title: Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Prospective study of intentional weight loss and mortality in never-smoking overweight US white women aged 40-64 years. Swedish obese subjects (SOS) – an intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for severe obesity Gastric Surgery for Morbid Obesity: The Adelaide Study Who Would Have Thought It? An Operation Proves to Be the Most Effective Therapy for Adult‐Onset Diabetes Mellitus Gastric Bypass is an Effective Treatment for Obstructive Sleep Apnea in Patients with Clinically Significant Obesity Gastrointestinal hormone responses to meals before and after gastric bypass and vertical banded gastroplasty. The Laparoscopic Adjustable Gastric Band (Lap-Band®): A Prospective Study of Medium-Term Effects on Weight, Health and Quality of Life Sex hormone-binding globulin levels and cardiovascular risk factors in morbidly obese subjects before and after weight reduction induced by diet or malabsorptive surgery. Prospective evaluation of vertical banded gastroplasty as the primary operation for morbid obesity. Laparoscopic Versus Open Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs 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) A pilot study of long-term effects of a novel obesity treatment: omentectomy in connection with adjustable gastric banding Vertical Banded Gastroplasty Versus Standard or Distal Roux-en-Y Gastric Bypass Based on Specific Selection Criteria in the Morbidly Obese: Preliminary Results The spread of the obesity epidemic in the United States, 1991-1998. Intra-abdominal pressure, sagittal abdominal diameter and obesity comorbidity. A prospective study comparing vertical banded gastroplasty versus laparoscopic adjustable gastric banding in the treatment of morbid and super-obesity. Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions
abstract: OBJECTIVE To examine the effect of a large , long st and ing and intentional weight reduction on the incidence of diabetes , hypertension and lipid disturbances in severely obese individuals as compared to weight-stable obese controls . RESEARCH METHODS AND PROCEDURES The ongoing prospect i ve SOS ( Swedish Obese Subjects ) intervention consists of a surgically treated group and a matched control group obtaining conventional obesity treatment . This report is based on 845 surgically treated patients and 845 controls ( BMI 41.0+/-4.6 kg/m2 ( mean+/-st and ard deviation [ S ] ) ) followed for 2 years . RESULTS Surgically treated patients lost 28+/-15 kg and controls 0.5+/-8.9 kg ( p<0.0001 ) . Two-year incidence of hypertension , diabetes , hyperinsulinemia , and lipid disturbances was compared in the two treatment groups . Adjusted odds ratios ( 95 % CI ) for the surgically treated group versus controls were 0.38 ( 0.22 , 0.65 ) for hypertension , 0.02 ( 0.00 , 0.16 ) for diabetes , 0.10 ( 0.03 , 0.28 ) for hyperinsulinemia , 0 . 10 ( 0.04 , 0.25 ) for hypertriglyceridemia , 0.28 ( 0.16 , 0.49 ) for low HDL-cholesterol and 1.24 ( 0.84 , 1.8 ) for hypercholesterolemia . Compared to controls , the 2-year recovery rates from hypertension , diabetes , hypo-HDL , and hypertriglyceridemia were significantly higher in the surgically treated group . DISCUSSION Intentional weight loss in the obese causes a marked reduction in the 2-year incidence of hypertension , diabetes and some lipid disturbances . The results suggest that severe obesity can and should be treated Although 40 % of US women indicate they are currently trying to lose weight , the association between intentional weight loss and longevity is unknown . The authors analyzed prospect i ve data from 43,457 overweight , never-smoking US white women aged 40 - 64 years who in 1959 - 1960 completed a question naire  that included questions on weight change direction , amount , time interval , and intentionality . Vital status was determined in 1972 . Proportional hazards regression was used to estimate mortality rate ratios for women who intentionally lost weight compared with women who had no change in weight . Women who died within the first 3 years of follow-up were excluded . Analyses were stratified by preexisting illness and adjusted for age , beginning body mass index , alcohol intake , education , physical activity , and health conditions . In women with obesity-related health conditions ( n = 15,069 ) , intentional weight loss  of any amount was associated with a 20 % reduction in all-cause mortality , primarily due to a 40 - 50 % reduction in mortality from obesity-related cancers ; diabetes-associated mortality was also reduced by 30 - 40 % in those who intentionally lost weight . In women with no preexisting illness ( n = 28,388 ) ,  intentional weight loss  of > or = 20 lb ( > or = 9.1 kg ) that occurred within the previous year was associated with about a 25 % reduction in all-cause , cardiovascular , and cancer mortality ; however , loss of < 20 lb ( < 9.1 kg ) or loss that occurred over an interval of > or = 1 year was generally associated with small to modest increases in mortality . The association between  intentional weight loss  and longevity in middle-aged overweight women appears to depend on their health status . Intentional weight loss among women with obesity-related conditions is generally associated with decreased premature mortality , whereas among women with no preexisting illness , the association is equivocal OBJECTIVE : To examine the effects of weight loss on health-related quality of life ( HRQL ) in subjects with severe obesity . DESIGN : Controlled clinical trial of the outcomes of surgical vs conventional weight reduction treatment . SUBJECTS : The first 487 surgical cases and their conventionally treated , matched controls were followed for two years in the Swedish Obese Subjects ( SOS ) intervention study . MEASUREMENTS : A battery of generic and study -specific self- assessment instruments or subscales was used to characterize HRQL in the severely obese ( BMI ) ≥34 kg/m2 for males and BMI ≥38 kg/m2 for females ) . Measures of general health perceptions ( general health rating index ; current health ) , mental well-being ( mood adjective check list ; pleasantness , activation and calmness ) , mood disorders ( hospital anxiety and depression scale ; anxiety and depression ) and social interaction ( sickness impact profile ) , were supplemented by obesity-specific modules on obesity-related psychosocial problems and eating behavior ( three-factor eating question naire ; restrained eating , disinhibition and perceived hunger ) . Assessment s were conducted prior to treatment and repeated after 6 , 12 and 24 months . RESULTS : Poor HRQL before intervention was dramatically improved after gastric restriction surgery , while only minor fluctuations in HRQL scores were observed in the conventionally treated controls . Peak values were observed in the surgical group at 6 or 12 months after intervention with a slight to moderate decrease at the two-year follow-up . The positive changes in HRQL after two years were related to the magnitude of weight loss , that is , the greater the weight reduction , the greater the HRQL improvements . Eating behavior improved accordingly . CONCLUSION : Quality of life in the severely obese is improved by substantial weight loss . Most patients benefit from weight reduction surgery , while HRQL in surgical patients with minor reduction in overweight is less positive . Further research is needed to determine outcome predictors of the surgical management of severe obesity and to ensure that HRQL improvements are maintained The efficacy of three gastric restriction operations were compared in a prospect i ve r and omized study of 310 morbidly obese subjects . The median patient age was 34 years ( range , 18 to 62 years ) . They were predominantly female ( 13:1 ) and had a median pre-operative weight that was 198 % of their ideal weight ( range , 160 % to 318 % ) . There was an equitable dispersion of perceived risk factors between the groups under study and there were no deaths during the perioperative period . Compliance with follow-up at 3 years was 91 % . When success was defined as a loss of more than 50 % of excess weight or a current pregnancy , the success rates at 3 years were 17 % for gastrogastrostomy , 48 % for vertical gastroplasty , and 67 % for Roux-en-Y gastric bypass ( p less than 0.001 ) . Although the gastric bypass operation took longer to perform , there were similar outcome patterns for the three groups during the postoperative period . We conclude that the Roux-en-Y gastric bypass is the preferred procedure for the surgical treatment of morbid obesity 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 Background : We have demonstrated that obstructive sleep apnea ( OSA ) is prevalent in 60 % of patients undergoing bariatric surgery .  A study was conducted to determine whether weight loss following bariatric surgery ameliorates OSA . Methods : All 100 consecutive patients with symptoms of OSA were prospect ively evaluated by polysomnography before gastric bypass . Preoperative and postoperative scores of Epworth Sleepiness Scale ( ESS ) , Respiratory Disturbance Index ( RDI ) , and other parameters of sleep quality were compared using t-test . Results : Preoperative RDI was 40±4 ( normal 5 events/hour , n=100 ) . 13 patients had no OSA , 29 had mild OSA , while the remaining 58 patients were treated preoperatively for moderate-severe OSA . At a median of 6 months follow-up , BMI and ESS scores improved ( 38±1 vs 54±1 kg/m2 , 6±1 vs 12±0.1 , P<0.001 , postoperatively vs preoperatively ) . To date , 11 patients have completed postoperative polysomnography ( 3 - 21 months ) after losing weight ( BMI 40±2 vs 62±3 kg/m2 , P<0.001).There was significant improvement in ESS ( 3±1 vs 14±2 ) , minimum O2 saturation ( SpO2 86±2 vs 77±5 ) , sleep efficiency ( 85±2 % vs 65±5 % ) , all P<0.001 , postop vs preop ; and RDI ( 56±13 vs 23±7 , P=0.041 ) . Regression analysis demonstrated no correlation between preoperative BMI , ESS score and the severity of OSA ; and no correlation between % excess body weight loss and postoperative RDI . Conclusion : Weight loss following gastric bypass results in profound improvement in OSA . The severity of apnea can not be reliably predicted by preoperative BMI and ESS ; therefore , patients with symptoms of OSA should undergo polysomnography The purpose of the study was to examine the gastrointestinal hormone responses to meals in morbidly obese patients before and after Roux-en-Y gastric bypass ( GBP ; n = 9 ) or vertical b and ed gastroplasty ( VBG ; n = 7 ) . On consecutive days before and after operation , we measured changes in peripheral blood levels of glucose , insulin , enteroglucagon , serotonin , vasoactive intestinal polypeptide ( VIP ) , and cholecystokinin ( CCK ) in response to a st and ardized glucose or protein-fat meal . The percentage of excess weight lost at 6 months after operation was 66.3 % + /- 4 % and 41.8 % + /- 5 % for GBP and VBG , respectively ( p less than 0.01 ) . The 3-hour integrated glucose response to a glucose meal decreased from 145.3 + /- 33.7 to 75.8 + /- 15.7 g min/L ( p less than 0.02 ) after GBP . This was associated with a decrease in 3-hour integrated insulin response from 22.8 + /- 8.2 to 10.5 + /- 4.9 mU min/L. Vertical b and ed gastroplasty patients had lesser reductions of hyperglycemia and hyperinsulinemia . Neither the CCK , serotonin , nor VIP responses to meals were altered by either operation . The 3-hour integrated enteroglucagon response to glucose increased markedly in GBP patients after operation from 11.8 + /- 6 to 133.4 + /- 38 nmol min/mL ( p less than 0.02 ) . This increase in enteroglucagon occurred at the same time as development of dumping symptoms , which occurred exclusively in GBP patients after glucose but not protein . We conclude that ( 1 ) GBP surgery for morbid obesity results in amelioration of glucose intolerance and hyperinsulinemia , ( 2 ) CCK does not mediate an endocrine satiety effect of surgery , ( 3 ) GBP is associated with an exaggerated enteroglucagon response to glucose , and ( 4 ) enteroglucagon appears to be a marker of the dumping syndrome in GBP patients Background : Obesity is now one of our major public health problems . Effective and acceptable treatment options are needed . The Lap-B and ® system is placed laparoscopically and allows adjustment of the level of gastric restriction . Methods : A prospect i ve study of 709 severely obese patients was conducted over a 6-year period at a university-based multidisciplinary referral center . After extensive preoperative evaluation , patients with a body mass index > 35 were treated by  LapB and ® placement . Close follow-up with progressive adjustment of gastric restriction continued permanently . Medical co-morbidities were monitored as part of comprehensive prospect i ve data collection . Results : There have been no deaths perioperatively or during follow-up . Significant perioperative adverse events occurred in 1.2 % only . Reoperation has been needed for prolapse ( slippage ) in 12.5 % , erosion of the b and into the stomach in 2.8 % and for tubing breaks in 3.6 % . A steady progression of weight loss has occurred through the duration of the study with 52 ± 19 % EWL at 24 months ( n=333 ) , 53±22 % EWL at 36 months ( n=264 ) , 52 ± 24 % EWL at 48 months ( n=108 ) , 54 ± 24 % EWL at 60 months ( n=30 ) , and 57 ± 15 % EWL at 72 months ( n=10 ) . Major improvements have occurred in diabetes , asthma , gastroesophageal reflux , dyslipidemia , sleep apnea and depression . Quality of life as measured by R and SF-36 shows highly significant improvement . Conclusions : Placement of the Lap-B and ® system provides safe and effective control of severe obesity . The effect on weight loss is durable and is associated with major improvement in health and quality of life . It has the potential to provide a broadly acceptable option for this common and serious disease One of the main goals of weight reduction in morbidly obese subjects is its benefit on coronary heart disease ( CHD ) risk . A cross-sectional study was design ed to r and omly assign 79 morbidly obese subjects ( 27 men and 52 women ; age : 30 - 45 years ) either to a diet protocol ( 20 kcal per kg fat-free mass ( FFM ) ; 55 % carbohydrates , 30 % fat , and 15 % proteins ) or to malabsorptive surgery ( biliopancreatic diversion ) .  Fatness parameters , measured by dual-energy X-ray absorptiometry , lipid profile , insulin , leptin , sex steroid hormones and sex hormone-binding globulin ( SHBG ) levels were compared at baseline and 1 year after the beginning of the study . The data showed that plasma SHBG levels , but not testosterone levels , correlated negatively to fasting insulin levels and positively to HDL-cholesterol in both men and women . Total leptin levels were significantly lower ( P<0.0001 ) in post-BPD subjects of both sexes compared to dietary treated obese subjects . The logarithm of plasma leptin correlated significantly and positively with insulin but negatively with SHBG.A step-down regression analysis showed that FFM and SHBG , but not insulin levels , were the most powerful independent variables for predicting HDL-cholesterol levels in morbidly obese patients . The negative relationship between SHBG levels and CHD risk appears to be mediated by a concomitant variation in body fatness . Finally , in obese patients , SHBG levels seem to be an indicator of total adiposity rather than an index of an altered insulin/glucose homeostasis Our previous experience with vertical ( nonb and ed ) gastroplasty proved disappointing because of unsatisfactory maintenance of weight loss .  Vertical b and ed gastroplasty seemed to be an attractive alternative operation because it provided an externally reinforced ( b and ed ) stoma that would not enlarge over time . In this study , our aim was to determine prospect ively the results of vertical b and ed gastroplasty used as a primary , weight-reducing procedure in patients with morbid obesity . Seventy consecutive patients with morbid obesity ( mean weight , 139 kg ) , all of whom had obesity-related complications , underwent vertical b and ed gastroplasty and prospect i ve follow-up . The hospital mortality was nil , and substantial morbidity occurred in 3 % ( two patients ) . Long-term achievement and maintenance of satisfactory weight loss , however , were variable . The median weight loss at 1 year after operation was 36.7 kg or 48 % of excess body weight . At 3 years postoperatively , however , weight loss was only 32.4 kg or 40 % of excess body weight , and only 38 % of patients had achieved and maintained a weight loss of 50 % or more of their preoperative excess body weight . Vertical b and ed gastroplasty caused major changes in eating habits , and many patients were unable to eat red meat or untoasted bread ; moreover , approximately 30 to 50 % of patients continued to vomit once or more per week . Despite theoretically attractive advantages as a weight-reduction operation , vertical b and ed gastroplasty does not seem to be the optimal procedure for most patients with morbid obesity Objective To compare outcomes , quality of life ( QOL ) , and costs of laparoscopic and open gastric bypass ( GBP ) .  Summary Background Data Laparoscopic GBP has been reported to be a safe and effective approach for the treatment of morbid obesity . The authors performed a prospect i ve r and omized trial to compare outcomes , QOL , and costs of laparoscopic GBP with those of open GBP . Methods From May 1999 to March 2001 , 155 patients with a body mass index ( BMI ) of 40 to 60 kg/m2 were r and omly assigned to undergo laparoscopic ( n = 79 ) or open ( n = 76 ) GBP .  The two groups were similar in age , sex ratio , mean BMI , and comorbidities . Main outcome measures included operative time , estimated blood loss , length of hospital stay , operative complications , percentage of excess body weight loss , and time to return to activities of daily living and work . Changes in QOL were assessed using the SF-36 Health Survey and the bariatric analysis of reporting outcome system ( BAROS ) . Operative and hospital costs of the two operations were also compared . Results There were no deaths in either group . Mean operative time was longer for laparoscopic GBP than for open GBP , but operative blood loss was less . Two ( 2.5 % ) of the 79 patients in the laparoscopic group required conversion to laparotomy . Median length of hospital stay was shorter for laparoscopic GBP patients ( 3 vs 4 days ) . The rate of postoperative anastomotic leak was similar between groups . Wound-related complications such as infection ( 10.5 vs 1.3 % ) and incisional hernia ( 7.9 vs 0 % ) were more common after open GBP ; late anastomotic stricture was less frequent after open GBP ( 2.6 vs 11.4 % ) . Time to return to activities of daily living and work were shorter after laparoscopic GBP than after open GBP .  Weight loss at 1 year was similar between groups . Preoperative SF-36 scores were similar between groups ; however , at 1 month after surgery , laparoscopic patients had better physical conditioning , social functioning , general health , and less body pain than open GBP patients . At 6 months , the BAROS outcome was classified as good or better in 97 % of laparoscopic GBP patients compared with 82 % of open GBP patients . Operative costs were higher for laparoscopic GBP patients , but hospital costs were lower . Conclusions Laparoscopic GBP is a safe and cost-effective alternative to open GBP . Despite a longer operative time , patients undergoing laparoscopic GBP benefited from less blood loss , a shorter hospital stay , and faster convalescence .  Laparoscopic GBP patients had comparable weight loss at 1 year but a more rapid improvement in QOL than open GBP patients . The higher initial operative costs for laparoscopic GBP were adequately offset by the lower hospital costs 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 AIM : To determine whether visceral fat reduction in connection with bariatric surgery could improve weight loss and metabolic profile of obese subjects . PATIENTS AND METHODS : In a one-center , r and omized and controlled pilot trial we assigned 50 subjects with severe obesity ( body mass index > 35 kg/m2 ) to either adjustable gastric b and ing ( AGB ) alone ( 11 men and 14 women ) , or AGB plus surgical removal of the total greater omentum ( 11 men and 14 women ) . The patients were followed at regular intervals for 2 y and examined at 0 and 24 months with respect to body composition and metabolic profile . RESULTS : No significant differences between control and omentectomized patients were observed at baseline . The removed greater omentum constituted 0.8±0.4 % ( mean±s.d . ) of total body fat . At 2 y follow-up there was an expected decrease in body weight and an improvement in metabolic profile in both groups . Although omentectomized subjects tended to lose more weight than control subjects the difference was not statistically significant and changes in waist-to-hip ratio and saggital diameter did not differ between groups . However , the improvements in oral glucose tolerance , insulin sensitivity and fasting plasma glucose and insulin were 2–3 times greater in omentectomized as compared to control subjects ( P from 0.009 to 0.04 ) , which was statistically independent of the loss in body mass index . No differences in blood lipids between the groups were recorded . No adverse effects related to omentectomy were observed . CONCLUSIONS : Omentectomy , when performed together with AGB , has significant positive and long-term effects on the glucose and insulin metabolic profiles in obese subjects Background : Predicting successful outcomes after  bariatric surgical procedures  has been difficult , and the establishment of specific selection criteria has been a subject of ongoing research . In an effort to choose the most appropriate surgical procedure for each patient , we have established a specific set of selection criteria for each procedure based on degree of obesity , preoperative dietary habits , eating behavior , and various metabolic features . Methods : From June 1994 to December 1998 , 90 bariatric surgical procedures were performed at the authors ' institution by a single surgeon ( F.K. ) based on specific selection criteria . Vertical b and ed gastroplasty ( VBG ) was performed in 35 patients , st and ard Roux-en-Y gastric bypass ( RYGB ) in 38 patients , and distal RYGB in 17 patients . All patients were monitored postoperatively 1 , 3 , 6 , and 12 months and once per year thereafter , with an additional visit at 18 months in distal RYGB patients . Results : Early postoperative morbidity ( < 30 days ) did not differ significantly between the three groups and averaged 9 % of total patients . Long-term postoperative morbidity ( > 30 days ) included 9 incisional hernias ( 2 in the VBG group , 5 after RYGB , and 2 in the distal RYGB group ) . There were 6 cases of staple-line disruption , 4 after VBG and 2 after st and ard RYGB , 1 of which result ed in stomal ulcer . Early postoperative mortality was 0 % , and long-term mortality was 1.1 % , which was due to pulmonary embolism in 1 st and ard RYGB patient on the 65th postoperative day . Average percentage of excess weight loss ( % EWL ) was 62 % the first year , 61 % the second year , and 50 % the third year in VBG patients , and 63.6 % , 65 % , and 63.3 % , respectively , in st and ard RYGB patients . In distal RYGB patients , where the patient number was significantly smaller , the % EWL at 1 and 2 years , respectively , was 51 % and 53 % . The most significant metabolic/nutritional complication was the appearance of hypoproteinemia ( hypoalbuminemia ) in 1 distal RYGB patient 20 months after surgery , which was corrected by total parenteral nutrition and subsequent increase in dietary protein intake . Significant improvement or resolution of pre-existing comorbid conditions was observed in all patient groups . The postoperative quality of eating , as evaluated by variety of food intake and frequency of vomiting , was significantly better in RYGB patients . Conclusions : These results show that selection of the bariatric surgical procedure to be performed in each patient based on specific criteria leads to acceptable weight loss , improvement in preexisting comorbid conditions , and a high degree of patient satisfaction in most patients . On the basis of our own observations as well as those of others , our selection criteria have become more strict over time and our selection of VBG as the operation of choice increasingly infrequent CONTEXT The increasing prevalence of obesity is a major public health concern , since obesity is associated with several chronic diseases . OBJECTIVE To monitor trends in state-specific data and to examine changes in the prevalence of obesity among adults . DESIGN Cross-sectional r and om-digit telephone survey ( Behavioral Risk Factor Surveillance System ) of noninstitutionalized adults aged 18 years or older conducted by the Centers for Disease Control and Prevention and state health departments from 1991 to 1998 . SETTING States that participated in the Behavioral Risk Factor Surveillance System . MAIN OUTCOME MEASURES Body mass index calculated from self-reported weight and height . RESULTS The prevalence of obesity ( defined as a body mass index > or = 30 kg/m2 ) increased from 12.0 % in 1991 to 17.9 % in 1998 . A steady increase was observed in all states ; in both sexes ; across age groups , races , educational levels ; and occurred regardless of smoking status . The greatest magnitude of increase was found in the following groups : 18- to 29-year-olds ( 7.1 % to 12.1 % ) , those with some college education ( 10.6 % to 17.8 % ) , and those of Hispanic ethnicity ( 11.6 % to 20.8 % ) . The magnitude of the increased prevalence varied by region ( ranging from 31.9 % for mid Atlantic to 67.2 % for South Atlantic , the area with the greatest increases ) and by state ( ranging from 11.3 % for Delaware to 101.8 % for Georgia , the state with the greatest increases ) . CONCLUSIONS Obesity continues to increase rapidly in the United States . To alter this trend , strategies and programs for weight maintenance as well as weight reduction must become a higher public health priority OBJECTIVES To determine relationship of intra-abdominal pressure to central obesity and the comorbidity of obesity . DESIGN Non-r and omized , prospect i ve . SETTING University hospital , operating room . SUBJECTS Eighty-four anaesthetized consecutive patients prior to gastric bypass for morbid obesity and five non-obese patients before colectomy for ulcerative colitis . MAIN OUTCOME MEASURES Weight , body mass index ( BMI ) , co-morbid history , sagittal abdominal diameter , waist : hip ( W : H ) ratio and urinary bladder pressure , as an estimate of intra-abdominal pressure . RESULTS Urinary bladder pressure was greater in the obese than the non-obese ( 18 + /- 0.7 vs. 7 + /- 1.6 cm H2O , P < 0.001 ) , correlated with sagittal abdominal diameter ( r = + 0.67 , P < 0.001 ) and was greater ( P < 0.05 ) in patients with , than those without , morbidity probably ( hypoventilation , gastroesophageal reflux , venous stasis , stress incontinence , incisional hernia ) or possibly ( hypertension , diabetes ) due to increased abdominal pressure . W : H ratio correlated with urinary bladder pressure in men ( r = + 0.6 , P < 0.05 ) but not women ( r = -0.3 ) . CONCLUSIONS Increased sagittal abdominal diameter was associated with increased intraabdominal pressure which contributed to obesity-related comorbidity . W : H ratio was not a reliable indicator of intra-abdominal pressure for women who often have both peripheral and central obesity . Further studies are needed to evaluate the relationship between intra-abdominal pressure and Type II diabetes and hypertension We present our prospect i ve comparative study on 60 patients subjected to two types of gastric restrictive procedures , i.e. Vertical B and ed Gastroplasty ( VBG ) and Laparoscopic Adjustable Gastric B and ing ( LAGB ) at King Abdul Aziz University Hospital , Jeddah , Saudi Arabia . The aim of our study was to compare weight reduction after both procedures . Thirty patients had VBG and thirty had LAGB based upon informed consents . The age , sex and preoperative weight and BMI were comparable in both groups . Excess weight loss of 87 % was achieved in the VBG group while only 50 % was noticed in the LAGB group at 6 months postoperatively At the end of a long week in the office , you sink back into your chair , reflecting on some of the more memorable patients you cared for and counseled . Through gentle history taking , you discovered that urinary incontinence is the underlying cause of an elderly patient 's increasing social isolation . During a careful physical examination , you detected bruising on the torso of a woman with chronic headaches and began to explore the longst and ing abusive relationship between the woman and her alcoholic partner . You discontinued procainamide therapy in a 72-year-old man who had asymptomatic premature ventricular contractions after myocardial infa rct ion . To prevent bleeding from esophageal varices , you started -blocker therapy in a woman with long-st and ing cryptogenic cirrhosis and portal hypertension . In couples ' therapy , discussing the future quality of life of a middle-aged gay man with human immunodeficiency virus infection , you journeyed through emotionally intense dialogue about advance directives . You presented the risk factors for major and minor bleeding to a 39-year-old woman who was considering warfarin therapy because of recently diagnosed atrial fibrillation and valvular heart disease . You listened to , made diagnoses for , treated , advised , and comforted many patients . Yet there were some hiccoughs in your practice along the way . You stumbled while debating the pros and cons of breast cancer screening with a healthy 48-year-old woman who has been staying current with information on the Internet . You question ed the merits of a personalized walking program suggested to you by a motivated 66-year-old man with severe claudication . Explaining that you wanted to review the best current evidence on these issues , you resolved to address your uncertainties before these patients made their next office visits , in a week 's time . Sighing deeply , you acknowledge that you have little time to read . You subscribe to three journals , which you browse months after they arrive-either when your journal stack becomes precariously high or when your guilt is sufficiently motivational . You sometimes find the conclusions of individual articles conflicting or confusing . You know that some of the decisions and suggestions you made this week , specifically your decisions about stopping procainamide therapy and starting -blocker therapy and your advice about bleeding risks from anticoagulant therapy , were based on the best current research evidence [ 1 - 3 ] . On the other h and , your patients ' inquiries about breast cancer screening and exercise treatment for claudication highlight your need for a concise , current , rigorous synthesis of the best available evidence on each of these topics : in brief , a systematic review [ 4 , 5 ] . Incorporating Research Evidence into Clinical Decision Making The foregoing scenario is familiar to practitioners . In a typical week , we encounter patients with diverse problems ; exercise numerous clinical , interpersonal , and technical skills ; and make many decisions . The factors that affect these decisions and their outcomes are complex . For instance , each patient has unique sociodemographic characteristics , cultural circumstances , and personal preferences . Each physician has unique knowledge , experiences , and values . Moreover , practitioners and their patients make decisions within the context of a rapidly changing health care system that influences the availability , accessibility , and cost of diagnostic tests and therapies [ 6 ] . Timely , useful evidence from the biomedical literature should be an integral component of clinical decision making . If one treatment has been shown to be better than another , we need to know , so that we can recommend the treatment to the appropriate patients . The worldwide effort to develop new tests and treatments , and to determine their usefulness , has never been stronger , and our patients and their families expect us to be fonts of the knowledge that results from this effort [ 7 ] . Unfortunately , it is easy for current best research evidence to pass us by [ 8 ] . We may lack the time , motivation , and basic skills needed to find , critically appraise , and synthesize information , all of which we must do if we are to integrate the results of original studies into our practice . Fortunately , several potent methods are emerging that can greatly enhance our ability to interpret and apply research evidence ; foremost among them is the systematic review . This article begins a series in Annals that will examine systematic review s in detail and explore their many applications . Systematic review s represent the best chance that most practitioners will have to underst and and accurately apply the key signals arising from the robust and increasingly productive search for solutions to medical problems . A properly conducted systematic review faithfully summarizes the evidence from all relevant studies on the topic of interest , and it does so concisely and transparently . What Is a Systematic Review ? Systematic review s are scientific investigations in themselves , with pre-planned methods and an assembly of original studies as their subjects . They synthesize the results of multiple primary investigations by using strategies that limit bias and r and om error [ 9 , 10 ] . These strategies include a comprehensive search of all potentially relevant articles and the use of explicit , reproducible criteria in the selection of articles for review . Primary research design s and study characteristics are appraised , data are synthesized , and results are interpreted . When the results of primary studies are summarized but not statistically combined , the review may be called a qualitative systematic review . A quantitative systematic review , or meta- analysis , is a systematic review that uses statistical methods to combine the results of two or more studies . The term overview is sometimes used to denote a systematic review , whether quantitative or qualitative . Summaries of research that lack explicit descriptions of systematic methods are often called narrative review s. Review articles are one type of integrative publication ; practice guidelines , economic evaluations , and clinical decision analyses are others . These other types of integrative articles often incorporate the results of systematic review s. For example , practice guidelines are systematic ally developed statements intended to assist practitioners and patients with decisions about appropriate health care for specific clinical circumstances [ 11 ] . Evidence -based practice guidelines are based on systematic review s of the literature , appropriately adapted to local circumstances and values . Economic evaluations compare both the costs and the consequences of different courses of action ; the knowledge of consequences that are considered in these evaluations is often generated by systematic review s of primary studies . Decision analyses quantify both the likelihood and the valuation of the expected outcomes associated with competing alternatives . Differences between Systematic and Narrative Review s All review s , narrative and systematic alike , are retrospective , observational research studies and are therefore subject to systematic and r and om error . Accordingly , the quality of a review - and thus its worth-depends on the extent to which scientific review methods have been used to minimize error and bias . This is the key feature that distinguishes traditional narrative review s from systematic review s ( Table 1 ) . If a review is prepared according to the steps outlined in the right column of Table 1 , it is more likely to be systematic and to provide unbiased conclusions . If review methods approximate those found in the middle column of Table 1 , the article is more likely to be a narrative review , and the conclusions are less likely to be based on an unbiased summary of all relevant evidence . Table 1 . Differences between Narrative Review s and Systematic Review s Systematic review s are generated to answer specific , often narrow , clinical questions in depth . These questions can be formulated explicitly according to four variables : a specific population and setting ( such as elderly out patients ) , the condition of interest ( for example , hypertension ) , an exposure to a test or treatment ( such as pharmacologic management ) , and one or more specific outcomes ( such as cardiovascular and cerebrovascular events and mortality ) [ 12 ] . Thus , an example of a well-formulated , clinical ly relevant question is , Does pharmacologic treatment of hypertension in the elderly prevent strokes and myocardial infa rct ions or delay death ? If the question that is driving the review is not clear from the title , abstract , or introduction , or if no methods section is included , the paper is more likely to be a narrative review than a systematic review [ 13 ] . Most narrative review articles deal with a broad range of issues related to a given topic rather than addressing a particular issue in depth [ 9 ] . For example , a narrative review on diabetes ( such as that which might be found in a textbook chapter ) might include sections on the physiology and pathophysiology of carbohydrate , lipid , and protein metabolism ; the epidemiology of and prognosis associated with diabetes ; diagnostic and screening approaches ; and preventive , therapeutic , rehabilitative , and palliative interventions . Thus , narrative review s may be most useful for obtaining a broad perspective on a topic ; they are less often useful in furnishing quantitative answers to specific clinical questions . Narrative review s are appropriate for describing the history or development of a problem and its management . Narrative review s may better describe cutting-edge developments if research is scant or preliminary or if studies are very limited by flawed design or execution [ 13 ] . They may be particularly useful for discussing data in light of underlying theory and context . Narrative review s can draw analogies and can conceptually integrate two independent fields of research , such as
target: Effective weight loss was achieved in morbidly obese patients after undergoing  bariatric surgery .
  A substantial majority of patients with diabetes , hyperlipidemia , hypertension , and obstructive sleep apnea experienced complete resolution or improvement
background: CONTEXT About 5 % of the US population is morbidly obese .
  This disease remains largely refractory to diet and drug therapy , but generally responds well to bariatric surgery .
  OBJECTIVE To determine the impact of bariatric surgery on weight loss , operative mortality outcome , and 4  obesity  comorbidities ( diabetes , hyperlipidemia , hypertension , and obstructive sleep apnea ) .