title: Early Statin Treatment in Patients With Acute Coronary Syndrome: Demonstration of the Beneficial Effect on Atherosclerotic Lesions by Serial Volumetric Intravascular Ultrasound Analysis During Half a Year After Coronary Event: The ESTABLISH Study The role of bile after Roux-en-Y gastric bypass in promoting weight loss and improving glycaemic control. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial Regression of Coronary Atherosclerosis by Simvastatin: A Serial Intravascular Ultrasound Study Weight Loss and Dietary Intake After Vertical Banded Gastroplasty and Roux‐en‐Y Gastric Bypass Diabetes Remission and Insulin Secretion After Gastric Bypass in Patients with Body Mass Index <35 kg/m2 Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. Fat malabsorption and increased intestinal oxalate absorption are common after Roux-en-Y gastric bypass surgery. Nocturnal and postprandial free fatty acid kinetics in normal and type 2 diabetic subjects: effects of insulin sensitization therapy. Within- and between-subject variation in commonly measured anthropometric and biochemical variables. Who Would Have Thought It? An Operation Proves to Be the Most Effective Therapy for Adult‐Onset Diabetes Mellitus Enhanced fasting and post-prandial plasma bile acid responses after Roux-en-Y gastric bypass surgery A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. 1977. Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia. Report of the Program on the Surgical Control of the Hyperlipidemias (POSCH) Fasting compared with nonfasting triglycerides and risk of cardiovascular events in women. Gut Hormones as Mediators of Appetite and Weight Loss After Roux-en-Y Gastric Bypass Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. Body Composition, Dietary Intake, and Energy Expenditure After Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Vertical Banded Gastroplasty: A Randomized Clinical Trial Progressive rise in gut hormone levels after Roux‐en‐Y gastric bypass suggests gut adaptation and explains altered satiety Perioperative safety in the longitudinal assessment of bariatric surgery. Extended-release niacin or ezetimibe and carotid intima-media thickness. Cholesterol absorption decreases after Roux-en-Y gastric bypass but not after gastric banding. Weight loss induced by Roux-en-Y gastric bypass but not laparoscopic adjustable gastric banding increases circulating bile acids. Physical Activity Predicts Weight Loss Following Gastric Bypass Surgery: Findings from a Support Group Survey
abstract: Background —Recent clinical trials have demonstrated that aggressive lipid lowering by statins could prevent recurrent events after acute coronary syndrome ( ACS ) . We hypothesized that this efficacy was caused by a significant reduction in plaque volume by aggressive LDL cholesterol ( LCL-C ) lowering . The present study investigated the effect of early statin treatment on plaque volume of a nonculprit lesion by serial volumetric intravascular ultrasound in patients with ACS . Methods and Results —Seventy patients with ACS were enrolled . All patients underwent emergency coronary angiography and percutaneous coronary intervention ( PCI ) .  They were r and omized to intensive lipid-lowering therapy ( n=35 ; atorvastatin 20 mg/d ) or control ( n=35 ) groups after PCI . Volumetric intravascular ultrasound analyses were performed at baseline and 6-month follow-up for a non-PCI site in 48 patients ( atorvastatin , n=24 ; control , n=24 ) . LDL-C level was significantly decreased by 41.7 % in the atorvastatin group compared with the control group , in which LDL-C was increased by 0.7 % ( P<0.0001 ) . Plaque volume was significantly reduced in the atorvastatin group ( 13.1±12.8 % decrease ) compared with the control group ( 8.7±14.9 % increase ; P<0.0001 ) . Percent change in plaque volume showed a significant positive correlation with follow-up LDL-C level ( R=0.456 , P=0.0011 ) and percent LDL-C reduction ( R=0.612 , P<0.0001 ) , even in patients with baseline LDL-C < 125 mg/dL. Conclusions —Early aggressive lipid-lowering therapy by atorvastatin for 6 months significantly reduced the plaque volume in patients with ACS . Percent change in plaque volume showed a significant positive correlation with percent LDL-C reduction , even in patients with low baseline Gastric bypass leads to the remission of  type 2 diabetes  independently of weight loss . Our hypothesis is that changes in bile flow due to the altered anatomy may partly explain the metabolic outcomes of the operation . We prospect ively studied 12 patients undergoing gastric bypass and six patients undergoing gastric b and ing over a 6-wk period . Plasma fibroblast growth factor (FGF)19 , stimulated by bile acid absorption in the terminal ileum , and plasma bile acids were measured . In canine and rodent models , we investigated changes in the gut hormone response after altered bile flow . FGF19 and total plasma bile acids levels increased after gastric bypass compared with no change after gastric b and ing . In the canine model , both food and bile , on their own , stimulated satiety gut hormone responses . However , when combined , the response was doubled . In rats , drainage of endogenous bile into the terminal ileum was associated with an enhanced satiety gut hormone response , reduced food intake , and lower body weight . In conclusion , after gastric bypass , bile flow is altered , leading to increased plasma bile acids , FGF19 , incretin . and satiety gut hormone concentrations . Elucidating the mechanism of action of gastric bypass surgery may lead to novel treatments for type 2 diabetes BACKGROUND Although statins reduce coronary and cerebrovascular morbidity and mortality in middle-aged individuals , their efficacy and safety in elderly people is not fully established . Our aim was to test the benefits of pravastatin treatment in an elderly cohort of men and women with , or at high risk of developing , cardiovascular disease and stroke . METHODS We did a r and omised controlled trial in which we assigned 5804 men ( n=2804 ) and women ( n=3000 ) aged 70 - 82 years with a history of , or risk factors for , vascular disease to pravastatin ( 40 mg per day ; n=2891 ) or placebo ( n=2913 ) . Baseline cholesterol concentrations ranged from 4.0 mmol/L to 9.0 mmol/L. Follow-up was 3.2 years on average and our primary endpoint was a composite of coronary death , non-fatal myocardial infa rct ion , and fatal or non-fatal stroke . Analysis was by intention-to-treat . FINDINGS Pravastatin lowered LDL cholesterol concentrations by 34 % and reduced the incidence of the primary endpoint to 408 events compared with 473 on placebo ( hazard ratio 0.85 , 95 % CI 0.74 - 0.97 , p=0.014 ) . Coronary heart disease death and non-fatal myocardial infa rct ion risk was also reduced ( 0.81 , 0.69 - 0.94 , p=0.006 ) . Stroke risk was unaffected ( 1.03 , 0.81 - 1.31 , p=0.8 ) , but the hazard ratio for transient ischaemic attack was 0.75 ( 0.55 - 1.00 , p=0.051 ) . New cancer diagnoses were more frequent on pravastatin than on placebo ( 1.25 , 1.04 - 1.51 , p=0.020 ) . However , incorporation of this finding in a meta- analysis of all pravastatin and all statin trials showed no overall increase in risk . Mortality from coronary disease fell by 24 % ( p=0.043 ) in the pravastatin group . Pravastatin had no significant effect on cognitive function or disability . INTERPRETATION Pravastatin given for 3 years reduced the risk of coronary disease in elderly individuals . PROSPER therefore extends to elderly individuals the treatment strategy currently used in middle aged people Background —Angiography of the coronary arteries reflects only changes in luminal dimensions . With intravascular ultrasound , cross-sectional images can be obtained and area measurements can be added to calculate volumes of the external elastic membrane ( EEM ) , plaque plus media ( P+M ) , and lumen . The aim of this study was to investigate the effect of lipid lowering by simvastatin on coronary atherosclerotic P+M as changes in volumes of EEM , P+M , and lumen . Methods and Results —In 40 male patients with hypercholesterolemia , ischemic heart disease , and a nonsignificant coronary artery lesion in a not previously revascularized coronary artery , serial intravascular ultrasound studies with an ECG-triggered pullback were performed at baseline , after 3 months on a lipid-lowering diet , and after another 12 months on simvastatin 40 mg/d . Mean length of the analyzed atherosclerotic segments was 5.9±3.3 mm . After 12 months on simvastatin , a significant reduction in P+M volume of 6.3 % ( P = 0.002 ) was observed , whereas only a nonsignificant reduction in EEM volume of 1.8 % was seen without any concomitant change in lumen volume . A significant reduction in total cholesterol of 31.0 % ( 6.1±0.8 versus 4.2±0.7 mmol/L , P < 0.001 ) and LDL cholesterol of 42.6 % ( 4.0±0.8 versus 2.2±0.6 mmol/L , P < 0.001 ) was obtained . Conclusions —Lipid-lowering therapy with simvastatin for 12 months is associated with a significant P+M regression in coronary arteries measured as reduction in P+M and EEM volumes without any concomitant change in lumen volume Objective The purpose of this study was to learn whether preoperative eating habits can be used to predict outcome after  vertical b and ed gastroplasty ( VBG ) and Roux-en-Y gastric bypass ( RYGB ) .  Background Summary Several independent r and omized and sequential studies have reported significantly greater weight loss after RYGB in comparison with VBG . Although the mechanism responsible for weight loss after both procedures is restriction of intake rather than malabsorption , the relationships between calorie intake , food preferences , and postoperative weight loss are not well defined . Methods During the past 5 years , 138 patients were prospect ively selected for either VBG or RYGB , based on their preoperative eating habits . All patients were screened by a dietitian who determined total calorie intake and diet composition before recommending VBG or RYGB .  Thirty patients were selected for VBG ; the remaining 108 patients were classified as “ sweets eaters ” or “ snackers ” and had RYGB . Detailed recall diet histories also were performed at each postoperative visit . Results Early morbidity rate was zero after VBG versus 3 % after RYGB . There were no deaths . Mean follow-up was 39 ± 11 months after VBG and 38 ± 14 months after RYGB . Mean weight loss peaked at 74 ± 23 lb at 12 months after VBG and 99 ± 24 lb at 16 months after RYGB ( p ≤ 0.001 ) . Twelve of 30 VBG patients lost > 50 % of their excess weight versus 100 of 108 RYGB patients ( p ≤ 0.0001 ) . Milk/ice cream intake was significantly greater postoperatively in patients who underwent VBG versus patients who underwent RYGB after 6 months ( p ≤ 0.003 ) , whereas solid sweets intake was significantly greater after VBG during the first 18 months postoperatively ( p ≤ 0.004 ) . Revision of VBG was performed in 6 of 30 patients ( 20 % ) for complications or poor weight loss , whereas only 2 of 108 patients who underwent RYGB required surgical revisions ( p ≤ 0.001 ) . Conclusions These data show that VBG adversely alters postoperative eating behavior toward soft , high-calorie foods , result ing in problematic postoperative weight loss . Conversely , RYGB patients had significantly greater weight loss despite inferior preoperative eating habits . The high rate Background Most morbidly obese patients who undergo gastric bypass  experience rapid remission of type 2 diabetes mellitus ( T2DM ) but the response in non-morbidly obese patients is not clear . This trial prospect ively assessed the effect of diabetes remission , glucose metabolism , and the serial changes of insulin secretion after gastric bypass in inadequately controlled T2DM patients with a BMI of 23–35 kg/m2 . Methods A total of 62 consecutive patients with T2DM and a BMI of 23–35 kg/m2 underwent gastric bypass .  Data were prospect ively collected before surgery and 1 , 4 , 12 , 26 , and 52 weeks and 2 years after surgery . Insulin secretion was measured by insulinogenic index and area under the curve ( AUC ) during a st and ard oral glucose tolerance test ( OGTT ) . Remission of type 2 diabetes was defined as fasting glucose level < 110 mg/dl and HbA1c < 6.0 % without any glycemic therapy . Results Of the 62 patients , 24 were men and 38 were women ( age 43.1 ± 10.8 years ) . Their preoperative characteristics were as follows : BMI 30.1 ± 3.3 kg/m2 , waist circumference 99.6 ± 9.6 cm , C-peptide 3.1 ± 1.4 ng/ml , and duration of T2DM 5.4 ± 5.1 years . The mean BMI decreased postoperatively to 22.6 ± 2.3 kg/m2 in 1 year and 23.0 ± 2.7 kg/m2 in 2 years . The mean HbA1c decreased from 9.7 ± 1.9 % to 5.8 ± 0.5 % in 1 year and 5.9 ± 0.5 % in 2 years . Complete remission of T2DM was achieved in 57 % in 1 year and 55 % in 2 years after surgery . Before surgery , the OGTT test showed a blunted insulin secretion pattern with an insulinogenic index of 0.1 ± 0.2 and AUC of 2,324 ± 1,015 μIU min/ml . In 1 week after surgery , the insulinogenic index increased to 0.16 and AUC decreased to 1,366 μIU min/ml along with a rapid drop of insulin resistance . The insulinogenic index and AUC gradually increased to 0.27 and 3,220 , respectively , 1 year after surgery and remained stable up to 2 years with a very low insulin resistance . Conclusions Laparoscopic gastric bypass facilitates immediate improvement in the glucose metabolism of inadequately controlled non-severe  obese T2DM patients , and the benefit is sustained up to 2 years after surgery . The benefit is regulated by the decrease in insulin resistance , increase in early insulin response , and total insulin secretion to glucose load BACKGROUND In patients with established cardiovascular disease , residual cardiovascular risk persists despite the achievement of target low-density lipoprotein ( LDL ) cholesterol levels with statin therapy . It is unclear whether extended-release niacin added to simvastatin to raise low levels of high-density lipoprotein ( HDL ) cholesterol is superior to simvastatin alone in reducing such residual risk . METHODS We r and omly assigned eligible patients to receive extended-release niacin , 1500 to 2000 mg per day , or matching placebo . All patients received simvastatin , 40 to 80 mg per day , plus ezetimibe , 10 mg per day , if needed , to maintain an LDL cholesterol level of 40 to 80 mg per deciliter ( 1.03 to 2.07 mmol per liter ) . The primary end point was the first event of the composite of death from coronary heart disease , nonfatal myocardial infa rct ion , ischemic stroke , hospitalization for an acute coronary syndrome , or symptom-driven coronary or cerebral revascularization . RESULTS A total of 3414 patients were r and omly assigned to receive niacin ( 1718 ) or placebo ( 1696 ) . The trial was stopped after a mean follow-up period of 3 years owing to a lack of efficacy . At 2 years , niacin therapy had significantly increased the median HDL cholesterol level from 35 mg per deciliter ( 0.91 mmol per liter ) to 42 mg per deciliter ( 1.08 mmol per liter ) , lowered the triglyceride level from 164 mg per deciliter ( 1.85 mmol per liter ) to 122 mg per deciliter ( 1.38 mmol per liter ) , and lowered the LDL cholesterol level from 74 mg per deciliter ( 1.91 mmol per liter ) to 62 mg per deciliter ( 1.60 mmol per liter ) . The primary end point occurred in 282 patients in the niacin group ( 16.4 % ) and in 274 patients in the placebo group ( 16.2 % ) ( hazard ratio , 1.02 ; 95 % confidence interval , 0.87 to 1.21 ; P=0.79 by the log-rank test ) . CONCLUSIONS Among patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of less than 70 mg per deciliter ( 1.81 mmol per liter ) , there was no incremental clinical benefit from the addition of niacin to statin therapy during a 36-month follow-up period , despite significant improvements in HDL cholesterol and triglyceride levels . ( Funded by the National Heart , Lung , and Blood Institute and Abbott Laboratories ; AIM -HIGH Clinical Trials.gov number , NCT00120289 . ) BACKGROUND Hyperoxaluria and increased calcium oxalate stone formation occur after Roux-en-Y gastric bypass ( RYGB ) surgery for morbid obesity . The etiology of this hyperoxaluria is unknown . We hypothesized that after bariatric surgery , intestinal hyperabsorption of oxalate contributes to increases in plasma oxalate and urinary calcium oxalate supersaturation . METHODS We prospect ively examined oxalate metabolism in 11 morbidly obese subjects before and 6 and 12 months after RYGB ( n = 9 ) and biliopancreatic diversion-duodenal switch ( BPD-DS ) ( n = 2 ) . We measured 24-hour urinary supersaturations for calcium oxalate , apatite , brushite , uric acid , and sodium urate ; fasting plasma oxalate ; 72-hour fecal fat ; and increases in urine oxalate following an oral oxalate load . RESULTS Six and 12 months after RYGB , plasma oxalate and urine calcium oxalate supersaturation increased significantly compared with similar measurements obtained before surgery ( all P ≤ .02 ) . Fecal fat excretion at 6 and 12 months was increased ( P = .026 and .055 , 0 vs 6 and 12 months ) . An increase in urine oxalate excretion after an oral dose of oxalate was observed at 6 and 12 months ( all P ≤ .02 ) . Therefore , after bariatric surgery , increases in fecal fat excretion , urinary oxalate excretion after an oral oxalate load , plasma oxalate , and urinary calcium oxalate supersaturation values were observed . CONCLUSION Enteric hyperoxaluria is often present in patients after the operations  of RYGB and BPD-DS  that utilize an element of intestinal malabsorption as a mechanism for weight loss Whether free fatty acid ( FFA ) rate of appearance ( R(a ) ) is increased in type 2 diabetes is controversial . To characterize nocturnal and postpr and ial abnormalities in FFA kinetics and to determine the effects of treatment with insulin sensitizers on lipolysis , we measured palmitate R(a ) in control subjects ( n = 6 ) and individuals with poorly controlled , sulfonylurea-treated type 2 diabetes ( HbA(1c ) = 8.7 + /- 0.2 % , n = 20 ) , the latter before and at the end of 12 weeks of treatment with troglitazone ( 600 mg/day , n = 4 ) , metformin ( approximately 2,000 mg/day , n = 8) , or placebo ( n = 8) . Subjects consumed a st and ard breakfast at 0800 h. Results in control subjects and type 2 diabetic subjects were compared at baseline . Integrated nocturnal FFA R(a ) ( AUC(1:00 - 8:00 A.M. ) ) was approximately 50 % higher in type 2 diabetic subjects than in control subjects ( 29.4 + /- 3.0 vs. 19.4 + /- 3.9 mmol . m(-2 ) . 7 h(-1 ) , respectively , P < 0.05 ) , whereas postpr and ial palmitate R(a ) ( AUC(0 - 240 min ) ) was almost threefold higher in type 2 diabetic subjects than in control subjects ( 14.2 + /- 1.7 vs. 5.3 + /- 1.0 mmol . m(-2 ) . 4 h(-1 ) , respectively , P < 0.01 ) . After troglitazone treatment , nocturnal palmitate R(a ) did not change , but postpr and ial palmitate R(a ) decreased by approximately 30 % ( P < 0.05 ) . Palmitate kinetics did not change with metformin or placebo treatment . In summary , nocturnal and postpr and ial FFA R(a ) is increased in type 2 diabetes . Postpr and ial lipolysis appears to be preferentially improved by thiazolidinediones compared with nocturnal lipolysis BACKGROUND The biological variation of some commonly assessed metabolic variables in healthy subjects has not been studied extensively . The aim of the study was to assess , in 12 healthy subjects ( 6 male and 6 female ; mean ( SD ) age ; 22.7 ( 1.5 ) years ) following an overnight fast  , the day-to-day variation of body fat ( impedance method ) , triglycerides , nonesterified fatty acid ( NEFAs ) , glycerol , 3-hydroxybutyrate ( 3-OHB ) , lactate , glucose , insulin ( RIA ) , C-peptide , and glucagon on 12 consecutive days . METHODS Between- and within-subject coefficients of variation ( CVG and CVW ) were estimated using a r and om effects analysis of variance , and assay variation was subtracted to give the coefficient of within-subject biological variation ( CVI ) . Individuality indices were calculated as CVW/CVG . RESULTS The overall means , CVI , and individuality indices were as follows : for body fat , 24.2 % , 10 % , and 0.3 ; for triglycerides , 0.61 mmol/L , 21 % , and 1.1 ; for NEFAs , 376 micromol/L , 45 % , and 1.4 ; for glycerol , 48 micromol/L , 36 % , and 0.8 ; for 3-OHB , 43 micromol/L , 61 % , and 1.5 ; for lactate , 0.88 mmol/L , 31 % , and 1.1 ; for glucose , 4.9 mmol/L , 4.8 % , and 0.7 ; for insulin , 52 pmol/L , 26 % , and 1.0 ; for C-peptide , 0.39 nmol/L , 24 % , and 0.9 ; and for glucagon , 53 ng/L , 19 % , and 0.8 . CONCLUSIONS The data presented here are necessary for the evaluation of several important metabolic variables in individual and group studies . The biological variation of some metabolites makes it difficult to characterize the status of healthy subjects with a single measurement Objective This report documents that the gastric bypass operation provides long-term control for obesity and diabetes .  Summary Background Data Obesity and diabetes , both notoriously resistant to medical therapy , continue to be two of our most common and serious diseases . Methods Over the last 14 years , 608 morbidly obese patients underwent gastric bypass  , an operation that restricts caloric intake by ( 1 ) reducing the functional stomach to approximately 30 mL , ( 2 ) delaying gastric emptying with a c. 0.8 to 1.0 cm gastric outlet , and ( 3 ) excluding foregut with a 40 to 60 cm Roux-en-Y gastrojejunostomy . Even though many of the patients were seriously ill , the operation was performed with a perioperative mortality and complication rate of 1.5 % and 8.5 % , respectively . Seventeen of the 608 patients ( <3 % ) were lost to follow-up . Results Gastric bypass provides durable weight control . Weights fell from a preoperative mean of 304.4 lb ( range , 198 to 615 lb ) to 192.2 lb ( range , 104 to 466 ) by 1 year and were maintained at 205.4 lb ( range , 107 to 512 lb ) at 5 years , 206.5 lb ( 130 to 388 lb ) at 10 years , and 204.7 lb ( 158 to 270 lb ) at 14 years . The operation provides long-term control of non-insulin-dependent diabetes mellitus ( NIDDM ) . In those patients with adequate follow-up , 121 of 146 patients ( 82.9 % ) with NIDDM and 150 of 152 patients ( 98.7 % ) with glucose impairment maintained normal levels of plasma glucose , glycosylated hemoglobin , and insulin . These antidiabetic effects appear to be due primarily to a reduction in caloric intake , suggesting that insulin resistance is a secondary protective effect rather than the initial lesion . In addition to the control of weight and NIDDM , gastric bypass also corrected or alleviated a number of other comorbidities of obesity , including hypertension , sleep apnea , cardiopulmonary failure , arthritis , and infertility Abstract Objective . Exogenous bile acid ( BA ) administration is associated with beneficial metabolic effects very similar to those seen after Roux-en-Y gastric bypass ( RYGB ) surgery . Re-routing of bile into a biliopancreatic limb with simultaneous exclusion of food occurs after RYGB , with subsequent increased fasting plasma BAs . The study assessed fasting and post-pr and ial plasma BA response before and 15 months after RYGB . Material and methods . The prospect i ve study recruited 63 obese individuals ( 43 females ) , aged 43 ( 36–56 ) [ median ( IQR ) ] years .  Blood sample s were collected before and every 30 min for 120 min after a st and ard 400 kcal meal .  Fasting and post-pr and ial plasma BAs , glucagons like peptide-1 ( GLP-1 ) , –tyrosine ( PYY ) , fasting C-reactive protein ( CRP ) , glucose and insulin were measured and homeostasis model assessment -insulin resistance ( HOMA-IR ) was calculated . Results . Following RYGB , body mass index , CRP , fasting glucose and HOMA-IR decreased ; 43.7 ( 39.3–49.2 ) kg/m2 to 29.2 ( 25.1–35.0 ) kg/m2 , 7.9 ( 4.1–11.9 ) mg/L to 0.4 ( 0.2–1.0 ) mg/L , 5.5 ( 5.0–6.0 ) mmol/L to 4.6 ( 4.3–4.9 ) mmol/L and 5.9 ( 3.5–9.2 ) to 1.7 ( 1.1–2.2 ) , respectively , all P < 0.001 . Fasting total BAs , GLP-1 and PYY increased after RYGB ; 1.69 ( 0.70–2.56 ) µmol/L to 2.43 ( 1.23–3.82 ) µmol/L ( P = 0.02 ) , 6.8 ( 1.5–15.3 ) pmol/L to 17.1 ( 12.6–23.9 ) pmol/L ( P < 0.001 ) and 4.0 ( 1.0–7.1 ) pmol/L to 15.2 ( 10.0–28.3 ) pmol/L ( P < 0.001 ) , respectively . The area under the curve for post-pr and ial total BAs , total glycine-conjugated BAs , GLP-1 and PYY were greater after RYGB ; 486 ( 312–732 ) µmol/L/min versus 1012 ( 684–1921 ) µmol/L/min , 315 ( 221–466 ) µmol/L/min versus 686 ( 424–877 ) µmol/L/min , 3679 ( 3162–4537 ) pmol/L/min versus 5347 ( 4727–5781 ) pmol/L/min and 1887 ( 1423–2092 ) pmol/L/min versus 3296 ( 2534–3834 ) pmol/L/min , respectively , all P < 0.0001 . Conclusion . Weight loss following RYGB is associated with an increase in post-pr and ial plasma BA response due to larger amounts of glycine-conjugated BAs . This suggests up regulation of BA production and conjugation after RYGB A r and omized prospect i ve evaluation of the  gastric and jejunoileal bypass procedures for morbid obesity was performed . The gastric bypass was performed predominantly as a 90 % gastric exclusion with a Roux-en-Y reconstitution . The jejunoileal bypass was an end-to-end anastomosis between 30 cm of BACKGROUND AND METHODS The Program on the Surgical Control of the Hyperlipidemias ( POSCH ) , a r and omized clinical trial , was design ed to test whether cholesterol lowering induced by the partial ileal bypass operation would favorably affect overall mortality or mortality due to coronary heart disease . The study population consisted of 838 patients ( 417 in the control group and 421 in the surgery group ) , both men ( 90.7 percent ) and women , with an average age of 51 years , who had survived a first myocardial infa rct ion . The mean follow-up period was 9.7 years . RESULTS When compared with the control group at five years , the surgery group had a total plasma cholesterol level 23.3 percent lower ( 4.71 + /- 0.91 vs. 6.14 + /- 0.89 mmol per liter [ mean + /- SD ] ; P less than 0.0001 ) , a low-density lipoprotein cholesterol level 37.7 percent lower ( 2.68 + /- 0.78 vs. 4.30 + /- 0.89 mmol per liter ; P less than 0.0001 ) , and a high-density lipoprotein cholesterol level 4.3 percent higher ( 1.08 + /- 0.26 vs. 1.04 + /- 0.25 mmol per liter ; P = 0.02 ) . Overall mortality and mortality due to coronary heart disease were reduced , but not significantly so ( deaths overall [ control vs. surgery ] , 62 vs. 49 , P = 0.164 ; deaths due to coronary disease , 44 vs. 32 , P = 0.113 ) . The overall mortality in the surgery subgroup with an ejection fraction greater than or equal to 50 percent was 36 percent lower ( control vs. surgery , 39 vs. 24 ; P = 0.021 ) . The value for two end points combined -- death due to coronary heart disease and confirmed nonfatal myocardial infa rct ion -- was 35 percent lower in the surgery group ( 125 vs. 82 events ; P less than 0.001 ) . During follow-up , 137 control-group and 52 surgery-group patients underwent coronary-artery bypass grafting ( P less than 0.0001 ) . A comparison of base-line coronary arteriograms with those obtained at 3 , 5 , 7 , and 10 years consistently showed less disease progression in the surgery group ( P less than 0.001 ) . The most common side effect of partial ileal bypass was diarrhea ; others included occasional kidney stones , gallstones , and intestinal obstruction . CONCLUSIONS Partial ileal bypass produces sustained improvement in the blood lipid patterns of patients who have had a myocardial infa rct ion and reduces their subsequent morbidity due to coronary heart disease . The role of this procedure in the management of hypercholesterolemia remains to be determined . These results provide strong evidence supporting the beneficial effects of lipid modification in the reduction of atherosclerosis progression CONTEXT The association of triglycerides with incident cardiovascular disease  remains controversial . Although triglyceride levels are typically obtained in the fasting state , postpr and ial hypertriglyceridemia may play an important role in atherosclerosis . OBJECTIVE To determine the association of  triglyceride levels ( fasting vs nonfasting ) and risk of future cardiovascular events . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve study of 26,509 initially healthy US women ( 20,118 fasting and 6391 nonfasting ) participating in the Women 's Health Study , enrolled between November 1992 and July 1995 and undergoing follow-up for a median of 11.4 years .  Triglyceride levels  were measured in blood sample s obtained at time of enrollment . MAIN OUTCOME MEASURE Hazard ratios for incident cardiovascular events ( nonfatal myocardial infa rct ion , nonfatal ischemic stroke , coronary revascularization , or cardiovascular death ) . RESULTS At baseline , triglyceride levels in fasting as well as nonfasting women correlated with traditional cardiac risk factors and markers of insulin resistance . During a median follow-up of 11.4 years , 1001 participants experienced an incident cardiovascular event ( including 276 nonfatal myocardial infa rct ions , 265 ischemic strokes , 628 coronary revascularizations , and 163 cardiovascular deaths ) , for an overall rate of 3.46 cardiovascular events per 1000 person-years of follow-up . After adjusting for age , blood pressure , smoking , and use of hormone therapy , both fasting and nonfasting triglyceride levels predicted cardiovascular events . Among fasting participants , further adjustment for levels of total and high-density lipoprotein cholesterol and measures of insulin resistance weakened this association ( fully adjusted hazard ratio [ 95 % confidence interval ] for increasing tertiles of triglyceride levels : 1 [ reference ] , 1.21 [ 0.96 - 1.52 ] , and 1.09 [ 0.85 - 1.41 ] [ P = .90 for trend ] ) . In contrast , nonfasting triglyceride levels maintained a strong independent relationship with cardiovascular events in fully adjusted models ( hazard ratio [ 95 % confidence interval ] for increasing tertiles of levels : 1 [ reference ] , 1.44 [ 0.90 - 2.29 ] , and 1.98 [ 1.21 - 3.25 ] [ P = .006 for trend ] ) . In secondary analyses stratified by time since participants ' last meal , triglyceride levels measured 2 to 4 hours postpr and ially had the strongest association with cardiovascular events ( fully adjusted hazard ratio [ 95 % confidence interval ] for highest vs lowest tertiles of levels , 4.48 [ 1.98 - 10.15 ] [ P<.001 for trend ] ) , and this association progressively decreased with longer periods of fasting . CONCLUSIONS In this cohort of initially healthy women , nonfasting triglyceride levels were associated with incident cardiovascular events , independent of traditional cardiac risk factors , levels of other lipids , and markers of insulin resistance ; by contrast , fasting triglyceride levels showed little independent relationship Objective : To evaluate the physiologic importance of the satiety gut hormones . Background : Controversy surrounds the physiologic role of gut hormones in the control of appetite . Bariatric surgery remains the most effective treatment option for obesity , and gut hormones are implicated in the reduction of appetite and weight after Roux-en-Y gastric bypass . Methods : We correlated peptide YY ( PYY ) and glucagon-like peptide 1 ( GLP-1 ) changes within the first week after gastric bypass with changes in appetite . We also evaluated the gut hormone responses of patients with good or poor weight loss after gastric bypass .  Finally , we inhibited the gut hormone responses in gastric bypass patients and then evaluated appetite and food intake . Results : Postpr and ial PYY and GLP-1 profiles start rising as early as 2 days after gastric bypass ( P < 0.05 ) . Changes in appetite are evident within days after gastric bypass surgery ( P < 0.05 ) , and unlike other operations , the reduced appetite continues . However , in patients with poor weight loss after gastric bypass associated with increased appetite , the postpr and ial PYY and GLP-1 responses are attenuated compared with patients with good weight loss ( P < 0.05 ) . Inhibiting gut hormone responses , including PYY and GLP-1 after gastric bypass , results in return of appetite and increased food intake ( P < 0.05 ) . Conclusion : The attenuated appetite after gastric bypass is associated with elevated PYY and GLP-1 concentrations , and appetite returns when the release of gut hormones is inhibited . The results suggest a role for gut hormones in the mechanism of weight loss after gastric bypass and may have implication s for the treatment of obesity BACKGROUND Weight loss is associated with short-term amelioration and prevention of metabolic and cardiovascular risk , but whether these benefits persist over time is unknown . METHODS The prospect i ve , controlled Swedish Obese Subjects Study involved obese subjects who underwent gastric surgery and contemporaneously matched , conventionally treated obese control subjects . We now report follow-up data for subjects ( mean age , 48 years ; mean body-mass index , 41 ) who had been enrolled for at least 2 years ( 4047 subjects ) or 10 years ( 1703 subjects ) before the analysis ( January 1 , 2004 ) . The follow-up rate for laboratory examinations was 86.6 percent at 2 years and 74.5 percent at 10 years . RESULTS After two years , the weight had increased by 0.1 percent in the control group and had decreased by 23.4 percent in the surgery group ( P<0.001 ) . After 10 years , the weight had increased by 1.6 percent and decreased by 16.1 percent , respectively ( P<0.001 ) . Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period . Two- and 10-year rates of recovery from diabetes , hypertriglyceridemia , low levels of high-density lipoprotein cholesterol , hypertension , and hyperuricemia were more favorable in the surgery group than in the control group , whereas recovery from hypercholesterolemia did not differ between the groups . The surgery group had lower 2- and 10-year incidence rates of diabetes , hypertriglyceridemia , and hyperuricemia than the control group ; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable . CONCLUSIONS As compared with conventional therapy , bariatric surgery appears to be a viable option for the treatment of severe obesity , result ing in long-term weight loss , improved lifestyle , and , except for hypercholesterolemia , amelioration in risk factors that were elevated at baseline Objective : To assess body composition , eating pattern , and basal metabolic rate in patients undergoing obesity surgery in a r and omized trial . Introduction : There is limited knowledge regarding how different bariatric surgical techniques function in terms of altering body composition , dietary intake , and basic metabolic rate . Methods : Non-superobese patients were r and omized to laparoscopic Roux-en-Y gastric bypass ( LGBP , n = 37 ) or laparoscopic vertical b and ed gastroplasty ( LVBG , n = 46 ) . Anthropometry , dual-energy x-ray absorptiometry ( DEXA ) , computed tomography ( CT ) , indirect calorimetry , and reported dietary intake were registered prior to and 1 year after surgery . Results : Follow-up rate was 97.6 % . LGBP patients had significantly greater reduction of waist circumference and sagittal diameter compared with LVBG . DEXA demonstrated a larger reduction of body fat in all compartments after LGBP , especially at the trunk ( P<0.001 ) . CT demonstrated more reduction of the visceral fat ( P=0.016 ) . Patients were able to eat all types of food after LGBP , although about 30 % cl aim ed they avoided fats . LGBP patients decreased their proportion of dietary fat significantly more than those operated on with LVBG ( P = 0.005 ) , who consumed more sweet foods and avoided whole meat and vegetables . Lean tissue mass ( LTM ) was proportionally less reduced , especially in men , after LGBP . The decreases in BMR postoperatively reflected the lower body mass in a pattern that did not differ among the groups . Conclusion : LGBP patients demonstrated better outcomes compared with LVBG patients in terms of body composition . Energy expenditure developed as expected postoperatively . A “ steering ” away from fatty foods after LGBP may be an important mechanism of action in gastric bypass Bariatric surgery is the most effective treatment for achieving long‐term weight loss in morbidly obese patients . This study investigated prospect i ve changes in gut hormones and metabolic indices after Roux‐en‐$\font\ss = cmss10 scaled 1000 \hbox{\ss Y}$ gastric bypass ( RYGB ) BACKGROUND To improve decision making in the treatment of extreme obesity , the risks of bariatric surgical procedures require further characterization . METHODS We performed a prospect i ve , multicenter , observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States from 2005 through 2007 . A composite end point of 30-day major adverse outcomes ( including death ; venous thromboembolism ; percutaneous , endoscopic , or operative reintervention ; and failure to be discharged from the hospital ) was evaluated among patients undergoing first-time bariatric surgery .  RESULTS There were 4776 patients who had a first-time bariatric procedure ( mean age , 44.5 years ; 21.1 % men ; 10.9 % nonwhite ; median body-mass index [ the weight in kilograms divided by the square of the height in meters ] , 46.5 ) . More than half had at least two coexisting conditions . A Roux-en-Y gastric bypass was performed in 3412 patients ( with 87.2 % of the procedures performed laparoscopically ) , and laparoscopic adjustable gastric b and ing was performed in 1198 patients ; 166 patients underwent other procedures and were not included in the analysis . The 30-day rate of death among patients who underwent a Roux-en-Y gastric bypass or laparoscopic adjustable gastric b and ing was 0.3 % ; a total of 4.3 % of patients had at least one major adverse outcome . A history of deep-vein thrombosis or pulmonary embolus , a diagnosis of obstructive sleep apnea , and impaired functional status were each independently associated with an increased risk of the composite end point . Extreme values of body-mass index were significantly associated with an increased risk of the composite end point , whereas age , sex , race , ethnic group , and other coexisting conditions were not . CONCLUSIONS The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics . In helping patients make appropriate choices , short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese . ( Clinical Trials.gov number , NCT00433810 . BACKGROUND Treatment added to statin monotherapy to further modify the lipid profile may include combination therapy to either raise the high-density lipoprotein ( HDL ) cholesterol level or further lower the low-density lipoprotein ( LDL ) cholesterol level . METHODS We enrolled patients who had coronary heart disease or a coronary heart disease risk equivalent , who were receiving long-term statin therapy , and in whom an LDL cholesterol level under 100 mg per deciliter ( 2.6 mmol per liter ) and an HDL cholesterol level under 50 mg per deciliter for men or 55 mg per deciliter for women ( 1.3 or 1.4 mmol per liter , respectively ) had been achieved . The patients were r and omly assigned to receive extended-release niacin ( target dose , 2000 mg per day ) or ezetimibe ( 10 mg per day ) . The primary end point was the between-group difference in the change from baseline in the mean common carotid intima-media thickness after 14 months . The trial was terminated early , on the basis of efficacy , according to a prespecified analysis conducted after 208 patients had completed the trial . RESULTS The mean HDL cholesterol level in the niacin group increased by 18.4 % over the 14-month study period , to 50 mg per deciliter ( P < 0.001 ) , and the mean LDL cholesterol level in the ezetimibe group decreased by 19.2 % , to 66 mg per deciliter ( 1.7 mmol per liter ) ( P < 0.001 ) . Niacin therapy significantly reduced LDL cholesterol and triglyceride levels ;  ezetimibe reduced the HDL cholesterol and triglyceride levels . As compared with ezetimibe , niacin had greater efficacy regarding the change in mean carotid intima-media thickness over 14 months ( P = 0.003 ) , leading to significant reduction of both mean ( P = 0.001 ) and maximal carotid intima-media thickness ( P < or = 0.001 for all comparisons ) . Paradoxically , greater reductions in the LDL cholesterol level in association with ezetimibe were significantly associated with an increase in the carotid intima-media thickness ( R = -0.31 , P < 0.001 ) . The incidence of major cardiovascular events was lower in the niacin group than in the ezetimibe group ( 1 % vs. 5 % , P = 0.04 by the chi-square test ) . CONCLUSIONS This comparative-effectiveness trial shows that the use of extended-release niacin causes a significant regression of carotid intima-media thickness when combined with a statin and that niacin is superior to ezetimibe . ( Clinical Trials.gov number , NCT00397657 . The differences in cholesterol metabolism after the 2 most common forms of obesity surgery , Roux-en-Y gastric bypass ( RYGB ) and gastric b and ing ( GB ) , have not been well characterized . In this study , effects of RYGB and GB on cholesterol absorption and synthesis were investigated . To this aim , 1-year follow-up of cholesterol metabolism in 2 nonr and omized cohorts undergoing either RYGB ( n = 29 ; age , 45.2 + /- 7.7 years ; body mass index [ BMI ] , 46.0 + /- 6.1 kg/m(2 ) ) or GB ( n = 26 ; age , 45.9 + /- 8.6 years ; BMI , 50.1 + /- 7.7 kg/m(2 ) ) was performed in a university hospital center specializing in the treatment of morbid obesity .  Serum markers of cholesterol synthesis ( cholestenol , desmosterol , and lathosterol ) and cholesterol absorption ( campesterol , sitosterol , avenasterol , and cholestanol ) were measured preoperatively and at follow-up and expressed as ratios to cholesterol . As expected based on observed weight loss ( 25 % after RYGB and 17 % after GB , P < .001 between groups ) , both operations decreased serum levels of cholesterol synthesis markers by 12 % to 28 % ( all Ps < .001 ) . A decrease in cholesterol absorption markers was only observed after RYGB ( -26 % for sitosterol ) and not after GB ( + 16 % , P = 2 x 10(-6 ) for difference between the groups ) . The difference in sitosterol ratio between the groups remained significant after adjustment for age , BMI , fasting insulin levels , and nutritional status ( P = 2 x 10(-4 ) ) , indicating a specific effect related to RYGB . We conclude that decrease in cholesterol absorption is a novel beneficial effect of RYGB . Together with an improved control of blood glucose , this may contribute to a better cardiovascular risk profile after RYGB CONTEXT It has been hypothesized that increased plasma bile acids ( BAs ) contribute to metabolic improvements after Roux-en-Y gastric bypass ( RYGB ) surgery by the G protein-coupled receptor TGR5-mediated effects on glucagon-like peptide-1 secretion and thyroid hormones . OBJECTIVE The objective of this study was to evaluate the importance of bariatric surgery-induced alterations in BA physiology on factors that regulate glucose homeostasis ( insulin secretion and sensitivity ) and energy metabolism ( resting energy expenditure and thyroid hormone axis ) . DESIGN , PARTICIPANTS , INTERVENTION , AND MAIN OUTCOME MEASURE : Eighteen extremely obese subjects were studied before and after 20 % weight loss , induced by either laparoscopic adjustable gastric b and ing ( LAGB ) ( n = 10 ) or RYGB surgery ( n = 8) . RESULTS Plasma BAs more than doubled after RYGB [ fasting : 1.08 ( 0.26 - 1.42 ) to 2.28 ( 1.59 - 3.28 ) μmol/L , P = .03 ; postpr and ial : 2.46 ± 1.59 to 6.00 ± 2.75 μmol/L , P = .01 ] but were either lower or did not change after LAGB [ fasting : 1.80 ( 1.49 - 2.19 ) to 0.92 ( 0.73 - 1.15 ) μmol/L , P = .02 ; postpr and ial : 3.71 ± 2.61 to 2.82 ± 1.75 μmol/L , P = .14 ] . Skeletal muscle expression of TGR5 targets , Kir6.2 and cyclooxygenase IV , increased after RYGB but not LAGB . Surgery-induced changes in BAs were associated with increased peak postpr and ial plasma glucagon-like peptide-1 ( r(2 ) = 0.509 , P = .001 ) and decreased serum TSH ( r(2 ) = 0.562 , P < .001 ) but did not correlate with the change in insulin response to a meal ( r(2 ) = 0.013 , P = .658 ) , insulin sensitivity ( assessed as insulin stimulated glucose disposal during a hyperinsulinemic-euglycemic clamp procedure ) ( r(2 ) = 0.001 , P = .995 ) , or resting energy expenditure ( r(2 ) = 0.004 , P = .807 ) . CONCLUSIONS Compared with LAGB , RYGB increases circulating BAs and TGR5 signaling , but this increase in BAs is not a significant predictor of changes in glucose homeostasis or energy metabolism Background Patient adherence to recommended eating and physical activity behaviors is considered important to weight loss outcomes following gastric bypass surgery , but there has been little systematic research in this area to investigate behavioral predictors of weight loss . Method We developed a measure of postsurgical behaviors , the bariatric surgery self-management question naire ( BSSQ ) . A survey was conducted of 200 patients attending postsurgical support groups ( mean time since surgery 14 months , mean age 40 years , 85 % female , presurgical weight 150 kg ) . Patients completed the BSSQ  and measures of treatment regimen distress , perceived benefits of weight loss , and weight-related physical symptoms . Results Mean BSSQ adherence was in the 70 % range , with subscale scores varying considerably . Distress levels associated with the new lifestyle were consistently low ( ≈20 % ) and perceived benefits of weight loss were high early on and maintained consistently ( 70–90 % ) . A final predictive model showed premorbid weight , time since surgery , and BSSQ physical activity subscale were significant predictors of weight loss , accounting for 73 % of variance .  Conclusions Physical activity adherence was the sole significant behavioral predictor of weight loss , although maladaptive dietary habits and patient selection issues were identified for future research . It will be important to replicate the current study in prospect i ve , longitudinal studies with representative patient cohorts . A challenge for research ers will be to develop novel , intensive recruiting and retention strategies to allow closer examination of these issues
target: Conclusions RYGB surgery reverses the dyslipidaemia of obesity .
  These findings support the use of RYGB in the management of high cardiovascular risk lipid profiles in morbid obesity
background: Background Obesity-related dyslipidaemia comprises hypercholesterolaemia , hypertriglyceridaemia , low HDL-cholesterol and normal to raised LDL-cholesterol levels .
  40 % of morbidly obese surgical patients have dyslipidaemia .
  Roux-en-Y gastric bypass ( RYGB ) surgery has many beneficial metabolic effects , but the full impact on plasma lipids has not been clearly defined .