Sự Chênh Lệch Chủng Tộc Trong Mỡ Thừa: Tập Trung Vào Bệnh Gan Mỡ Không Cồn, Mỡ Vùng Dịch Mạch, và Béo Phì Tổng Quát

CURRENT OBESITY REPORTS - Tập 8 - Trang 243-254 - 2019
Uchenna Agbim1, Rotonya M. Carr2, Octavia Pickett-Blakely2, Sam Dagogo-Jack3
1Division of Transplant Surgery, Department of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, USA
2Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Pennsylvania, Philadelphia, USA
3Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, USA

Tóm tắt

Mỡ thừa quá mức đã trở thành một vấn đề sức khỏe cộng đồng trên toàn cầu, góp phần làm gia tăng các bệnh liên quan đến béo phì và tỷ lệ mắc bệnh và tử vong liên quan. Bài tổng quan này chi tiết về tầm quan trọng tương đối của chủng tộc/dân tộc liên quan đến mỡ thừa và bệnh gan không cồn (NAFLD). Phân bố mỡ vẫn là một chỉ số tin cậy hơn về mỡ thừa so với các chỉ số nhân trắc, với mô mỡ nội tạng (VAT) có liên quan đến nguy cơ gia tăng bệnh lý tim mạch chuyển hóa. Trong khi béo phì là yếu tố nguy cơ phổ biến nhất đối với NAFLD, tỷ lệ béo phì theo chủng tộc/dân tộc không hoàn toàn tương ứng với nguy cơ NAFLD. Việc chống lại sự chênh lệch chủng tộc/dân tộc trong béo phì đòi hỏi phải hiểu được nguy cơ khác biệt giữa các nhóm khác nhau. Người Tây Ban Nha bị ảnh hưởng không cân xứng bởi NAFLD và có tỷ lệ béo phì, VAT, và kháng insulin (IR) cao. Điều này trái ngược với người da đen, những người có tỷ lệ béo phì và IR cao, đi kèm với hồ sơ lipid thuận lợi một cách nghịch lý và tỷ lệ VAT và NAFLD thấp. Nhiều đặc điểm của mỡ thừa và NAFLD được trung gian bởi các yếu tố di truyền và môi trường, trong đó các yếu tố môi trường có thể điều chỉnh và là trọng tâm của các can thiệp.

Từ khóa

#mỡ thừa #béo phì #bệnh gan không cồn #mô mỡ nội tạng #sự chênh lệch chủng tộc

Tài liệu tham khảo

• N. C. D. Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet. 2016;387(10026):1377–96. https://doi.org/10.1016/S0140-6736(16)30054-X This study uses population-based data to summarize worldwide changes in BMI and estimates risk of achieving the global obesity target. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766–81. https://doi.org/10.1016/S0140-6736(14)60460-8. Stokes A, Preston SH. The contribution of rising adiposity to the increasing prevalence of diabetes in the United States. Prev Med. 2017;101:91–5. https://doi.org/10.1016/j.ypmed.2017.05.031. Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, et al. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association scientific statement on obesity and heart disease from the obesity Committee of the Council on nutrition, physical activity, and metabolism. Circulation. 2006;113(6):898–918. https://doi.org/10.1161/CIRCULATIONAHA.106.171016. • Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment 28431.Of prevalence, incidence, and outcomes. Hepatology. 2016;64(1):73–84. https://doi.org/10.1002/hep.28431 . This study is a meta-analysis of global prevalence of NAFLD and highlights areas of the world with high prevalence of NAFLD. Carr RM, Oranu A, Khungar V. Nonalcoholic fatty liver disease: pathophysiology and management. Gastroenterol Clin N Am. 2016;45(4):639–52. https://doi.org/10.1016/j.gtc.2016.07.003. Cusi K. Role of insulin resistance and lipotoxicity in non-alcoholic steatohepatitis. Clin Liver Dis. 2009;13(4):545–63. https://doi.org/10.1016/j.cld.2009.07.009. •• Trico D, Caprio S, Rosaria Umano G, Pierpont B, Nouws J, Galderisi A, et al. Metabolic features of nonalcoholic fatty liver (NAFL) in obese adolescents: findings from a multiethnic cohort. Hepatology (Baltimore, Md). 2018;68(4):1376–90. https://doi.org/10.1002/hep.30035 . The authors characterize metabolic phenotype, prevalence of NAFLD, and genotype analysis of common single nucleotide polymorphisms in a group of diverse adolescents. Despres JP. Body fat distribution and risk of cardiovascular disease: an update. Circulation. 2012;126(10):1301–13. https://doi.org/10.1161/CIRCULATIONAHA.111.067264. Fox CS, Massaro JM, Hoffmann U, Pou KM, Maurovich-Horvat P, Liu CY, et al. Abdominal visceral and subcutaneous adipose tissue compartments: association with metabolic risk factors in the Framingham Heart Study. Circulation. 2007;116(1):39–48. https://doi.org/10.1161/CIRCULATIONAHA.106.675355. Liu J, Fox CS, Hickson D, Bidulescu A, Carr JJ, Taylor HA. Fatty liver, abdominal visceral fat, and cardiometabolic risk factors: the Jackson Heart Study. Arterioscler Thromb Vasc Biol. 2011;31(11):2715–22. https://doi.org/10.1161/ATVBAHA.111.234062. Guerrero R, Vega GL, Grundy SM, Browning JD. Ethnic differences in hepatic steatosis: an insulin resistance paradox? Hepatology (Baltimore, Md). 2009;49(3):791–801. https://doi.org/10.1002/hep.22726. van der Poorten D, Milner KL, Hui J, Hodge A, Trenell MI, Kench JG, et al. Visceral fat: a key mediator of steatohepatitis in metabolic liver disease. Hepatology (Baltimore, Md). 2008;48(2):449–57. https://doi.org/10.1002/hep.22350. Alberti KG, Zimmet P, Shaw J. Metabolic syndrome--a new world-wide definition. A consensus statement from the International Diabetes Federation. Diabet Med. 2006;23(5):469–80. https://doi.org/10.1111/j.1464-5491.2006.01858.x. Garg SK, Lin F, Kandula N, Ding J, Carr J, Allison M, et al. Ectopic fat depots and coronary artery calcium in South Asians compared with other racial/ethnic groups. J Am Heart Assoc. 2016;5(11). https://doi.org/10.1161/JAHA.116.004257. Hanley C, Matthews KA, Brooks MM, Janssen I, Budoff MJ, Sekikawa A, et al. Cardiovascular fat in women at midlife: effects of race, overall adiposity, and central adiposity. The SWAN Cardiovascular Fat Study. Menopause (New York, NY). 2018;25(1):38–45. https://doi.org/10.1097/GME.0000000000000945. Wang J, Thornton JC, Russell M, Burastero S, Heymsfield S, Pierson RN Jr. Asians have lower body mass index (BMI) but higher percent body fat than do whites: comparisons of anthropometric measurements. Am J Clin Nutr. 1994;60(1):23–8. https://doi.org/10.1093/ajcn/60.1.23. Bergman RN, Stefanovski D, Buchanan TA, Sumner AE, Reynolds JC, Sebring NG, et al. A better index of body adiposity. Obesity (Silver Spring, Md). 2011;19(5):1083–9. https://doi.org/10.1038/oby.2011.38. Dugas LR, Cao G, Luke AH, Durazo-Arvizu RA. Adiposity is not equal in a multi-race/ethnic adolescent population: NHANES 1999-2004. Obesity (Silver Spring, Md). 2011;19(10):2099–101. https://doi.org/10.1038/oby.2011.52. Katzmarzyk PT, Mire E, Bray GA, Greenway FL, Heymsfield SB, Bouchard C. Anthropometric markers of obesity and mortality in white and African American adults: the pennington center longitudinal study. Obesity (Silver Spring, Md). 2013;21(5):1070–5. https://doi.org/10.1002/oby.20151. Fabbrini E, Conte C, Magkos F. Methods for assessing intrahepatic fat content and steatosis. Current opinion in clinical nutrition and metabolic care. 2009;12(5):474–81. https://doi.org/10.1097/MCO.0b013e32832eb587. Camhi SM, Must A, Gona PN, Hankinson A, Odegaard A, Reis J, et al. Duration and stability of metabolically healthy obesity over 30 years. International journal of obesity (2005). 2018. https://doi.org/10.1038/s41366-018-0197-8. Lomonaco R, Ortiz-Lopez C, Orsak B, Webb A, Hardies J, Darland C, et al. Effect of adipose tissue insulin resistance on metabolic parameters and liver histology in obese patients with nonalcoholic fatty liver disease. Hepatology (Baltimore, Md). 2012;55(5):1389–97. https://doi.org/10.1002/hep.25539. • Chang Y, Jung HS, Cho J, Zhang Y, Yun KE, Lazo M, et al. Metabolically healthy obesity and the development of nonalcoholic fatty liver disease. Am J Gastroenterol. 2016;111(8):1133–40. https://doi.org/10.1038/ajg.2016.178 This study tracks the incidence and development of NAFLD among the MHO. • Hwang YC, Hayashi T, Fujimoto WY, Kahn SE, Leonetti DL, McNeely MJ, et al. Visceral abdominal fat accumulation predicts the conversion of metabolically healthy obese subjects to an unhealthy phenotype. International journal of obesity (2005). 2015;39(9):1365–70. https://doi.org/10.1038/ijo.2015.75 In this study, the authors note the association of VAT in the transition of the MHO to MUO. Caleyachetty R, Thomas GN, Toulis KA, Mohammed N, Gokhale KM, Balachandran K, et al. Metabolically healthy obese and incident cardiovascular disease events among 3.5 million men and women. J Am Coll Cardiol. 2017;70(12):1429–37. https://doi.org/10.1016/j.jacc.2017.07.763. Hagstrom H, Nasr P, Ekstedt M, Hammar U, Stal P, Hultcrantz R, et al. Risk for development of severe liver disease in lean patients with nonalcoholic fatty liver disease: a long-term follow-up study. Hepatology communications. 2018;2(1):48–57. https://doi.org/10.1002/hep4.1124. • Wei JL, Leung JC, Loong TC, Wong GL, Yeung DK, Chan RS, et al. Prevalence and severity of nonalcoholic fatty liver disease in non-obese patients: a population study using proton-magnetic resonance spectroscopy. Am J Gastroenterol. 2015;110(9):1306–14 quiz 15. doi:10.1038/ajg.2015.235. The authors characterize NAFLD among subjects with lean NAFLD. Kim D, Kim WR. Nonobese fatty liver disease. Clin Gastroenterol Hepatol. 2017;15(4):474–85. https://doi.org/10.1016/j.cgh.2016.08.028. Owei I, Umekwe N, Provo C, Wan J, Dagogo-Jack S. Insulin-sensitive and insulin-resistant obese and non-obese phenotypes: role in prediction of incident pre-diabetes in a longitudinal biracial cohort. BMJ Open Diabetes Res Care. 2017;5(1):e000415. https://doi.org/10.1136/bmjdrc-2017-000415. Neel JV. Diabetes mellitus: a “thrifty” genotype rendered detrimental by “progress”. Am J Hum Genet. 1962;14:353–62. Neel JV. The “thrifty genotype” in 1998. Nutr Rev. 1999;57(5 Pt 2):S2–9. Speakman JR. Thrifty genes for obesity, an attractive but flawed idea, and an alternative perspective: the ‘drifty gene’ hypothesis. International journal of obesity (2005). 2008;32(11):1611–7. https://doi.org/10.1038/ijo.2008.161. Romeo S, Kozlitina J, Xing C, Pertsemlidis A, Cox D, Pennacchio LA, et al. Genetic variation in PNPLA3 confers susceptibility to nonalcoholic fatty liver disease. Nat Genet. 2008;40(12):1461–5. https://doi.org/10.1038/ng.257. Lotta LA, Wittemans LBL, Zuber V, Stewart ID, Sharp SJ, Luan J, et al. Association of genetic variants related to gluteofemoral vs abdominal fat distribution with type 2 diabetes, coronary disease, and cardiovascular risk factors. Jama. 2018;320(24):2553–63. https://doi.org/10.1001/jama.2018.19329. Hernaez R, McLean J, Lazo M, Brancati FL, Hirschhorn JN, Borecki IB, et al. Association between variants in or near PNPLA3, GCKR, and PPP1R3B with ultrasound-defined steatosis based on data from the third National Health and Nutrition Examination Survey. Clin Gastroenterol Hepatol. 2013;11(9):1183–90 e2. https://doi.org/10.1016/j.cgh.2013.02.011. Palmer ND, Musani SK, Yerges-Armstrong LM, Feitosa MF, Bielak LF, Hernaez R, et al. Characterization of European ancestry nonalcoholic fatty liver disease-associated variants in individuals of African and Hispanic descent. Hepatology (Baltimore, Md). 2013;58(3):966–75. https://doi.org/10.1002/hep.26440. Schwimmer JB, Celedon MA, Lavine JE, Salem R, Campbell N, Schork NJ, et al. Heritability of nonalcoholic fatty liver disease. Gastroenterology. 2009;136(5):1585–92. https://doi.org/10.1053/j.gastro.2009.01.050. Wagenknecht LE, Palmer ND, Bowden DW, Rotter JI, Norris JM, Ziegler J, et al. Association of PNPLA3 with non-alcoholic fatty liver disease in a minority cohort: the Insulin Resistance Atherosclerosis Family Study. Liver Int. 2011;31(3):412–6. https://doi.org/10.1111/j.1478-3231.2010.02444.x. Abul-Husn NS, Cheng X, Li AH, Xin Y, Schurmann C, Stevis P, et al. A protein-truncating HSD17B13 variant and protection from chronic liver disease. N Engl J Med. 2018;378(12):1096–106. https://doi.org/10.1056/NEJMoa1712191. Yang TC, South SJ. Neighborhood effects on body mass: temporal and spatial dimensions. Social science & medicine (1982). 2018;217:45–54. https://doi.org/10.1016/j.socscimed.2018.09.055. Hales CM, Fryar CD, Carroll MD, Freedman DS, Aoki Y, Ogden CL. Differences in obesity prevalence by demographic characteristics and urbanization level among adults in the United States, 2013-2016. Jama. 2018;319(23):2419–29. https://doi.org/10.1001/jama.2018.7270. Ogden CL, Lamb MM, Carroll MD, Flegal KM. Obesity and socioeconomic status in adults: United States, 2005-2008. NCHS data brief. 2010;2010(50):1–8. Liu J, Coady S, Carr JJ, Hoffmann U, Taylor HA, Fox CS. Differential associations of abdominal visceral, subcutaneous adipose tissue with cardiometabolic risk factors between African and European Americans. Obesity (Silver Spring, Md). 2014;22(3):811–8. https://doi.org/10.1002/oby.20307. •• Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015-2016. NCHS data brief. 2017;288:1–8 Using NHANES data, the authors report the prevalence of obesity among youth and adults stratified by sex and race/ethnicity. Mongraw-Chaffin ML, Anderson CA, Allison MA, Ouyang P, Szklo M, Vaidya D, et al. Association between sex hormones and adiposity: qualitative differences in women and men in the multi-ethnic study of atherosclerosis. J Clin Endocrinol Metab. 2015;100(4):E596–600. https://doi.org/10.1210/jc.2014-2934. Jiang Y, Owei I, Wan J, Ebenibo S, Dagogo-Jack S. Adiponectin levels predict prediabetes risk: the Pathobiology of Prediabetes in A Biracial Cohort (POP-ABC) study. BMJ Open Diabetes Res Care. 2016;4(1):e000194. https://doi.org/10.1136/bmjdrc-2016-000194. Wong RJ, Chou C, Sinha SR, Kamal A, Ahmed A. Ethnic disparities in the association of body mass index with the risk of hypertension and diabetes. J Community Health. 2014;39(3):437–45. https://doi.org/10.1007/s10900-013-9792-8. Deurenberg-Yap M, Deurenberg P. Is a re-evaluation of WHO body mass index cut-off values needed? The case of Asians in Singapore. Nutr Rev. 2003;61(5 Pt 2):S80–7. Weston SR, Leyden W, Murphy R, Bass NM, Bell BP, Manos MM, et al. Racial and ethnic distribution of nonalcoholic fatty liver in persons with newly diagnosed chronic liver disease. Hepatology (Baltimore, Md). 2005;41(2):372–9. https://doi.org/10.1002/hep.20554. Jih J, Mukherjea A, Vittinghoff E, Nguyen TT, Tsoh JY, Fukuoka Y, et al. Using appropriate body mass index cut points for overweight and obesity among Asian Americans. Prev Med. 2014;65:1–6. https://doi.org/10.1016/j.ypmed.2014.04.010. Expert Consultation WHO. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363(9403):157–63. https://doi.org/10.1016/S0140-6736(03)15268-3. Hsu WC, Araneta MR, Kanaya AM, Chiang JL, Fujimoto W. BMI cut points to identify at-risk Asian Americans for type 2 diabetes screening. Diabetes Care. 2015;38(1):150–8. https://doi.org/10.2337/dc14-2391. Conway JM, Yanovski SZ, Avila NA, Hubbard VS. Visceral adipose tissue differences in black and white women. Am J Clin Nutr. 1995;61(4):765–71. https://doi.org/10.1093/ajcn/61.4.765. Lear SA, Humphries KH, Kohli S, Chockalingam A, Frohlich JJ, Birmingham CL. Visceral adipose tissue accumulation differs according to ethnic background: results of the Multicultural Community Health Assessment Trial (M-CHAT). Am J Clin Nutr. 2007;86(2):353–9. https://doi.org/10.1093/ajcn/86.2.353. Katzmarzyk PT, Bray GA, Greenway FL, Johnson WD, Newton RL Jr, Ravussin E, et al. Racial differences in abdominal depot-specific adiposity in white and African American adults. Am J Clin Nutr. 2010;91(1):7–15. https://doi.org/10.3945/ajcn.2009.28136. McClain J, Hsu F, Brown E, Burke G, Carr J, Harris T, et al. Pericardial adipose tissue and coronary artery calcification in the Multi-ethnic Study of Atherosclerosis (MESA). Obesity (Silver Spring, Md). 2013;21(5):1056–63. https://doi.org/10.1002/oby.20090. Bambha K, Belt P, Abraham M, Wilson LA, Pabst M, Ferrell L, et al. Ethnicity and nonalcoholic fatty liver disease. Hepatology (Baltimore, Md). 2012;55(3):769–80. https://doi.org/10.1002/hep.24726. Browning MG, Khoraki J, DeAntonio JH, Mazzini G, Mangino MJ, Siddiqui MS, et al. Protective effect of black relative to white race against non-alcoholic fatty liver disease in patients with severe obesity. independent of type 2 diabetes International journal of obesity (2005). 2018;42(4):926–9. https://doi.org/10.1038/ijo.2017.309. Mohanty SR, Troy TN, Huo D, O'Brien BL, Jensen DM, Hart J. Influence of ethnicity on histological differences in non-alcoholic fatty liver disease. J Hepatol. 2009;50(4):797–804. https://doi.org/10.1016/j.jhep.2008.11.017. Rich NE, Oji S, Mufti AR, Browning JD, Parikh ND, Odewole M, et al. Racial and ethnic disparities in nonalcoholic fatty liver disease prevalence, severity, and outcomes in the United States: a systematic review and meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice. journal of the American Gastroenterological Association. 2018;16(2):198–210 e2. https://doi.org/10.1016/j.cgh.2017.09.041. Ekstedt M, Hagstrom H, Nasr P, Fredrikson M, Stal P, Kechagias S, et al. Fibrosis stage is the strongest predictor for disease-specific mortality in NAFLD after up to 33 years of follow-up. Hepatology (Baltimore, Md). 2015;61(5):1547–54. https://doi.org/10.1002/hep.27368. Browning JD, Szczepaniak LS, Dobbins R, Nuremberg P, Horton JD, Cohen JC, et al. Prevalence of hepatic steatosis in an urban population in the United States: impact of ethnicity. Hepatology (Baltimore, Md). 2004;40(6):1387–95. https://doi.org/10.1002/hep.20466. Garcia AE, Kasim N, Tamboli RA, Gonzalez RS, Antoun J, Eckert EA, et al. Lipoprotein profiles in class III obese Caucasian and African American women with nonalcoholic fatty liver disease. PLoS One. 2015;10(11):e0142676. https://doi.org/10.1371/journal.pone.0142676. Lee S, Kuk JL. Visceral fat is associated with the racial differences in liver fat between black and white adolescent boys with obesity. Pediatr Diabetes. 2017;18(7):660–3. https://doi.org/10.1111/pedi.12492. Lomonaco R, Ortiz-Lopez C, Orsak B, Finch J, Webb A, Bril F, et al. Role of ethnicity in overweight and obese patients with nonalcoholic steatohepatitis. Hepatology (Baltimore, Md). 2011;54(3):837–45. https://doi.org/10.1002/hep.24483. Bril F, Portillo-Sanchez P, Liu IC, Kalavalapalli S, Dayton K, Cusi K. Clinical and histologic characterization of nonalcoholic steatohepatitis in African American patients. Diabetes Care. 2018;41(1):187–92. https://doi.org/10.2337/dc17-1349. Shen J, Wong GL, Chan HL, Chan HY, Yeung DK, Chan RS, et al. PNPLA3 gene polymorphism accounts for fatty liver in community subjects without metabolic syndrome. Aliment Pharmacol Ther. 2014;39(5):532–9. https://doi.org/10.1111/apt.12609. Williams CD, Stengel J, Asike MI, Torres DM, Shaw J, Contreras M, et al. Prevalence of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis among a largely middle-aged population utilizing ultrasound and liver biopsy: a prospective study. Gastroenterology. 2011;140(1):124–31. https://doi.org/10.1053/j.gastro.2010.09.038. Ryu S, Chang Y, Jung HS, Yun KE, Kwon MJ, Choi Y, et al. Relationship of sitting time and physical activity with non-alcoholic fatty liver disease. J Hepatol. 2015;63(5):1229–37. https://doi.org/10.1016/j.jhep.2015.07.010. Rinella M, Charlton M. The globalization of nonalcoholic fatty liver disease: prevalence and impact on world health. Hepatology (Baltimore, Md). 2016;64(1):19–22. https://doi.org/10.1002/hep.28524. Fleischman MW, Budoff M, Zeb I, Li D, Foster T. NAFLD prevalence differs among Hispanic subgroups: the Multi-Ethnic Study of Atherosclerosis. World J Gastroenterol : WJG. 2014;20(17):4987–93. https://doi.org/10.3748/wjg.v20.i17.4987. Chan WK, Treeprasertsuk S, Imajo K, Nakajima A, Seki Y, Kasama K, et al. Clinical features and treatment of nonalcoholic fatty liver disease across the Asia Pacific region-the GO ASIA initiative. Aliment Pharmacol Ther. 2018;47(6):816–25. https://doi.org/10.1111/apt.14506. Merlotti C, Ceriani V, Morabito A, Pontiroli AE. Subcutaneous fat loss is greater than visceral fat loss with diet and exercise, weight-loss promoting drugs and bariatric surgery: a critical review and meta-analysis. International journal of obesity (2005). 2017;41(5):672–82. https://doi.org/10.1038/ijo.2017.31. Nyenwe EA, Ogwo CC, Owei I, Wan JY, Dagogo-Jack S. Parental history of type 2 diabetes is associated with lower resting energy expenditure in normoglycemic subjects. BMJ Open Diab Res Care. 2018;6:e000511. https://doi.org/10.1136/bmjdrc-2018-000511. DeLany JP, Jakicic JM, Lowery JB, Hames KC, Kelley DE, Goodpaster BH. African American women exhibit similar adherence to intervention but lose less weight due to lower energy requirements. Int J Obes (Lond) (2005). 2014;38(9):1147–52. https://doi.org/10.1038/ijo.2013.240. Srivastava G, Apovian CM. Current pharmacotherapy for obesity. Nat Rev Endocrinol. 2018;14(1):12–24. https://doi.org/10.1038/nrendo.2017.122. Admiraal WM, Celik F, Gerdes VE, Dallal RM, Hoekstra JB, Holleman F. Ethnic differences in weight loss and diabetes remission after bariatric surgery: a meta-analysis. Diabetes Care. 2012;35(9):1951–8. https://doi.org/10.2337/dc12-0260. Wee CC, Jones DB, Apovian C, Hess DT, Chiodi SN, Bourland AC, et al. Weight loss after bariatric surgery: do clinical and behavioral factors explain racial differences? Obes Surg. 2017;27(11):2873–84. https://doi.org/10.1007/s11695-017-2701-y. Valencia A, Garcia LC, Morton J. The impact of ethnicity on metabolic outcomes after bariatric surgery. J Surg Res. 2019;236:345–51. https://doi.org/10.1016/j.jss.2018.09.061. Intercept announces positive topline results from pivotal phase 3 REGENERATE study of obeticholic acid in patients with liver fibrosis due to NASH. http://ir.interceptpharma.com/news-releases/news-release-details/intercept-announces-positive-topline-results-pivotal-phase-3. Accessed February 23 2019. Chalasani N, Younossi Z, Lavine JE, Charlton M, Cusi K, Rinella M, et al. The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases. Hepatology (Baltimore, Md). 2018;67(1):328–57. https://doi.org/10.1002/hep.29367.