer weight outcomes [33]. A thorough preoperative assessment to evaluate patients’ understanding of the disease condition, identifying any misconceptions, assessing readiness and commitment to undergo a radical change in lifestyle and behaviour modification, as well identifying issues that may pose as barriers may be the key to a successful and sustainable weight management postoperatively. Sheets et al. recommend that preoperative assessment should include identifying patients strengths and weaknesses, educating patients thoroughly about postoperative changes including dietary intake and physical activity, coaching on lifestyle change strategies as well as offering specific recommendations to address any areas of concern [34]. The period post bariatric surgery is still a vulnerable time for most individuals as the reality sinks in as adjustment of behaviours and new habits take place. The need for continuous care and screening of psychosocial issues throughout both pre-and postoperative periods cannot be undermined. Screening for aberrant eating behaviours and depressive symptoms should be assessed whilst administering interventions to address emotional and psychological issues, behavioural modification strategies, increase compliance, and provide support [34]. It is the responsibility of each team member to detect or identify the presence of any psychological issues, and administer interventions through early referral to mental health professionals to improve outcomes of these individuals.
An ecosystem is qualified as extreme when it’s physicochemical parameters are most often hostile to life Grégoire, Fardeau, Guasco, Bouanane, Michotey and Bonin [1]. Indeed, any biotope characterized by a very low or very high value of the main parameters that influence their life cycle can be characterized as an extreme environment [2]. These parameters are essentially temperature, salinity, pH, pressure, radiation, desiccation, and oxygenation. Organisms with the ability to live in extreme environments are called “extremophiles”. And as a result, several groups have been described taking into account the extreme conditions they can tolerate [1]. These are essentially prokaryotic microorganisms, mostly belonging to the Archaea group. Eukaryotes can also be recorded in extreme environments. They are essentially unicellular algal or fungal organisms [3].
Among these environments, hypersaline ecosystems are very widespread and they can be classified into natural and artificial biotopes. While the natural environments are essentially represented by salt lakes, lagoon and, Sabkhas, the artificial hypersaline environments are represented by saltworks. These latter are transitional ecosystems between the marine and the continental domain [4], consisting of shallow ponds used for the production of halite (NaCl) from seawater which is pumped to the first series of ponds. After an evaporation cause a sufficient increase in salinity, the water is transferred to the next series of ponds, and so on, until brine saturated with NaCl is obtained, from which the halite precipitates in the last series of ponds recognized the crystallization ponds. The salinity in each of the ponds is thus maintained more or less constant over time [5]. This process leads to the selection of the variety of microbial heterotrophs and autotrophs and ciliated protozoa [4]. Species were adapted to different salinity variations [6]. The Sfax solar saltern (Tunisia) is an artificial paralic ecosystem characterized by its floristic and faunal richness [7], as well as by its microalgae richness [8, 9]. This biotope has been the site of several studies since 1998: (i) microalgae [10], (ii) ciliates [11] and (iii) zooplankton [12, 13, 14] especially the branchiopod crustacean
Microalgae are very rarely grouped according to their energy metabolism or even according to their ability to synthesize the necessary metabolites, but rather according to their morphological properties [21]. There are therefore different taxonomic classes of microalgae, the main ones being Rhodophyceae, Chlorophyceae, Bacillariophyceae, Euglenophyceae, Dinophyceae and Cyanobacteria. Microalgae occupy a very important place in nature since they are at the base of a long food chain and contain impressive nutritional proerties [22]. Moreover, they have various fields of exploitation, due to the value-added molecules. The biochemical composition of microalgae proves that they contain high value natural fatty acids (omega-3), which can produce a high value dietary supplement [23]. Furthermore, microalgae contain a high amount of proteins reaching up to 70% of the dry matter for
In this chapter we will present the biodiversity of the halophilic microalgae of the Sfax solar saltern and the different techniques used for the isolation and valorization of culture or metabolites extracted from three microalgal species.
The Sfax solar salternor the Thyna salt works (Figure 1) is an artificial system located in the Gulf of Gabes in an arid climate (34° 39′N and 10° 42′E). This system is composed of several interconnected shallow ponds (20 to 70 cm deep) with increasing salinities from the water intake (40 PSU) to the salt Tables (450 PSU) [9]. The saline is separated from the sea by a dam of red silt about 4 m high running along the southern coast of the city of Sfax for about 13 km (Figure 1), from the port area to the village of Gargour, occupying an area of 1500 ha [29]. It is one of the most important salt production areas in Tunisia (300,000 T of salt per year). A total of 45 microalgae taxa were recorded from the Sfax solar saltern and identified belonging to five groups: diatoms, dinoflagellates, Chlorophyceae, Euglenophyceae and Cyanobacteria. For each group, we clearly observed a marked decrease in the number of taxa with the increase of salinity (Table 1, Figure 2). Diatoms were dominant in ponds that have salinity ranges from 40 to 80 PSU (67.95% of the microalgae total abundance), whereas the dinoflagellates represented only 22.19% and Euglenophyceae were poorly represented in this pond (1.2%) (Figure 2). Dinoflagellates dominated the densities and biomasses of microalgae in the ponds of 80–200 PSU, contributing to 56.7% and 34.4% of the microalgae total abundance, respectively. Chlorophytes largely dominated in the crystallization ponds>200 salinity which accounting for 69.1% of the total microalgae. While Cyanobacteria were relatively abundant in ponds of medium salinity (19.9%) they were rare in hypersaline ponds (0.5%) (Figure 2, Table 1).
General map of the Sfax Saltern showing the three levels of increasing salinity.
Salinity (PSU) | Microalgae | Species |
---|---|---|
40–80 | Pennate diatoms | |
Centric diatoms | ||
Dinoflagellates | ||
Euglenophyceae | ||
80–200 | Pennate diatoms | |
Dinoflagellates | ||
Cyanobacteria | ||
Chlorophyceae | ||
200–450 | Cyanobacteria | |
Chlorophyceae |
Classification of microalgae species recorded in Sfax solar saltern according to the salinity gradient [9].
*Species isolated and cultured in laboratory.
Mean relative contribution of microalgae groups to total microalgae biomass in six ponds of increasing salinity in the saline of Sfax Tunisia [
Three different microalgae species were isolated from the three level of salinity of Sfax solar saltern: the diatom
Microscopic observation (G ×100) of (a)
The growth of
The cyanobacterium
with.
OD: Optical density.
υ: volume of the acetone extract (ml).
V: volume of the algae suspension (ml).
The dosage of photosynthetic pigments of each microalgal species was carried out after extraction in 90% acetone. The concentration of Chlorophyll
Equation of Jeffrey and Humphrey [36] for Chlorophyceae:
Equation of Jeffrey and Humphrey [35] for Diatom
Carotenoid concentrations were calculated according to the equation of Chamovitz, Sandmann and Hirschberg [36] for cyanobacterium and according to Salguero et al. [37] for Chlorophyceae.
Cyanobacteria carotenoid (μg l−1) = (OD461nm − 0.046OD664nm) × 4
Chlorophyceae Carotenoid (μg l−1) = 0.0045 (3000OD470nm − 1.63OD750nmChl
The phycocyanin (C-PC) pigment was isolated from
The dry matter of microalgae was determined according to the AOAC standard methods [39]. The protein assay method of Lowry [40] was used by the combination of Folin with Biuret’s reagents. The Lipids content was determined gravimetrically after the Soxhlet extraction of dried samples with hexane for 2 hours using Nahita Model 655 (Navarra, Spain). The sugars were estimated by phenol-sulfuric acid method [41] using glucose as a standard. The total phenol content of the
The analyses of sodium, potassium, calcium, magnesium, iron, copper, and zinc contents in
For fatty acids analyses, cultures were harvested at the end of the log phase. All lipids were evaporated to dryness with nitrogen and concentrated with hexane. Fatty acids methyl esters (FAMEs) were prepared from the lipid extract by transesterification using a direct transmethylation method according to Lepage and Roy [44]. The FAMEs were then extracted with hexane and determined quantitatively by capillary gas chromatography. We used a Chromopack, CP 9001 gas chromatograph, HPS 5890 series II chromatograph, equipped with a polar 25-m capillary column CP wax 58 (Varian SA, France) (0.32 mm diameter and a layer thickness of 0.52 mm), and a flame ionization detector (FID). We used a splitless injection system with nitrogen as the carrier gas. The oven was programmed to rise from an initial temperature of 180–250°C at rates of 10°C min−1 (from 180 to 220), 2°C min−1 (from 220 to 240), and 5°C min−1 (from 240 to 250). Individual FAMEs were identified by comparing retention times with those obtained with laboratory standards and the manufacturer’s instructions (Supelco).
The four growth phases—lag, exponential, stationary and decline growth phases—are only observed on growth curves of
For
Growth curves of
Microalgae could be easily grown in a laboratory and used for large-scale cultivation in bioreactors with the ability to control the quality of the cultures by providing purified culture medium that is free of toxic substances. Therefore, microalgae provide a more accessible way to produce qualitative biomolecules of interest [48, 49, 50]. Physicochemical characteristics of
Component | |||
---|---|---|---|
Dry matter (%Fw) | 7 ± 0.45 | 10 ± 0.66 | — |
Proteins (%Dw) | 27.62 ± 0.33 | 42 ± 0.78 | 41.39 ± 6.40 |
Lipids (%Dw) | 11.14 ± 0.19 | 15.7 | 27.04 ± 19.74 |
Total sugars (%Dw) | 12.60 ± 0.76 | 21.56 ± 0.99 | 13.33 ± 8.06 |
Aches(% Dw) | 37.78 ± 0.43 | — | — |
Chlorophyll a (%Dw) | 4.94 ± 0.27 | 7.05 ± 0.81 | 17.02 ± 7.78 |
Phycocyanin (%Dw) | — | 13 ± 0.47 | — |
Cartenoids(%DW) | 1.083 ± 0.05 | 1.79 ± 0.08 | 1.22 ± 0.39 |
Polyphenols(mgGAE g−1) | 38.27 ± 2.21 | 408.5 ± 18,18 | — |
Flavonoides(mgGAE g−1) | 17.69 ± 0.70 | 13.67 ± 0.78 | — |
Physicochemical characteristics of three microalgae species.
Data are expressed as mean ± standard deviation of triplicates. FW: fresh weight; DW: dry weight; GAE: gallic acid equivalent; − not realized.
Mineral | |
---|---|
Sodium (g Kg−1DW) | 1.125 ± 0.2 |
Potassium (g Kg−1DW) | 0.485 ± 0.05 |
Calcium (g Kg−1DW) | 0.584 ± 0.05 |
Magnesium (g Kg−1DW) | 0.747 ± 0.1 |
Iron (g Kg−1DW) | 0.016 ± 0.002 |
Copper (g Kg−1DW) | 0.008 ± 0.001 |
Zinc (g Kg−1DW) | 0.008 ± 0.001 |
Mineral content of
The fatty acid profile of
Fatty acids | ||
---|---|---|
C14:0 | 3.623 ± 0.3 | 2.8 ± 1.2 |
C15:0 | 3.418 ± 0.3 | — |
C16:0 | 27.427 ± 0.5 | 21.0 ± 3.5 |
C17:0 | 1.664 ± 0.4 | — |
C18:0 | 1.974 ± 0.3 | 9.05 ± 1.0 |
C20:0 | 0.734 ± 0.2 | — |
C24:0 | 2.468 ± 0.2 | — |
SFA | ||
C14:1 | 3.386 ± 0.3 | 9.6 ± 1.1 |
C16:1 | 45.089 ± 0.8 | 2.2 ± 1.2 |
C17:1 | 0.521 ± 0.1 | — |
C18:1 | 3.658 ± 0.3 | 14.9 ± 1.2 |
MUFA | ||
C16:2 | 1.603 ± 0.2 | — |
C16:3 | 0.924 ± 0.3 | 0.1 ± 0.1 |
C16:4 | — | 14.0 ± 2.3 |
C18:2 | 0.432 ± 0.1 | 0.9 ± 0.2 |
C18:3 | — | 0.8 ± 0.3 |
C18:4 | — | 0.6 ± 0.2 |
C20:4 | 0.712 ± 0.2 | — |
C20:5 (EPA) | 2.367 ± 0.3 | 0.1 ± 0.1 |
C22:6 (DHA) | — | 4.3 ± 1.3 |
PUFA |
Moreover,
In conclusion, the saline of Sfax presents a high microalga diversified. Three species
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Structures and Mode of Action as Potential Chemotherapeutic Agents",slug:"phytochemicals-extraction-methods-basic-structures-and-mode-of-action-as-potential-chemotherapeutic-",totalDownloads:95158,totalCrossrefCites:15,totalDimensionsCites:113,abstract:null,book:{id:"878",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",title:"Phytochemicals",fullTitle:"Phytochemicals - A Global Perspective of Their Role in Nutrition and Health"},signatures:"James Hamuel Doughari",authors:[{id:"65370",title:"Dr.",name:"James",middleName:null,surname:"Hamuel Doughari",slug:"james-hamuel-doughari",fullName:"James Hamuel Doughari"}]},{id:"49274",doi:"10.5772/61368",title:"Reactive Oxygen Species and Antioxidant Enzymes Involved in Plant Tolerance to Stress",slug:"reactive-oxygen-species-and-antioxidant-enzymes-involved-in-plant-tolerance-to-stress",totalDownloads:4920,totalCrossrefCites:47,totalDimensionsCites:106,abstract:"Plants are continuously exposed to several stress factors in field, which affect their production. These environmental adversities generally induce the accumulation of reactive oxygen species (ROS), which can cause severe oxidative damage to plants. ROS are toxic molecules found in various subcellular compartments. The equilibrium between the production and detoxification of ROS is sustained by enzymatic and nonenzymatic antioxidants. Due to advances in molecular approaches during the last decades, nowadays it is possible to develop economically important transgenic crops that have increased tolerance to stresses. This chapter discusses the oxidative stress and damage to plants. In addition, it reports the involvement of antioxidant enzymes in the tolerance of plants to various stresses.",book:{id:"5066",slug:"abiotic-and-biotic-stress-in-plants-recent-advances-and-future-perspectives",title:"Abiotic and Biotic Stress in Plants",fullTitle:"Abiotic and Biotic Stress in Plants - Recent Advances and Future Perspectives"},signatures:"Andréia Caverzan, Alice Casassola and Sandra Patussi Brammer",authors:[{id:"176303",title:"Dr.",name:"Alice",middleName:null,surname:"Casassola",slug:"alice-casassola",fullName:"Alice Casassola"},{id:"176409",title:"Dr.",name:"Andréia",middleName:null,surname:"Caverzan",slug:"andreia-caverzan",fullName:"Andréia Caverzan"},{id:"176410",title:"Dr.",name:"Sandra",middleName:null,surname:"Patussi Brammer",slug:"sandra-patussi-brammer",fullName:"Sandra Patussi Brammer"}]},{id:"49289",doi:"10.5772/61442",title:"Abiotic and Biotic Elicitors–Role in Secondary Metabolites Production through In Vitro Culture of Medicinal Plants",slug:"abiotic-and-biotic-elicitors-role-in-secondary-metabolites-production-through-in-vitro-culture-of-me",totalDownloads:6998,totalCrossrefCites:40,totalDimensionsCites:106,abstract:"Plant secondary metabolites are having the great application in human health and nutritional aspect. Plant cell and organ culture systems are feasible option for the production of secondary metabolites that are of commercial importance in pharmaceuticals, food additives, flavors, and other industrial materials. The stress, including various elicitors or signal molecules, often induces the secondary metabolite production in the plant tissue culture system. The recent developments in elicitation of plant tissue culture have opened a new avenue for the production of secondary metabolite compounds. Secondary metabolite synthesis and accumulation in cell and organ cultures can be triggered by the application of elicitors to the culture medium. Elicitors are the chemical compounds from abiotic and biotic sources that can stimulate stress responses in plants, leading to the enhanced synthesis and accumulation of secondary metabolites or the induction of novel secondary metabolites. Elicitor type, dose, and treatment schedule are major factors determining the effects on the secondary metabolite production. The number of parameters, such as elicitor concentrations, duration of exposure, cell line, nutrient composition, and age or stage of the culture, is also important factors influencing the successful production of biomass and secondary metabolite accumulation. This chapter reviews the various abiotic and biotic elicitors applied to cultural system and their stimulating effects on the accumulation of secondary metabolites.",book:{id:"5066",slug:"abiotic-and-biotic-stress-in-plants-recent-advances-and-future-perspectives",title:"Abiotic and Biotic Stress in Plants",fullTitle:"Abiotic and Biotic Stress in Plants - Recent Advances and Future Perspectives"},signatures:"Poornananda M. Naik and Jameel M. Al–Khayri",authors:[{id:"176282",title:"Prof.",name:"Jameel M.",middleName:null,surname:"Al-Khayri",slug:"jameel-m.-al-khayri",fullName:"Jameel M. Al-Khayri"},{id:"176284",title:"Dr.",name:"Poornananda M.",middleName:null,surname:"Naik",slug:"poornananda-m.-naik",fullName:"Poornananda M. Naik"}]}],mostDownloadedChaptersLast30Days:[{id:"66996",title:"Ethiopian Common Medicinal Plants: Their Parts and Uses in Traditional Medicine - Ecology and Quality Control",slug:"ethiopian-common-medicinal-plants-their-parts-and-uses-in-traditional-medicine-ecology-and-quality-c",totalDownloads:4059,totalCrossrefCites:6,totalDimensionsCites:10,abstract:"The main purpose of this review is to document medicinal plants used for traditional treatments with their parts, use, ecology, and quality control. Accordingly, 80 medicinal plant species were reviewed; leaves and roots are the main parts of the plants used for preparation of traditional medicines. The local practitioners provided various traditional medications to their patients’ diseases such as stomachaches, asthma, dysentery, malaria, evil eyes, cancer, skin diseases, and headaches. The uses of medicinal plants for human and animal treatments are practiced from time immemorial. Stream/riverbanks, cultivated lands, disturbed sites, bushlands, forested areas and their margins, woodlands, grasslands, and home gardens are major habitats of medicinal plants. Generally, medicinal plants used for traditional medicine play a significant role in the healthcare of the majority of the people in Ethiopia. The major threats to medicinal plants are habitat destruction, urbanization, agricultural expansion, investment, road construction, and deforestation. Because of these, medicinal plants are being declined and lost with their habitats. Community- and research-based conservation mechanisms could be an appropriate approach for mitigating the problems pertinent to the loss of medicinal plants and their habitats and for documenting medicinal plants. Chromatography; electrophoretic, macroscopic, and microscopic techniques; and pharmaceutical practice are mainly used for quality control of herbal medicines.",book:{id:"8502",slug:"plant-science-structure-anatomy-and-physiology-in-plants-cultured-in-vivo-and-in-vitro",title:"Plant Science",fullTitle:"Plant Science - Structure, Anatomy and Physiology in Plants Cultured in Vivo and in Vitro"},signatures:"Admasu Moges and Yohannes Moges",authors:[{id:"249746",title:"Ph.D.",name:"Admasu",middleName:null,surname:"Moges",slug:"admasu-moges",fullName:"Admasu Moges"},{id:"297761",title:"MSc.",name:"Yohannes",middleName:null,surname:"Moges",slug:"yohannes-moges",fullName:"Yohannes Moges"}]},{id:"63148",title:"Domestic Livestock and Its Alleged Role in Climate Change",slug:"domestic-livestock-and-its-alleged-role-in-climate-change",totalDownloads:15897,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"It is very old wisdom that climate dictates farm management strategies. In recent years, however, we are increasingly confronted with claims that agriculture, livestock husbandry, and even food consumption habits are forcing the climate to change. We subjected this worrisome concern expressed by public institutions, the media, policy makers, and even scientists to a rigorous review, cross-checking critical coherence and (in)compatibilities within and between published scientific papers. Our key conclusion is there is no need for anthropogenic emissions of greenhouse gases (GHGs), and even less so for livestock-born emissions, to explain climate change. Climate has always been changing, and even the present warming is most likely driven by natural factors. The warming potential of anthropogenic GHG emissions has been exaggerated, and the beneficial impacts of manmade CO2 emissions for nature, agriculture, and global food security have been systematically suppressed, ignored, or at least downplayed by the IPCC (Intergovernmental Panel on Climate Change) and other UN (United Nations) agencies. Furthermore, we expose important methodological deficiencies in IPCC and FAO (Food Agriculture Organization) instructions and applications for the quantification of the manmade part of non-CO2-GHG emissions from agro-ecosystems. However, so far, these fatal errors inexorably propagated through scientific literature. Finally, we could not find a clear domestic livestock fingerprint, neither in the geographical methane distribution nor in the historical evolution of mean atmospheric methane concentration. In conclusion, everybody is free to choose a vegetarian or vegan lifestyle, but there is no scientific basis, whatsoever, for claiming this decision could contribute to save the planet’s climate.",book:{id:"7491",slug:"forage-groups",title:"Forage Groups",fullTitle:"Forage Groups"},signatures:"Albrecht Glatzle",authors:[{id:"252990",title:"Dr.",name:"Albrecht",middleName:null,surname:"Glatzle",slug:"albrecht-glatzle",fullName:"Albrecht Glatzle"}]},{id:"66714",title:"Biotic and Abiotic Stresses in Plants",slug:"biotic-and-abiotic-stresses-in-plants",totalDownloads:5808,totalCrossrefCites:54,totalDimensionsCites:96,abstract:"Plants are subjected to a wide range of environmental stresses which reduces and limits the productivity of agricultural crops. Two types of environmental stresses are encountered to plants which can be categorized as (1) Abiotic stress and (2) Biotic stress. The abiotic stress causes the loss of major crop plants worldwide and includes radiation, salinity, floods, drought, extremes in temperature, heavy metals, etc. On the other hand, attacks by various pathogens such as fungi, bacteria, oomycetes, nematodes and herbivores are included in biotic stresses. As plants are sessile in nature, they have no choice to escape from these environmental cues. Plants have developed various mechanisms in order to overcome these threats of biotic and abiotic stresses. They sense the external stress environment, get stimulated and then generate appropriate cellular responses. They do this by stimuli received from the sensors located on the cell surface or cytoplasm and transferred to the transcriptional machinery situated in the nucleus, with the help of various signal transduction pathways. This leads to differential transcriptional changes making the plant tolerant against the stress. The signaling pathways act as a connecting link and play an important role between sensing the stress environment and generating an appropriate biochemical and physiological response.",book:{id:"8015",slug:"abiotic-and-biotic-stress-in-plants",title:"Abiotic and Biotic Stress in Plants",fullTitle:"Abiotic and Biotic Stress in Plants"},signatures:"Audil Gull, Ajaz Ahmad Lone and Noor Ul Islam Wani",authors:null},{id:"62573",title:"Introductory Chapter: Terpenes and Terpenoids",slug:"introductory-chapter-terpenes-and-terpenoids",totalDownloads:7556,totalCrossrefCites:27,totalDimensionsCites:51,abstract:null,book:{id:"6530",slug:"terpenes-and-terpenoids",title:"Terpenes and Terpenoids",fullTitle:"Terpenes and Terpenoids"},signatures:"Shagufta Perveen",authors:[{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen"},{id:"192994",title:"Dr.",name:"Areej",middleName:null,surname:"Al-Taweel",slug:"areej-al-taweel",fullName:"Areej Al-Taweel"}]},{id:"62876",title:"Introduction to Phytochemicals: Secondary Metabolites from Plants with Active Principles for Pharmacological Importance",slug:"introduction-to-phytochemicals-secondary-metabolites-from-plants-with-active-principles-for-pharmaco",totalDownloads:5802,totalCrossrefCites:10,totalDimensionsCites:25,abstract:"Phytochemicals are substances produced mainly by plants, and these substances have biological activity. In the pharmaceutical industry, plants represent the main source to obtain various active ingredients. They exhibit pharmacological effects applicable to the treatment of bacterial and fungal infections and also chronic-degenerative diseases such as diabetes and cancer. However, the next step in science is to find new ways to obtain it. In this chapter, we discuss about the main groups of phytochemicals, in addition to presenting two case studies. One of the most important secondary metabolites is currently Taxol, which is a natural compound of the taxoid family and is also known for its antitumor activity against cancer located in breasts, lungs, and prostate and is also effective with Kaposi’s sarcoma. Our case studies will be about Taxol, extracted from an unexplored plant species, and the production of Taxol by its endophytic fungi.",book:{id:"6794",slug:"phytochemicals-source-of-antioxidants-and-role-in-disease-prevention",title:"Phytochemicals",fullTitle:"Phytochemicals - Source of Antioxidants and Role in Disease Prevention"},signatures:"Nadia Mendoza and Eleazar M. Escamilla Silva",authors:[{id:"51406",title:"Dr.",name:"Eleazar",middleName:"Máximo",surname:"Escamilla Silva",slug:"eleazar-escamilla-silva",fullName:"Eleazar Escamilla Silva"},{id:"243304",title:"Ph.D. Student",name:"Nadia",middleName:null,surname:"Mendoza",slug:"nadia-mendoza",fullName:"Nadia Mendoza"}]}],onlineFirstChaptersFilter:{topicId:"41",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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