Esophagus and Stomach

Redefining Clinical Obesity in Asian Populations Beyond BMI: Nature Reviews Endocrinology

Introduction Obesity in Asian populations is increasingly recognized as a distinct clinical and metabolic phenotype that is inadequately captured by conventional body mass index (BMI)-based definitions. Compared with White populations, Asian individuals often develop excess visceral adiposity, ectopic fat deposition and obesity-related metabolic disease at lower BMI thresholds, challenging the clinical utility of traditional obesity classification. Problem Statement Reliance on BMI alone leads to systematic under-recognition of obesity-related disease in Asian populations, delaying diagnosis and treatment despite substantial cardiometabolic risk. This limitation is particularly important in Asian individuals, who often exhibit reduced β-cell reserve, greater visceral fat burden and sarcopenic obesity, all of which contribute to earlier metabolic dysfunction despite relatively modest body weight. A more biologically relevant framework is needed to distinguish excess adiposity from clinically meaningful obesity-related disease. Summary This perspective advocates for a major shift in how clinical obesity is defined in Asian populations, moving from a BMI-centric model to an adiposity- and function-based framework. Building on the Lancet Commission’s concept of clinical obesity, the authors propose a more precise classification system that integrates anthropometric measures with body composition, metabolic markers, organ-specific dysfunction and functional impairment. This approach better distinguishes preclinical obesity from clinical obesity and more accurately reflects disease burden in Asian populations, where conventional BMI thresholds often fail to identify high-risk individuals. The proposed framework supports earlier diagnosis, improved risk stratification and stage-based treatment selection, including lifestyle intervention, pharmacotherapy and metabolic surgery. Importantly, the authors emphasize that redefining obesity in this way has implications beyond clinical care, extending to prevention strategies, reimbursement policy and public health planning. This work provides a strong conceptual foundation for more equitable and biologically meaningful obesity care in Asian populations and supports a precision medicine approach to metabolic risk assessment.

Screening and eradication of Helicobacter pylori for gastric cancer prevention

Screening and eradication of *Helicobacter pylori* (*H. pylori*) are critical strategies for preventing gastric cancer, as *H. pylori* infection is the primary etiological factor for gastric adenocarcinoma and gastric MALT lymphoma. Below is a detailed explanation of the significance, methods, and implementation of *H. pylori* screening and eradication for gastric cancer prevention: --- ### **1. Importance of *H. pylori* Eradication in Gastric Cancer Prevention** - **Causal Role of *H. pylori***: Strong epidemiological and biological evidence links *H. pylori* infection to gastric cancer development. It is considered a class I carcinogen by the International Agency for Research on Cancer (IARC). - **Reduction in Cancer Risk**: Eradication of *H. pylori* significantly lowers the incidence and mortality of gastric cancer. This benefit is observed in both asymptomatic individuals and those who have undergone endoscopic resection for early gastric cancer. - **Timing of Eradication**: The earlier the eradication occurs, the greater the benefit. Eradication is most effective before premalignant changes (e.g., atrophic gastritis or intestinal metaplasia) develop, as it interrupts the carcinogenic process. --- ### **2. Screening for *H. pylori*** Screening for *H. pylori* plays a vital role in identifying individuals at risk and initiating timely eradication therapy. Key considerations include: #### **Preferred Screening Methods** - **Noninvasive Tests**: - **¹³C-Urea Breath Test**: Highly accurate and noninvasive, making it the preferred choice for population screening. - **Monoclonal Stool Antigen Test**: Another accurate noninvasive option, particularly useful in resource-limited settings. - **Serologic Testing**: - Can be used in low-prevalence settings but requires confirmatory non-serologic testing (e.g., urea breath test or stool antigen test) to verify active infection. #### **Target Populations for Screening** - Screening should prioritize high-risk groups, including: - Individuals in high-incidence regions for gastric cancer. - Immigrants from *H. pylori*-endemic areas. - Those with a family history of gastric cancer. - Communities with poor hygiene and sanitation. #### **Optimal Age for Screening** - While the best age for screening is uncertain, earlier screening (e.g., in childhood or young adulthood) provides greater preventive benefits than delayed intervention. --- ### **3. Eradication Therapy for *H. pylori*** Eradication of *H. pylori* is essential for reducing gastric cancer risk and preventing other complications like peptic ulcers. Key aspects of eradication therapy include: #### **First-Line Treatment Options** - **Bismuth Quadruple Therapy**: Recommended as the first-line treatment in regions with high antibiotic resistance. This regimen includes: - Bismuth subsalicylate, - Tetracycline, - Metronidazole, - Proton pump inhibitor (PPI). - **PCAB-Based Regimens**: Potassium-competitive acid blockers (PCABs) combined with antibiotics are effective alternatives. #### **Special Considerations** - **Penicillin Allergy**: For penicillin-allergic patients, bismuth quadruple therapy or amoxicillin-free PCAB regimens are preferred. - **Empiric Treatment**: In areas where susceptibility testing is unavailable, empiric eradication therapy remains acceptable, provided the regimen is locally effective. #### **Post-Treatment Confirmation** - Confirmatory testing after treatment is essential to ensure successful eradication. This can be done using the urea breath test or stool antigen test. --- ### **4. Implementation Strategies** To maximize the impact of *H. pylori* screening and eradication programs, organized and systematic approaches are necessary: #### **Integration into Health Programs** - Screening should be integrated into existing preventive health initiatives, such as cancer screening programs, to optimize resources, reduce costs, and improve participation. #### **Family-Based Strategies** - Family-based screening and eradication can reduce intrafamilial transmission and reinfection rates, especially in high-prevalence communities. #### **Community Engagement** - Community education and involvement are critical to ensure high participation rates and adherence to eradication therapy. #### **Quality Assurance** - Structured programs with quality assurance measures (e.g., standardized testing and treatment protocols) and reliable follow-up systems are essential for success. --- ### **5. Broader Considerations** - **Hygiene and Sanitation**: Improved hygiene, sanitation, and access to safe water can reduce *H. pylori* transmission, particularly in low-resource settings. - **Genetic Risk Stratification**: Combining *H. pylori* screening with genetic susceptibility testing may enable more personalized risk assessments for gastric cancer. - **Safety**: Eradication therapy is generally safe and does not increase the risk of gastroesophageal reflux disease or esophageal adenocarcinoma. Any changes to the gut microbiota are typically transient. --- ### **6. Research Priorities** Ongoing research is needed to address key gaps in *H. pylori* management, including: - Development of an effective vaccine against *H. pylori*. - Understanding the long-term ecological effects of antibiotics used for eradication. - Refining risk-stratified prevention strategies to improve outcomes. --- ### **Conclusion** Screening and eradication of *H. pylori* are highly effective strategies for reducing gastric cancer risk, particularly when implemented early and in high-risk populations. By integrating screening into preventive health programs, prioritizing high-incidence regions, and ensuring proper treatment and follow-up, the burden of gastric cancer can be significantly reduced.

Long-Term Efficacy and Safety of Budesonide Orodispersible Tablets in Eosinophilic Esophagitis

The long-term efficacy and safety of budesonide orodispersible tablets (BOT) in treating eosinophilic esophagitis (EoE) have been evaluated in a comprehensive study, extending up to 96 weeks after an initial 48-week double-blind trial. Below is a detailed summary of the findings: ### **1. Chronic Nature of EoE and Need for Long-Term Treatment** Eosinophilic esophagitis is a chronic, immune-mediated disease that requires sustained maintenance therapy to prevent relapse. Previous clinical trials for EoE were generally limited to one year or less, leaving uncertainty about the long-term effectiveness and safety of treatments. This study provides critical insights into the prolonged use of BOT in managing EoE. --- ### **2. Study Design: Open-Label Extension** - **Participants:** 186 adults with EoE who had completed the initial 48-week trial were enrolled in the open-label extension phase. - **Duration:** The extension phase lasted for an additional 96 weeks, providing a total treatment period of up to 144 weeks. - **Dosing Strategy:** Patients received either 0.5 mg or 1.0 mg of BOT twice daily, with dosing tailored based on clinical judgment, mimicking real-world practice. --- ### **3. Long-Term Efficacy** #### **Clinical Remission:** - Sustained clinical remission was observed in over 80% of patients throughout the 96-week open-label treatment phase. - Dysphagia (difficulty swallowing) and odynophagia (painful swallowing) scores remained consistently near zero across all follow-up visits, indicating stable symptom control. #### **Histologic Remission:** - Approximately 80% of patients achieved histologic remission at week 96, defined as ≤6 eosinophils per high-power field (hpf) in esophageal biopsies. - Nearly four-fifths of patients demonstrated a deep histologic response, with complete absence of eosinophils in their biopsies. #### **Endoscopic Stability:** - Endoscopic Reference Scores remained minimal over the long-term follow-up, showing persistent control of inflammatory and fibrotic features in the esophagus. #### **Clinico-Histologic Remission:** - More than three-quarters of patients achieved combined clinical and histologic remission by the end of the 96-week extension phase. #### **Quality of Life Improvement:** - EoE-specific quality-of-life scores improved steadily over time with continued BOT therapy, reflecting enhanced patient well-being. #### **Low Relapse Rates:** - Symptomatic and histologic relapse occurred infrequently and was typically transient. - Patients who experienced relapse during the earlier blinded phase of the trial frequently regained remission during the open-label extension with reinduction therapy. --- ### **4. Safety Profile** #### **Adverse Events:** - The safety profile of BOT remained consistent throughout the study, with no evidence of cumulative toxicity. - The most common adverse events were oral and esophageal candidiasis, which were generally mild and successfully treated with antifungal medications. #### **Adrenal Function:** - Morning cortisol levels remained stable, and no clinically significant adrenal insufficiency was observed, indicating that BOT does not cause adrenal suppression. #### **No Progression to Fibrostenotic Disease:** - Long-term BOT therapy prevented the progression of EoE to fibrostenotic disease, eliminating the need for endoscopic dilation procedures. #### **Patient Satisfaction:** - Nearly all patients reported being satisfied or extremely satisfied with their long-term treatment experience using BOT. --- ### **5. Disease-Modifying Potential** The study findings suggest that budesonide orodispersible tablets may have disease-modifying potential in EoE. Sustained clinical, histologic, and endoscopic control over nearly two years indicates that BOT can effectively manage the disease course and prevent long-term complications. --- ### **6. Conclusion** The long-term use of budesonide orodispersible tablets demonstrates robust efficacy and safety in managing eosinophilic esophagitis. The treatment maintained clinical remission, histologic response, and endoscopic stability while improving patient quality of life and minimizing relapse rates. The consistent safety profile, including the absence of adrenal suppression or progression to fibrostenotic disease, underscores the suitability of BOT as a long-term maintenance therapy for EoE.