Relative comparison between pharmacological, surgical and meal replacement approaches to obesity treatment and prevention.
\r\n\tThis book intends to provide the reader with a comprehensive overview of the current state-of-the-art novel imaging techniques by focusing on the most important evidence-based developments in this area.
",isbn:null,printIsbn:null,pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"d9159ce31733bf78cc2a79b18c225994",bookSignature:"Dr. Gabriel Cismaru",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11867.jpg",keywords:"Hypertrophic Cardiomyopathy, Dilated Cardiomyopathy, Restrictive Cardiomyopathy, Transesophageal Echocardiography, Intracardiac Echocardiography, 3-Dimensional Echocardiography, Adult Congenital Heart Disease, Tetralogy of Fallot, Transposition of the Great Vessels, Coronary Artery Disease, Risk Stratification, Revascularization",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 21st 2022",dateEndSecondStepPublish:"May 19th 2022",dateEndThirdStepPublish:"July 18th 2022",dateEndFourthStepPublish:"October 6th 2022",dateEndFifthStepPublish:"December 5th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"3 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Cismaru Gabriel is an Assistant Professor at the University of Medicine and Pharmacy Cluj-Napoca, certified in Cardiology. After completing his certification in cardiology, Dr. Cismaru began his electrophysiology fellowship at the Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu. He has authored or co-authored peer-reviewed articles and book chapters in the field of cardiac pacing, defibrillation, electrophysiological study, and catheter ablation.",coeditorOneBiosketch:"Raluca Tomoaia is an MD, Ph.D. in novel techniques in Echocardiography at the University of Medicine and Pharmacy in Cluj-Napoca, Romania., assistant professor, and a researcher in echocardiography and cardiovascular imaging.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"191888",title:"Dr.",name:"Gabriel",middleName:null,surname:"Cismaru",slug:"gabriel-cismaru",fullName:"Gabriel Cismaru",profilePictureURL:"https://mts.intechopen.com/storage/users/191888/images/system/191888.png",biography:"Dr. Cismaru Gabriel is an assistant professor at the Cluj-Napoca University of Medicine and Pharmacy, Romania, where he has been qualified in cardiology since 2011. He obtained his Ph.D. in medicine with a research thesis on electrophysiology and pro-arrhythmic drugs in 2016. Dr. Cismaru began his electrophysiology fellowship at the Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, France, after finishing his cardiology certification with stages in Clermont-Ferrand and Dinan, France. He began working at the Rehabilitation Hospital\\'s Electrophysiology Laboratory in Cluj-Napoca in 2011. He is an experienced operator who can implant pacemakers, CRTs, and ICDs, as well as perform catheter ablation of supraventricular and ventricular arrhythmias such as ventricular tachycardia and ventricular fibrillation. He has been qualified in pediatric cardiology since 2022, and he regularly performs device implantation and catheter ablation in children. 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Nutrition survey data suggest that populations are becoming overfed, yet undernourished, due to the poor nutrient density of the diet, contributing simultaneously to elevated rates of chronic disease and nutrient inadequacy. Meal replacements (MR)—a prepackaged, calorie‐controlled product in a bar or powder mix that can be made into a shake or beverage—have long been validated as safe and effective tools for weight loss (and weight maintenance). More recent studies have indicated that high‐protein MR are also effective at maintaining lean body mass and reducing visceral body fat during weight loss. This review focuses on MR that do not require medical supervision (those classified as medical foods).
\nDepending on the formulation, MR also possess the advantage of having a low glycemic index (GI) value; low‐GI diets have been linked to improved weight maintenance and reduction in risk of diabetes and ocular disease. Many nutrition researchers and authoritative bodies around the world have highlighted the need to improve the nutrient density of diets as a means to reduce obesity while maintaining optimal nutrition status. MR also tend to be nutrient dense, meaning that they possess a high ratio of essential nutrients relative to calories.
\nSome markets have established clear regulatory standards and definitions for the composition and marketing claims for MR (e.g., Codex, Canada, EU, Brazil, Korea, Indonesia). However, several large markets (e.g., US, Mexico, China, Russia, India) still lack these important standards, in turn limiting research opportunities and recognition by governments, healthcare professionals and consumers of the value the category provides.
\nThe aim of this chapter is to review the extensive body of literature validating the safety and effectiveness of MR as weight loss and weight maintenance tools; explore the benefits of MR beyond weight loss, including maintenance of lean body mass and low glycemic index; discuss the concept of nutrient density, its importance in nutrition and how MR fit into a nutrient‐dense diet; and discuss the need for regulatory standards to be established in those countries that currently lack a definition for MR.
According to the most recent global analysis, obesity rates continue to rise at an alarming level overall, reaching 50% of the population in some countries (Figure 1), with the prevalence in women rising faster than that for men. Globally, the prevalence of obesity now exceeds that of underweight (NCD Risk Factor Collaboration 2016). Although obesity rates in some developed countries appear to have leveled off (e.g., US men) [1], comorbidities, such as type II diabetes, continue to rise. The World Health Organization (WHO) estimates the prevalence of diabetes has doubled worldwide since 1980 and resulted in 3.7 million deaths in 2012, with combined direct and indirect costs estimated in the $billions annually [2]. With overweight and obesity recognized as the strongest risk factors for type II diabetes, the WHO recommends obesity prevention, through healthy diet and physical activity, as a key approach.
World Health Organization Global Health Observatory (GHO) data. Global overweight and obesity prevalence.
Few tools have been validated as safe and effective in the treatment or prevention of obesity and overweight. Bariatric surgery is effective at treating those who are morbidly obese, yet it is associated with substantial risks and postsurgery complications, including nutrient deficiency. While advances in science and technology have eventually provided several efficacious pharmaceutical drugs for obesity treatment, the effects are modest and associated with a myriad of side effects [3], and many FDA‐approved prescription weight loss drugs have been subsequently withdrawn from the market due to safety concerns [4]. In contrast, nearly 150 studies demonstrate that use of MR (in various forms) safely reduces energy intake and results in sustainable weight loss (Table 1). A systematic review published concluded that MR safely and effectively produce sustainable weight loss [5]. The systematic review included six randomized, controlled MR intervention studies of at least 3 months duration, involving adults with a body mass index (BMI) ≥ 25 kg/m2.
Approach | Category | Effectiveness for obesity treatment—long term (>1 year) | Side and adverse effects |
---|---|---|---|
Pharmacological | Prescription drug | 5% total body weight (Khera 2016) | Significant and serious, with some drugs having received FDA approval, then subsequently withdrawn from the market |
Bariatric surgery | Medical device | 30% of total body weight in the morbidly obese (Chow 2016) | High risks associated with surgery and postsurgery complications, including nutrient inadequacy or deficiency |
Meal replacements | Conventional food and medical food | 7–8% total body weight (Heymsfield 2003) | Only nonserious (nuisance) effects reported |
Relative comparison between pharmacological, surgical and meal replacement approaches to obesity treatment and prevention.
More recent studies have demonstrated MR effectiveness at maintaining weight loss up to several years. Intervention studies involving MR use with a year or more of follow‐up have shown a range of sustained weight loss from 2% up to 11% of baseline body weight (Figure 2) [6–21].
Weight loss and maintenance from randomized controlled trials ≥1 year in duration involving meal replacement.
Portion size is a key factor in determining energy intake and may be closely linked to obesity. Research indicates that portion size is directly correlated with energy intake, suggesting that controlling portion size is an effective approach to reduce energy intake and combat obesity [22]. Among the few portion control tools researched to date, liquid MR are considered among the most effective and consistent, particularly if combined with other efforts to encourage consumption of high‐nutrient‐dense, low‐energy‐dense foods [22]. Furthermore, MR promote adherence to a restricted calorie diet due to simple preparation and convenience compared to preparing and cooking low‐calorie foods at home. MR generally contain a tight range of total calories, macro‐ and micronutrients (Figure 3), and are a nutrient‐dense tool, especially useful for supporting adherence to a calorie‐restricted diet through portion control.
General macro‐ and micronutrient composition of meal replacement products.
Satiety and appetite are known to impact total energy intake, as well as food choices and eating behavior. Both are regulated by a combination of mechanical and endocrine effects ranging from the gut to the brain. With respect to diet, protein has been identified as an important contributor to satiety, defined as the absence of hunger between meals. Dietary protein can induce satiety through several mechanisms including thermic effects and induction of gut hormones such as cholecystokinin (CCK) and glucagon‐like peptide 1 (GLP‐1) and ghrelin [23]. Intervention studies show that increased protein intake, using protein‐enriched MR, is effective at increasing satiety, reducing hunger sensations, decreasing energy intake and facilitating weight loss in obese subjects [24, 25].
\nMany authoritative bodies around the world have sanctioned the use of MR for weight loss and control. As far back as the mid‐1980s, Codex Alimentarius recognized the use of MRs for weight control [26]. In 2010, the European Food Safety Authority (EFSA) concluded that MR are effective for both weight loss and weight maintenance [27]. Most recently, the Academy of Nutrition & Dietetics (AND) rated strongly the use of MR as part of a comprehensive weight management program [28].
Weight loss in obese subjects during an intervention is comprised of water, fat and lean (muscle) mass. The amount and extent of fat and muscle loss depend on the specific weight loss intervention. As lean mass determines the basal metabolic rate (BMR), the goal for any weight loss program is to lose fat mass, while preserving muscle mass. This helps to maintain a higher BMR, which in turn helps to maintain energy expenditure, which can often decline with weight loss. Use of protein‐enriched MR products has been shown to effectively maintain lean body mass during weight loss [24, 29], particularly when combined with resistance exercise [30].
\nGlycemic index (GI) represents a measure of the ability or rapidity of a given food to raise an individual\'s postprandial blood glucose level. GI is determined for a given food in reference to a standard food, usually white bread, and reflects the blood glucose‐raising ability of digestible carbohydrates in a given food [31]. Examples of relative GI values of different foods can be found in Table 2.
\nGlycemic index (GI) values of select foods.
A growing body of evidence suggests that the GI and glycemic load (GL, a measure of how much a given food will raise an individual\'s blood glucose level following consumption) of the diet play an important role in human metabolic functions and health. High GI foods and a high GL stimulate a rapid rise in insulin levels, which on a chronic basis can result in insulin resistance [32, 33]. The GL of a food is calculated by multiplying its GI by the amount of carbohydrate it contains per serving, and then dividing by 100. GL is a function of the amount of carbohydrate intake and the GI of the food. In contrast, GI is an inherent property of a food, independent of the amount of carbohydrate ingested. The GI value of a diet can impact insulin sensitivity and glucose metabolism [34]. Blood sugar levels have also been implicated in appetite control, suggesting that. Furthermore, MR promote adherence to a restricted calorie diet due to simple preparation and convenience compared to preparing and cooking low‐calorie foods at home. The GI of a diet may impact overall food and energy intake [35]. Accordingly, low‐GI diets have been shown to be an effective approach for managing diabetes [36, 37] and obesity [38, 39]. The combination of a high‐protein, low‐GI diet in obese subjects is effective at inducing weight loss and maintenance of lean body mass [25, 36, 40]. Although it varies by formulation, MR tend to be high in protein and have a low GI (<55), making them ideal for incorporation into an overall low‐GI diet plan.
\nAs with insulin sensitivity, the degree of intrabdominal and visceral fat is tightly linked to metabolic syndrome. Surrounding the body\'s critical organs, such as the heart and liver, visceral fat stimulates systemic inflammation and is known as an increasingly serious risk factor for chronic diseases, including cardiovascular disease and diabetes [41]. In simple terms, “sarcopenic obesity” can be defined as low skeletal muscle mass and strength combined with excess body fat, much of which is visceral fat [42, 43]. The concept has also been described as “thin outside, fat inside” or “TOFI” [44]. Related to obesity, individuals can have the same body mass index (BMI), but vastly different inflammatory states and risk levels due to differences in distribution and degree of visceral fat [45]. As there is as yet no medical cure, resistance and strength exercise, combined with a high‐protein diet, is recommended as one of the only effective means of addressing sarcopenic obesity and complications of excess visceral fat [30, 46]. When used in conjunction with reduced total calorie intake and resistance exercise, MR can also be effective at reducing visceral fat [19, 30, 47].
\nWith respect to safety, use of MR for weight control and other metabolic benefits is among the safest approaches studied. Many individual intervention studies [48–50] as well as systematic reviews [51] have confirmed that MR safely facilitate weight loss and maintenance.
According to the
In the United States, more than half of the population fails to achieve the recommended intakes for key nutrients, including vitamins A, C, D and E, fiber, magnesium and potassium [56], all of which have been deemed “nutrients of concern” or “shortfall nutrients” by the 2015 Dietary Guidelines Advisory Committee [57]. Incorporation of more nutrient‐dense foods into the diet is an effective approach to achieve proper nutrient adequacy without adding excess calories.
\nOverweight and obese individuals are at even higher risk than the general population of experiencing nutrient deficiency, particularly vitamin D [58]. This is believed to be due, in part, to overconsumption of a high‐energy‐dense and low‐nutrient‐dense diet [59], a phenomenon described as “overfed but undernourished” [60]. Furthermore, weight loss regimens, particularly those involving rapid weight loss, can lead to compromised nutritional status [61].
\nWith a modest amount of calories, added essential vitamins, minerals and fiber, MR are considered to be a nutrient‐dense food. Indeed, a variety of studies demonstrates that use of MR during a weight control regimen helps to ensure adequate intake of essential nutrients [12, 62–64].
In some markets around the world, regulations exist to define MR, both in function and in composition. The definition, specific authorized claims for weight loss or management and composition standards (for both macro‐ and micronutrients) vary by country (Table 3). The
Codex | Australia | Brazil | Canada | Chile | EU | Indonesia | Korea | US & China | |
---|---|---|---|---|---|---|---|---|---|
200–400 kcal | ≥200 kcal | ≥200–400 kcal | ≥225 kcal | ≥200–400 kcal | 200–250 kcal | ≥200 kcal | ≥200–400 kcal | None | |
25–50% of total energy; ≤125 g/day | ≥12 g | 25–50% energy of product and <125 g | 20–40% energy of product | 25–50% energy of product and <125 g | 25–50% energy of product | ≥12 g | ≥10% NRV | None | |
≤30% of total energy | None | ≤30% energy of product | ≤35% energy of product | ≤30% energy of product | ≤30% energy of product | ≤13 g | None | None | |
≥3% of total energy of linoleic acid (glycderide form) | None | ≥3% energy of product | ≥3% energy of product | ≥3% energy of product | ≥1 g | None | None | None | |
None | None | None | 4:1–10:1 | None | None | None | None | None | |
33–25% of specified amount in Codex 181‐1991 (depend on # of servings/day) | Specific minimum indicated | Specific minimum indicated | Specific minimum indicated | Specific minimum indicated | ≥30% NRV | ≥25% RDA | ≥25% NRV | None | |
33–25% of specified amount in Codex 181‐1991 (depend on # of servings/day) | Specific minimum indicated | Specific minimum indicated | Specific minimum indicated | Specific minimum indicated | ≥30% NRV w/ specific limit on Na & K No min limit: F, Cr, Cl, Mo | ≥25% RDA | ≥25% NRV | None | |
None | None | None | None | None | Yes—profile WHO 1985 | None | None | None |
Comparison of standards and regulations for meal replacements in various markets around the world.
However, in other markets with high obesity prevalence, including the United States, Mexico, China and Russia, no such standards have been established. The reasons for the lack of MR regulations and standards in these countries vary, but are tied closely to the existing food and/or dietary supplement policy and regulatory framework. For example, in the United States, composition or identity standards are not expressly required in order for products to bear health benefit claims. For MR, as with conventional foods and dietary supplements, the ability to bear a weight loss claim is predicated on the availability, quality and quantity of scientific substantiation, not a formal definition for MR or composition standards [67]. In contrast, in the case of Mexico, MR are regulated under the category of food supplements. By regulation, food supplements are not permitted to bear claims of any kind [68], thus eliminating the ability to communicate a weight loss benefit for the category and reducing the need to establish a definition. Finally, in China, MR are regulated under the health or functional food category [69]. Products in this category are required to go through animal and/or human testing (depending on the desired claim) as part of a premarket registration process. This testing requirement to validate the health food product prior to market has precluded the need for a specific MR definition or standard.
\nEstablishing full recognition of the health benefits of MR in these markets may ultimately require a formal definition and composition standards. Indeed, the absence of a formal regulation for MR has allowed the category to be inappropriately targeted with antiobesity policies aimed at, for example, curbing the public\'s consumption of sugars. In Mexico, MR are subject to the same tax aimed at reducing intake of sodas and other sugar‐sweetened beverages as part of a broader public health initiative [70]. In the United States, similar policy has been proposed at both the Federal [71, 72] and state levels [73] and has passed at the local level [72, 74]. In some cases, MR have been exempted (Berkley, CA), and in others, this exemption has not been expressly granted (Philadelphia). Imposing such policy on MR seems incongruent with the state of the evidence, which clearly demonstrates that MR are part of the obesity solution, not the problem.
\nThe absence of a formal definition for MR may negatively impact the consumer, as products claiming to be a MR may not meet basic compositional expectations. Consumers conceivably stand to benefit from a standard or regulation by receiving properly formulated and consistent products. The absence of a formal definition has also prevented the category from being included in potentially beneficial public policy aimed at obesity and disease prevention. Without a clear standard of identity and recognition of its health benefits, MR cannot be included in government‐sponsored programs such as Flexible Savings Accounts or Health Savings Accounts.
Rates of obesity and comorbidities continue to rise worldwide. MR are among the safest most effective tools available demonstrating significant and long‐term weight loss. MR use provides benefits well beyond weight loss, including body composition and metabolic benefits from its low glycemic index. As a nutrient‐dense food, MR are also effective at achieving and maintaining nutrient adequacy without delivering excess calories. Although well defined in some markets, MR still lack a formal definition and regulation in several key markets around the world. The absence of this formal recognition and composition standards has left the category vulnerable to onerous public policy while being excluded from potentially beneficial policy. Efforts to establish formal regulations in these key markets should be considered in order for the category to provide its full impact on obesity and public health.
Dr. Shao is a full‐time employee of Herbalife International of America, Inc, a global nutrition company that manufactures and markets nutritional products (functional foods and dietary supplements), including meal replacement products.
Bariatric individuals not only present with specific medical complications and more prevalent risk factors for cardiovascular disease (CVD) and musculoskeletal (MSK) conditions, this population also has significantly greater potential for functional decline. 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.
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The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"117248",title:"Dr.",name:"Andrew",middleName:null,surname:"Macnab",slug:"andrew-macnab",fullName:"Andrew Macnab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"322007",title:"Dr.",name:"Maria Elizbeth",middleName:null,surname:"Alvarez-Sánchez",slug:"maria-elizbeth-alvarez-sanchez",fullName:"Maria Elizbeth Alvarez-Sánchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",country:{name:"Mexico"}}},{id:"337443",title:"Dr.",name:"Juan",middleName:null,surname:"A. 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The scope of this topic will range from molecular, biochemical, cellular, and physiological processes in all animal species. Work pertaining to the whole organism, organ systems, individual organs and tissues, cells, and biomolecules will be included. Medical, animal, cell, and comparative physiology and allied fields such as anatomy, histology, and pathology with physiology links will be covered in this topic. 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Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. 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