Weight loss: Pharmacological and non-pharmacological interventions Dr Guillaume Lassailly CHRU de Lille, INSERM U995 Lille, France.

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1 Lunch Breakout Session 4 Weight loss: Pharmacological and non-pharmacological interventions Dr Guillaume Lassailly CHRU de Lille, INSERM U995 Lille, France.

2 Weight loss : Non pharmacological interventions Summary 1. Bariatric Surgery A. Background of Bariatric Surgery B. Results in NASH C. Indications & Contra-indication D. Risk & population 2. Endoscopic alternative : Ex: Endobarrier

3 Weight loss : Non pharmacological interventions Summary 1. Bariatric Surgery A. Background of Bariatric Surgery B. Results in NASH C. Indications & Contra-indication D. Risk & population 2. Endoscopic alternative : Ex: Endobarrier

4 Weight loss and NASH Medical strategy is benefic in 10% of patients Could bariatric surgery be a therapeutic option for WL or NASH? Villar-Gomez E, Gastroenterology 2015

5 Obesity, The French data Prevalence of obesity in the French population Prevalence of obesity according to the generation Ref: Obépi 2012 Prevalence of obesity and severe obesity (BMI > 35 kg/m 2 ) is increasing. This evolution concerns all generations.

6 Surgery is increasing, but As a consequence of the high prevalence of obesity, bariatric surgery became frequent and common a surgical procedure. Evolution in USA Evolution in France Wolfe BM, Gastroenterology 2007 Only 1% of candidate for bariatric surgery are referred to the surgeon

7 What about long term data Efficacy of bariatric surgery on weight loss For morbid obese patients bariatric surgery is more effective than medical strategy Band : 10-20% WL Sleeve : 15-20% WL Bypass : 20-35% WL Sjöström L et al, nejm 2007

8 Results of bariatric surgery Reduces overall mortality Reduces CV events Sjöström L et al nejm 2007 Sjostrom L et al, JAMA 2012

9 Schauer PR et al nejm 2012, Schauer PR et al nejm 2017 Bariatric surgery and diabetes Bariatric surgery improves & can induce diabetes remission at 5 year (25-45%)

10 Bariatric surgery as a preventive treatment for metabolic complications Comparison of 1700 patients undergoing bariatric surgery matched with control group Carlsson et al, nejm 2012 this approach could interesting to prevent liver complications in morbid obese patients but no data are available.

11 Weight loss : Non pharmacological interventions Summary 1. Bariatric Surgery A. Background of Bariatric Surgery B. Results in NASH C. Indications & Contra-indication D. Risk & population 2. Endoscopic alternative : Ex: Endobarrier

12 Lassailly et al, Gastroenterology 2015 Evolution of histological features of NAFLD after bariatric surgery Before surgery Evolution after 1 year After surgery

13 Efficacy of bariatric surgery on NASH 85 % of NASH disappearance Evolution 1 year after surgery Dixon et al, Hepatology 2004 Lassailly et al, Gastroenterology 2015

14 Evolution of fibrosis Improvement of fibrosis biomarkers Improvement of fibrosis after surgery Klein S, Gastroenterology 2006 Lassailly G, Gastroenterology 2015

15 ΔBMI 1/QUICKI What about the patients with persistent NASH at 1 year? One year characteristics: Comparison of patients with refractory/persistent NASH at 1 year (non responders: NR) vs patients with NASH disappearence (Responders: N): 35 Weight loss Insulin Resistance Index * * 5,5 25 5,0 4,5 15 4,0 3,5 5 3,0 2,5-5 R NR 2,0 R NR Lassailly et al, Gastroenterology 2015

16 How does it works?

17 Steatosis & insulin resistance. Association before and after surgery IR is improved after surgery Klein S, Gastroenterology 2006 Histology is associated to IR profile before and after surgery Mathurin P et al, Gastroenterology 2006

18 Optimizing gut hormones Gut hormones GLP-1 Ghrelin PYY PP Oxyntomodulin After Bariatric surgery (sleeve) Improves : IR Changes in appetite and taste Gut microbiota Acosta A et al, Gut 2014; Lassailly G et al, J Hepatol 2013

Satiety Gut hormones Orexigene hormone Anorexigene Hormones PYY Oxytomodulin GLP-1 Leptin

19 Changing eating behavior Appetite and satiety are controlled by l hypothalamus in relation with the limbic system (emotion & reward area). behavior 1. Appetite Daily calories Weight 2. Satiety Gut hormones Orexigene hormone Anorexigene Hormones PYY Oxytomodulin GLP-1 Leptin Insulin/glucagon Vagual nerve* Gut-brain Axis Ghreline PYY GLP-1 Cholécystokinine Acosta A et al, Gut 2014

20 Changing eating behavior Taste Time 1 : 6 week after surgery Time 2 : 8 month Appetite Pleasure Van Vuuren MAJ et al, Obes Surg 2017

21 Weight loss : Non pharmacological interventions Summary 1. Bariatric Surgery A. Background of Bariatric Surgery B. Results in NASH C. Indications & Contra-indication D. Risk & population 2. Endoscopic alternative : Ex: Endobarrier

22 Current validated indications Indication - BMI > 40 kg/m² - BMI > 35 kg/m² with a least one complication secondary to severe obesity o Cardiovascular disease o Sleep Apnea o Type 2 diabetes o NASH (in France, HAS recommandation 2009) HAS 2009 : No recommandation for the BMI between 30 and 35 kg/m². FDA : gastric Banding if - BMI > 40 kg/m² - Or BMI > 30 kg/m² with : o Aretrial Hypertension o Obstructive Sleep apnea o Diabetes

23 Current validated contra-indications Contra-indication Alcohol > 20g/j for women and 30g/j for men Presence of Helicobacter pylori resistant to medical therapy Gastric or duodenal Ulcer in the past 2 month Gastric Dysplasia or history of gastric cancer Gastroesophagal reflux resistant to treatement ( for sleeve gastrectomy) Chronic Diarrhea Eating disorders (according to DSM V) Prader-Willi syndrome Severe Mental diseases Cirrhosis Disease related to short term life threating or aenesthesiological contraindications

24 Weight loss : Non pharmacological interventions Summary 1. Bariatric Surgery A. Background of Bariatric Surgery B. Results in NASH C. Indications & Contra-indication D. Risk & population 2. Endoscopic alternative : Ex: Endobarrier

25 Risk and morbidity of bariatric surgery Short term morbidity & mortality LABS Consortium, nejm 2009

26 Risk and morbidity of bariatric surgery Related to 30 days morbidity and mortality -Extreme BMI -History of deep-vein thrombosis -Obstructive Sleep Apnea -Inability to walk > 200 ft LABS Consortium, nejm 2009

27 Other complications bariatric surgery Complications after bariatric surgery Gobal mortality % Rate of rehospitalization at 1 year -20% for bypass -15% gastric banding (related to complications : 6-9%) General complications Specific complications PE & deep-vein thrombosis (3.3%)* Gastro-esophagal reflux (sleeve = 20%) Parietal Infection (open: 10-15% vs. Lap : 3-4%) Gastric fistula (2-5%) (sleeve +++) Vomiting (8-20%) Gastric stenosis Hemorraghe (ulcer anastomosis) (0.6-4%) Band migration (2-5%) Dumping syndrom Anastomotic stenosis (6-20%) Post-operative hypoglycemia Band dysfunction ( %) Malnutrition Diarrhea (40-55%) Gallstone (40% long term after surgery) * Implicated in 30% of death Buchwald et al, JAMA 2004 ; Flum D.R. et al, JAMA 2005 ; Zingmond DS et al, JAMA 2005; O. Emungania FMC Gastro2010

28 Data in cirrhotic patients NIS (National Inpatients Sample): Mortality of compensated cirrhosis (N=3888): 0,9% vs 0,3% increased risk x 2-3 Mortality of decompensated cirrhosis (N=62): 16,3% vs 0,3% Increased risk x 21 Mosko JD et al Clin Gastroenterol Hepatol, 2011 Retrospective monocentric study: 2119 patients opérés: Gastric Bypass N= 30 cirrhosis BMI: 50 vs 48 kg/m 2 Gender ratio 1.3 Diabetes: 70 vs 21% Diagnosis of cirrhosis was performed durinf the procedure in 90% des cas 30% of morbidity, but no decompensation, no death at 1 year. Dallal RM et al, Obes Surg 2004

29 Efficiency and cost-efficiciency of bariatric surgery in NASH Benefit appears in severe patients And are also those with the highest risk of complications Klebanoff MJ, Hepatology 2016

30 Which procedure should be proposed? For weight loss / or metabolic effect? We may have to adjust the gastric band a little

31 Gastric Banding vs Bypass Patients present more complications after bypass than banding. But bypass is more effective than gastric banding. Aterburn D et al, JAMA surg 2014

32 Gastric Banding vs Bypass

33 Gastric Banding vs Bypass 10 years results : gastric banding vs bypass Nguyen et al, Annals of Surgery 2017

34 Bypass or gastric band? Caiazzo R et al, Annals of Surgery 2014

35 Laparascopic sleeve gastrectomy vs laparoscopic Roux en y gastric bypass Study evaluating the superiority of bypass No equivalence between bypass and sleeve, no difference No difference in terms of morbidity and mortality Salminen et al, JAMA 2018 Peterli et al, JAMA 2018

36 Weight loss : Non pharmacological interventions Summary 1. Bariatric Surgery A. Background of Bariatric Surgery B. Results in NASH C. Indications & Contra-indication D. Risk & population 2. Endoscopic treatment

Intragastric Balloon Provisional device (around 6 month to 1 year) Indication : BMI 27-40 kg/m 2 Or patients refusing bariatric surgery Mild effect of intra-gastric balloon Significant relapse at

37 Intragastric Balloon Provisional device (around 6 month to 1 year) Indication : BMI kg/m 2 Or patients refusing bariatric surgery Mild effect of intra-gastric balloon Significant relapse at long term. Mortality 0.1% Eating Behavior therapy is recommanded In 2009, French Health authorities did ot recognize the clinical benefit compared to medical and lifestyle therapy. Données HAS 2009 Fuller et al, Obesity 2013

38 Intragastric Balloon Withdrawal 2018 : ORBERA & ReShape MORTALITY between Balloon vs. LAGB = 0.1% vs %

39 Alternatives? Endobarrier, Gasto-Liner Indication BMI > 30 kg/m2 with type 2 diabetes Provisional device Betzel et al, Surg Endosc Interesting, but recurrence after explantation of the device 2. Efficacy on NASH : data are lacking

40 Conclusion In weight loss strategies bariatric surgery seems to be effective and secure. Benefit > Risk Patients referred to bariatric surgery must be properly evaluated. Question : Is surgery suitable for NASH with BMI < 35 kg/m²? Only for F3 NASH patients? Is medical therapy better Medical therapy Bariatric surgery therapy BMI < 30 BMI : 30-35

41 Thank you Merci

Manuel Romero-Gómez Digestive Diseases and ciberehd. HUVRocío.

42 Lunch Breakout Session 4 Weight loss: Pharmacological and non-pharmacological interventions Prof. Manuel Romero-Gómez Digestive Diseases and ciberehd. HUVRocío. SeLiver Group. Institute of Biomedicine of Seville. University of Seville. Sevilla, Spain.

43 Agenda The main aim weight loss and avoiding regain Impact of weight loss on NAFLD/NASH How could we reach weight loss: Diet Physical activity Drugs Endoscopy/surgery Avoiding weight regain

How much weight loss is required to ameliorate/reverse comorbidities?

T2D prevention and control Weight-related QoL Improvements in CVD risk

remission Improvements in sleep apnea Reductions in intima-media

all-cause mortality Reductions in cancer risks (only with bariatric

1995;3(suppl 2):211-216; Foster GD. Arch Intern Med.

44 How much weight loss is required to ameliorate/reverse comorbidities? Weight loss is an excellent surrogate marker Greater WL Bigger benefits T2D prevention and control Weight-related QoL Improvements in CVD risk HDL-C, cholesterol, triglycerides, BP Previous improvements + T2D remission Improvements in sleep apnea Reductions in intima-media thickness Previous improvements + Reductions in CVD events Reductions in all-cause mortality Reductions in cancer risks (only with bariatric surgery 15% 10% 5% Blackburn G. Obes Res. 1995;3(suppl 2): ; Foster GD. Arch Intern Med. 2009;169: ; Greg EW. JAMA. 2012;308: ; Sjostrom L. J Intern Med. 2013;273: ; Christou NV. Surg Obes Relat Dis. 2008;4:

Diet Calories Macronutrients BEYOND CALORIES Geometry of Nutrition Alcohol Coffee NASH therapy Weight Loss Physical activity Sedentary behavior

45 Diet Calories Macronutrients BEYOND CALORIES Geometry of Nutrition Alcohol Coffee NASH therapy Weight Loss Physical activity Sedentary behavior Physical activity Multidisciplinary approach Exercise T2DM drugs Drugs Obesity drugs Gut-Liver Axis Liver-targeted drugs Fat-Liver Axis Brain-Liver axis

46 Weight Loss (kg) What is the best program to weight loss? Diet Dietary composition may have a similar effect on weight loss rates Meta-analysis of 48 RCT 7286 overweight/obese subjects Effectiveness of two type of diets (low-carbohydrate vs. Low-fat) Outcome: weight loss rates at 6 and 12 months Weight loss (Kg) Type of diet 6 months, 12 months Low carbohydrate 8.73 ( ) 7.25 ( ) Low fat 7.99 ( ) 7.27 ( ) Johnston BC, et al JAMA. 2014;312: RCT 811 overweight / obese pts 515 females and 296 males Randomly assigned to one of four diet groups Diets represented a deficit of 750 kcal/day 8% or less of saturated fat CH low-glycemic index (all diets) Behavioral therapies (individual and group sessions) Diet Composition (%) Carbohydrate / Protein / Fat 65/15/20 (low-fat, average protein) 55/25/20 (low-fat, high-protein) 45/15/40 (High-fat, average-protein) 35/25/40 (High-fat, high-protein) 90 minutes of moderate exercise per week 6 R/ 30-35% - WL>5% and 14-15% - WL>10% Diet adherence associated to long-term success 7 WL phase Maintenance phase Months Sacks FM et al. N Engl J Med. 2009;360: No significant difference were observed on WL rates during the run-in and maintenance phases

47 IMPACT OF DIET AND PHYSICAL ACTIVITY ON NAFLD WL: -9.3% vs -0.2% Promrat K, et al. Hepatology 2010 ; 51:

48 Physical exercise in NAFLD 500 kcal/d vs exercise 60 min 3 times per week N=21 NAFLD 26 w DIET: WL: 9.7 ± 4.6% Exercise: no change Hickman et al., J Diabetes Metab 2013, 4:8

49 Physical exercise in NAFLD 500 kcal/d vs exercise 60 min 3 times per week N=21 NAFLD 26 w DIET: WL: 9.7 ± 4.6% Exercise: no change Hickman et al., J Diabetes Metab 2013, 4:8

What is the best program to weight loss?

Control group (no caloric restriction). 2. Calorie restriction (25%). 3. Calorie restriction (12.5%) plus 12.

Very low calorie diet (890 kcal/d] until 15% reduction in body weight, followed by a weight maintenance diet).

50 What is the best program to weight loss? Physical activity Marginal benefit adding structured exercise to diet during run-in phase 48 overweight subjects were randomized into 4 groups. 1. Control group (no caloric restriction). 2. Calorie restriction (25%). 3. Calorie restriction (12.5%) plus 12.5% increase in energy expenditure by structured exercise). 4. Very low calorie diet (890 kcal/d] until 15% reduction in body weight, followed by a weight maintenance diet). High activity required for weight loss maintenance Heilbronn LK, et al. JAMA. 2006;295: RCT / 201 overweight and obese women All were told to reduce kcal/d Randomly assigned to 4 groups of exercise on PA energy expenditure and intensity 1.Moderate intensity/energy expenditure 2.Moderate intensity/ high energy exp. 3.Vigorous intensity/moderate energy exp. 4.Vigorous intensity/high energy exp. Jakicic JM et al. Arch Intern Med. 2008;168:

51 How to assess activity? Sedentary behaviour: Total amount of time sitting Number of breaks Physical activity: Inactive Minimally active Health-enhancing physically active Exercise: Aerobic exercise Resistance exercise High intensity intermittent exercise Vigorous aerobic exercise How to prescribe exercise?

Sedentary behaviour & physical activity in NAFLD Prevalence of NAFLD Prevalence of NAFLD 40 30 22,8% 28,2% 31,8% 40 30 25,5%

52 Sedentary behaviour & physical activity in NAFLD Prevalence of NAFLD Prevalence of NAFLD ,8% 28,2% 31,8% ,5% 29,7% 28,1% <5h/d 5-9 h/d >10 h/d Sedentary behaviour 0 HEPA MinA Inactive Physical activity Ryu S et al. J Hepatol 2015

53 Aerobic vs. resistance exercise in NAFLD: A systematic review Hashida R et al. J Hepatol 2017

54 Triple hit behavioural phenotype Sedentary behaviour Low physical activity Poor diet (High Fat & low PUFA/MUFA) NAFL D NAFLD is associated with low levels of physical activity, longer period sitting and no breaks (sedentary behaviour) and western diet. Romero-Gómez M, Zelber-Sagi S, Trenell M. J Hepatol 2017

55 PNPLA3 Influences Response to Lifestyle Modification in NAFLD Lifestyle Intervention Control IHTG change: CC: 3.7 ± 5.2%, CG: 6.5 ± 3.6% and GG: 11.3 ± 8.8% (p=0.002) Shen et al, J Gastro Hep 2015

56 Effect of exercise on NAFLD Romero-Gomez, et al. J Hepatol 2017

57 Weight loss and histological outcomes of NAFL patients How much impact the duration of ILI? ILI 24 weeks WL< 10% WL >10% Orlistat 36 weeks WL< 9% WL >9% NAS Steatosis Ballooning Lob. Inflamm -0,54-0,45-0,9-0,63-1,22-1,7-1,8 NAS Steatosis Ballooning Lob. Inflamm -0,39-0,44-0,46-1, ,96-1,45-3,9 Vilar-Gomez E, et al. APT 2009; 30: ,4 Harrison S, et al. Hepatology 2009;49: ILI 48 weeks ILI 52 weeks WL< 7% WL >7% WL< 7% WL >7% NAS Steatosis Ballooning Lob. Inflamm -0,41-0,53-0,24-0,82-1,18-1,36-1,27 NAS Steatosis Ballooning Lob. Inflamm -0,42-0,3-0,35-1,09-1,2-1,3-1,5-3,45 Pomrat K, et al. Hepatology 2010; 51: ,9 Vilar-Gomez E, et al Gastroenterology 2015; 149:

58 Weight loss a major driver in NASH resolution Exercise Diet Weight loss Physical activity Adapted from Johnson et al. Exercise and Liver: Implications for therapy in fatty liver disorders, Semin Liv Dis 2012

Weight Loss via Lifestyle Modification Significantly Reduces Features of Nonalcoholic Steatohepatitis Lifestyle changes focusing on weight loss remain the cornerstone of NASH treatment.

59 Weight Loss via Lifestyle Modification Significantly Reduces Features of Nonalcoholic Steatohepatitis Lifestyle changes focusing on weight loss remain the cornerstone of NASH treatment. WL between 7-10% may improve NAS score and their components. N=293 NASH proven patients Low-fat hypocaloric diet + walking 200 min/week + questionnaire + Group sessions Inclusion criteria: -Patients aged 18 years and both sexes -Histologic diagnosis of definite NASH. Exclusion criteria: - Borderline NASH or cirrhosis. -Alcohol consumption >20 g/d men > 10 g/d women -Uncontrolled T2DM (Hb A1c > 9) -Medications for NASH. Vilar-Gomez, Romero-Gomez, Gastroenterology 2015; 149:

60 52 weeks of lifestyle intervention % Weight loss (WL) 5% 7% 10% NASH-resolution 10% 26% 64% 90% FIBROSIS-regression 45% 38% 50% 81% STEATOSIS improvement 35% 65% 76% 100% % Patients achieving WL 70% 12% 9% 10% Romero-Gómez M, Zelber-Sagi S, Trenell M. J Hepatol 2017

61 Drugs options fro weight loss in NASH GLP1 RA: Liraglutide Naltrexone HCL/Bupropion HCL-ER Orlistat

62 Drucker. Cell Metab 2016 Systemic effects of GLP1-RA

63 Dual anti-obesity and anti-nash effects of GLP-1 agonists N= 52 (17 T2DM & 27 F3/F4) 45 paired liver biopsies NASHRES Armstrong MJ et al. Lancet 2016 Placebo Liraglutide 9% P<0.04; O.R ( ) 39% Van Gaal L. European Congress on Obesity (ECO) Abstract 0S2.1.

64 Body weight (kg) SEMAGLUTIDE Body weith Overall mean at baseline: 95.2 kg 96 Impact of GLP1 ra on weight loss Semaglutide 0.5 mg Dulaglutide 0.75 mg Semaglutide 1.0 mg Dulaglutide 1.5 mg 88 Time (weeks) Investigation of Efficacy and Safety of Three Dose Levels of Subcutaneous Semaglutide Once Daily Versus Placebo in Subjects With Non-alcoholic Steatohepatitis. Weight Loss and Maintenance in T2D ( mg)

65 Promoting weight loss and avoiding weight regain NUTRITION & PHYSICAL ACTIVITY ASSESSMENT HEPATOLOGIST ASSESSMENT PSYCHOLOGICAL ASSESSMENT MULTIDISCIPLINARY TEAM NUTRITIONAL COUNSELING EXERCISE PROGRAM PSYCHIATRIC PROGRAM DRUG THERAPY SURGERY FOLLOW-UP VISITS Modified fromkarmali et al. Obes Surg 2013

66 Hypocaloric Mediterranean diet for weight loss and NASH resolution Early breakfast: 1 HYPOCALORIC piece of FRUIT (avoid bananas, grapes, custard apple, fig and do not mix fruit types) 1 SKIM YOGURT or 1 glass of skim milk 1 COFFEE or tea with skimmed milk without sugar Sometimes (2-3 times per week) you could add a couple of biscuits of whole bread or ½ toast of wholemeal bread with olive oil (1 supper spoon) or margarine (10 grs) or wholegrain cereals without sugar (30 grs) Midmorning: 1 infusion (tea, coffee, chamomile, mint pennyroyal) with saccharin [You can repeat infusions several times per day] 1 HYPOCALORIC piece of FRUIT (avoid bananas, grapes, custard apple, fig and do not mix fruit types) or 1 SKIM YOGURT. Occasionally (1-2 times per week) you could add ½ vegetable sandwich or ham sandwich without cheese.

67 Hypocaloric Mediterranean diet for weight loss and NASH resolution Lunch: SALAD (lettuce, endives, tomato, pepper, onion, asparagus, mushrooms, cucumber, spinach, heart of palm, little corncob) or COOKED VEGETABLES, GRILLED VEGETABLES (cucumber, pepper, cauliflower, broccoli, cabbage, asparagus, mushrooms, spinach, chard, zucchini, eggplants, leek, green been, beet, carrots, pumpkin, artichokes)(potatoes, sprouts, pea, broad beans with moderation) or VEGETABLE SOUP Cooked or Grilled Fish or grilled chicken or turkey (without skin) or beef every other day. Sometimes (3 days per week) you could change fish or meat to a dish of rice, pasta, potatoes, vegetables in stew without fat or sauce.

68 Hypocaloric Mediterranean diet for weight loss and NASH resolution Snack: Orange juice (two pieces) or fruit (Kiwi or strawberry) or any other fruit. Infusion/coffee 1 SKIMMED YOGURT Dinner: vegetable soup or salad or cocked or grilled vegetables (different from the lunch) Eggs (omelette or cooked) (2 whites and ½ yolk) or fish or meat cooked or grilled or York ham or turkey ham or seafood with shell or natural tune Sometimes you could add fresh cheese or Iberico ham without fat. Optional fruit

69 @SeLiver_group

70 Mean changes in body weight (%) from baseline How sustainable is weight loss after ILI? Proportion of patients 8-Year weight loss in the Look AHEAD Trial Look AHEAD RCT including 5,145 overweight/obese with T2D Effects of intentional weight loss on CV morbidity and mortality Pts were randomly assigned to ILI or diabetes support and education ,63 Regain 54% -1,01-2,1-4,16-4,7 80% 70% 60% 50% 40% 30% 68% 38% 50% 27% DSE -8,5 ILI Years 20% 10% 0% 16% 11% 1 year 8 Year >= 5% >=10% >=15% Repeated measures adjusted for clinic and baseline level. P value for average effect across all visits: P < DSE, diabetes support and education; ILI, intensive lifestyle intervention. Look AHEAD Research Group, Obesity 2014; 22:5-13.

71 MECHANISMS INVOLVED IN WEIGHT REGAIN Greenway et al. Int J Obes 2015

72 Avoiding Weight loss regain BETTER INTREVENTION I BETTER CONTROL weight loss between intervention and control groups was 3.49 [95% CI 4.15, 2.84], 3.44 [4.23, 2.85], and 2.56 kg [3.79, 1.33] at follow-up closest to 6, 12, and 24 months, respectively. Borek AJ et al. Applied Psychol, doi: /aphw.12121

Bariatric Surgery in NASH Results, indications and contra-indications

Bariatric Surgery in NASH Results, indications and contra-indications Guillaume Lassailly CHRU de Lille Conflit of interest No conflict of interest related to this lecture Contract with: Novartis Gilead