Yaakov Henkin

Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet

BACKGROUND Trials comparing the effectiveness and safety of weight-loss diets are frequently limited by short follow-up times and high dropout rates. METHODS In this 2-year trial, we randomly assigned 322 moderately obese subjects (mean age, 52 years; mean body-mass index [the weight in kilograms divided by the square of the height in meters], 31; male sex, 86%) to one of three diets: low-fat, restricted-calorie; Mediterranean, restricted-calorie; or low-carbohydrate, non-restricted-calorie. RESULTS The rate of adherence to a study diet was 95.4% at 1 year and 84.6% at 2 years. The Mediterranean-diet group consumed the largest amounts of dietary fiber and had the highest ratio of monounsaturated to saturated fat (P<0.05 for all comparisons among treatment groups). The low-carbohydrate group consumed the smallest amount of carbohydrates and the largest amounts of fat, protein, and cholesterol and had the highest percentage of participants with detectable urinary ketones (P<0.05 for all comparisons among treatment groups). The mean weight loss was 2.9 kg for the low-fat group, 4.4 kg for the Mediterranean-diet group, and 4.7 kg for the low-carbohydrate group (P<0.001 for the interaction between diet group and time); among the 272 participants who completed the intervention, the mean weight losses were 3.3 kg, 4.6 kg, and 5.5 kg, respectively. The relative reduction in the ratio of total cholesterol to high-density lipoprotein cholesterol was 20% in the low-carbohydrate group and 12% in the low-fat group (P=0.01). Among the 36 subjects with diabetes, changes in fasting plasma glucose and insulin levels were more favorable among those assigned to the Mediterranean diet than among those assigned to the low-fat diet (P<0.001 for the interaction among diabetes and Mediterranean diet and time with respect to fasting glucose levels). CONCLUSIONS Mediterranean and low-carbohydrate diets may be effective alternatives to low-fat diets. The more favorable effects on lipids (with the low-carbohydrate diet) and on glycemic control (with the Mediterranean diet) suggest that personal preferences and metabolic considerations might inform individualized tailoring of dietary interventions. (ClinicalTrials.gov number, NCT00160108.)

Changes in Triglyceride Levels and Risk for Coronary Heart Disease in Young Men

Context Whether the serum triglyceride level is an independent risk factor for coronary heart disease (CHD) is not clear. Contribution The authors measured triglyceride levels and performed stress electrocardiographies 5 years apart on 13593 young Israeli male career soldiers and did coronary angiography if the stress test was abnormal. Triglycerides and change in triglyceride levels strongly predicted incident CHD after adjustment for known CHD risk factors and lifestyle. Decreases in triglyceride levels were associated with adoption of a healthier lifestyle and lower CHD risk. The lowest CHD risk occurred when triglyceride levels remained low. Caution The participants were healthy male soldiers. Implication In healthy young men, triglycerides and changes in triglyceride levels are an independent CHD risk factor. The Editors A recent meta-analysis (1) and most published papers suggest a moderate association between fasting triglyceride levels and coronary heart disease (CHD) (211). Of the lipid fractions, the triglyceride-rich very-low-density lipoprotein particle is probably the most sensitive to lifestyle modification (8). For example, estimates from meta-analyses suggest that for every 4.5 kg (approximately 10 lb) of stable weight reduction, triglyceride levels decrease by at least 0.068 mmol/L (6 mg/dL) (12). Accordingly, a considerable increase in the proportion of hypertriglyceridemic patients accompanies the obesity epidemic (6, 9). In addition, aerobic exercise, independent of weight loss, has been shown to modestly reduce triglyceride levels in a dose-dependent fashion (13). Hence, when assessing the risk associated with triglyceride levels, triglyceride measurement at a single time point (typically at enrollment) may not be a reliable indicator of a persons long-term triglyceridemia during follow-up. Whether changes in triglyceride levels over time can improve cardiovascular risk assessment is largely unknown, particularly in young adults, in whom information on the association between triglycerides and CHD is not available (1). For 13953 apparently healthy young adult men (mean age, 32 years; range, 26 to 45 years) from the MELANY (Metabolic, Lifestyle, and Nutrition Assessment in Young Adults) study (14), we obtained 2 measurements of fasting serum triglycerides and lifestyle variables 5 years apart and followed for incident cases of angiography-proven CHD. Here, we estimate the effect of baseline triglyceride levels (time 1) and changes (between time 1 and time 2) in triglyceride levels on CHD risk. Methods The MELANY Study The MELANY study, which was designed to investigate risk factors for common diseases in young adults, is being conducted at the Israel Defense Forces Staff Periodic Examination Center (SPEC), Zrifin, Israel. All career service personnel are evaluated every 5 years between 25 and 35 years of age and every 3 years thereafter until they are discharged from service. A computerized database established in 1992 is the source of data for the MELANY study. At each SPEC visit, participants complete a detailed questionnaire that assesses demographic, nutritional, lifestyle, and medical factors. Thereafter, blood samples are drawn after a 14-hour fast and analyzed. A trained medical technician measures height, weight, and blood pressure (by mercury sphygmomanometers), and a physician at the center performs a complete physical examination. Inclusion and Exclusion Criteria We included apparently healthy men 26 to 45 years of age who had fasting triglyceride levels less than 3.39 mmol/L (<300 mg/dL) at their initial SPEC visit. We used the cutoff value of 3.39 mmol/L (300 mg/dL) because SPEC persons with greater triglyceride values are subjected to additional interventionsnutritional, pharmacologic, or both. Of 15155 men age 26 to 45 years, 1202 were excluded because they had diabetes (type 1 or 2) (n= 227) or CHD (n= 17) at baseline; had fasting triglyceride levels of 3.39 mmol/L or greater (300 mg/dL) (n= 676); or were receiving long-term medications (n= 282), including lipid-lowering medications. Therefore, for analysis of the association between baseline triglyceride levels and incident CHD, we included 13953 men. In studying the effect of changes in triglyceride levels on CHD, we excluded an additional 413 men who did not have a triglyceride measurement from the second SPEC visit (n= 363) or had received a diagnosis of diabetes (n= 38) or CHD (n= 12) between the first and second SPEC visit or during the second visit. Women were not included because the number of new cases of CHD in women was too small to facilitate meaningful analysis. Outcome Definition The outcome definition of the study was clinically significant CHD (angiography-proven stenosis >50% in at least 1 coronary artery) or fatal or nonfatal myocardial infarction (MI). At each sequential SPEC visit, all Israel Defense Forces military personnel older than 35 years of age who were participating in the current analysis had a treadmill exercise test (Bruce protocol [15]) in the presence of a board-certified cardiologist. End points for the exercise test were clinically significant ST-segment depression (>2 mm in 2 contiguous leads, measured 80 ms after the J point), intolerable symptoms of angina and exhaustion, or achievement of the target heart rate. All cases with a pathologic stress test were referred for coronary angiography. In participants with a borderline stress test, or when participants reported angina symptoms without diagnostic electrocardiographic changes, stress perfusion imaging with thallium-201 was performed. Those with a pathologic thallium-201 cardiac scan underwent coronary angiography. All Israel Defense Forces personnel obtain primary care between scheduled SPEC visits at designated military clinics, and all medical records are stored in the same central database, thereby facilitating ongoing, tight, and uniform follow-up. Individuals presenting with symptoms of angina, MI, or both between SPEC visits were also referred for coronary angiography after consultation with a board-certified cardiologist. Laboratory Methods Investigators performed biochemical analyses of fresh blood samples in an adjacent core laboratory facility that handles 1.2 million samples per year. The laboratory is authorized to perform tests according to the International Organization for Standardization standard 9002. The United Kingdom National External Quality Assessment Service, Sheffield, United Kingdom, performed periodic assessment of quality control on a regular basis. All lipid levels were directly measured, except for low-density lipoprotein (LDL) levels, which were calculated. Investigators measured all biochemical markers by using a BM/Hitachi 917 automated analyzer (Boehringer, Mannheim, Germany). Statistical Analysis For the primary analysis, we included 13953 untreated, apparently healthy young men with triglyceride levels lower than 3.39 mmol/L (<300 mg/dL). We used a general linear model to assess the age-adjusted means and proportions of the populations characteristics across quintiles of triglycerides and to fit the median of the quintiles as a continuous variable to estimate the trend of variables across quintiles (Table 1). We conducted Cox proportional hazards analysis during the 10.5-year follow-up to estimate the hazard ratios and 95% CIs for the development of CHD (the dependent variable) according to triglyceride levels at time 1 (first measurement). In stepwise models (Table 2), we added the values for body mass index (BMI), high-density lipoprotein (HDL) cholesterol, and family history of CHD separately to the age-adjusted model to evaluate their potential role as confounders. In the final multivariate model, we controlled for age, BMI, HDL cholesterol, family history of CHD, fasting plasma glucose, mean arterial blood pressure, physical activity, and smoking status. Because the total cholesterolHDL cholesterol ratio is a predictor of CHD (8), we performed a secondary analysis that included this ratio instead of HDL cholesterol in the multivariate model. Table 1. Baseline (Time 1) Characteristics, by Quintile of Triglyceride Level Table 2. Hazard Ratios for Coronary Heart Disease, by Quintile of Time-1 Triglyceride Level To assess the risk associated with changes in triglyceride levels, we analyzed data from 13540 men who had 2 triglyceride measurements (obtained at time 1 and time 2, 5 years apart) that were available before the end of follow-up or before being censored after a diagnosis of CHD or diabetes. In the model, time 2 was considered the baseline of 5.2 years of subsequent follow-up, whereas time 1 was considered prebaseline. We cross-classified triglyceride levels at each time point by tertiles: median levels of 0.68, 1.18, and 2.08 mmol/L (60, 104, and 184 mg/dL) at time 1 and 0.79, 1.33, and 2.49 mmol/L (70, 118, and 220 mg/dL) at time 2. In parallel, we determined changes in BMI, smoking status, physical activity, and habit of eating breakfast between time 2 and time 1 (Figure 1). Next, we evaluated the joint risk attributed to triglyceride levels at time 1 and time 2, categorized according to low (bottom), intermediate, and high (top) tertiles, and we used men with triglyceride levels in the low tertile at both time 1 and time 2 as a reference group (low/low group; hazard ratio, 1.0). To evaluate the direct association of changes in triglyceride levels (Figure 2), we used a multivariate model to further adjust for the interval between the 2 measurements and for the changes between time 2 and time 1 in BMI and lifestyle variables (physical activity, smoking, and habit of eating breakfast). We included these variables by calculating differences () in BMI and creating 3 groups of each categorical variable (smoking, physical activity, and habit of eating breakfast) based on their status at time 1 and time 2 (yes/yes, yes/no, no/yes, or no/no). Figure 1. Changes in selected lifestyle variables

Dietary Intervention to Reverse Carotid Atherosclerosis

Background— It is currently unknown whether dietary weight loss interventions can induce regression of carotid atherosclerosis. Methods and Results— In a 2-year Dietary Intervention Randomized Controlled Trial–Carotid (DIRECT-Carotid) study, participants were randomized to low-fat, Mediterranean, or low-carbohydrate diets and were followed for changes in carotid artery intima-media thickness, measured with standard B-mode ultrasound, and carotid vessel wall volume (VWV), measured with carotid 3D ultrasound. Of 140 complete images of participants (aged 51 years; body mass index, 30 kg/m2; 88% men), higher baseline carotid VWV was associated with increased intima-media thickness, age, male sex, baseline weight, blood pressure, and insulin levels (P<0.05 for all). After 2 years of dietary intervention, we observed a significant 5% regression in mean carotid VWV (−58.1 mm3; 95% confidence interval, −81.0 to −35.1 mm3; P<0.001), with no differences in the low-fat, Mediterranean, or low-carbohydrate groups (−60.69 mm3, −37.69 mm3, −84.33 mm3, respectively; P=0.28). Mean change in intima-media thickness was −1.1% (P=0.18). A reduction in the ratio of apolipoprotein B100 to apolipoprotein A1 was observed in the low-carbohydrate compared with the low-fat group (P=0.001). Participants who exhibited carotid VWV regression (mean decrease, −128.0 mm3; 95% confidence interval, −148.1 to −107.9 mm3) compared with participants who exhibited progression (mean increase, +89.6 mm3; 95% confidence interval, +66.6 to +112.6 mm3) had achieved greater weight loss (−5.3 versus −3.2 kg; P=0.03), greater decreases in systolic blood pressure (−6.8 versus −1.1 mm Hg; P=0.009) and total homocysteine (−0.06 versus +1.44 &mgr;mol/L; P=0.04), and a higher increase of apolipoprotein A1 (+0.05 versus −0.00 g/L; P=0.06). In multivariate regression models, only the decrease in systolic blood pressure remained a significant independent modifiable predictor of subsequent greater regression in both carotid VWV (β=0.23; P=0.01) and intima-media thickness (β=0.28; P=0.008) levels. Conclusions— Two-year weight loss diets can induce a significant regression of measurable carotid VWV. The effect is similar in low-fat, Mediterranean, or low-carbohydrate strategies and appears to be mediated mainly by the weight loss–induced decline in blood pressure. Clinical Trial Registration— http://www.clinicaltrials.gov. Unique Identifier: NCT00160108.

Psoriasis and the metabolic syndrome.

Previous reports have shown a possible association between psoriasis and obesity, ischaemic heart disease, hypertension or diabetes mellitus. However, most of these studies were uncontrolled and were based on small sample sizes. We therefore investigated the association between psoriasis and the metabolic syndrome in a case control study. Case patients were defined as patients with a diagnosis of psoriasis vulgaris. Control patients were subjects who underwent hernioplasty or appendectomy. We used data mining techniques utilizing the database of the southern district of Clalit Health Services. The proportions of patients with diseases that belong to the metabolic syndrome were compared between case and control patients by univariate analyses. chi2 tests were used to compare categorical parameters between the groups. Logistic regression models were used to measure the association between psoriasis and the metabolic syndrome. A total of 340 patients with psoriasis and 6643 controls were included in the study. The mean age of case patients was 47.7 years (SD 10.7 years). There were 50.3% men and 49.7% women. Ischaemic heart disease was present in 23.5% of the patients with psoriasis, compared with 17.2% of the controls (p=0.003). Diabetes mellitus was present in 27.9% of the patients with psoriasis, compared with 19.5% of the controls (p <0.001). Hypertension was present in 44.4% of the patients with psoriasis, compared with 37.2% of the controls (p=0.007). Obesity was present in 29.4% of the patients with psoriasis, compared with 23.5% of the controls (p=0.012). Dyslipidaemia was present in 50.9% of the patients with psoriasis, compared with 44.2% of the controls (p=0.015). The association between psoriasis and the metabolic syndrome was pronounced after the age of 50 years and in men. Multivariate models adjusting for age and gender demonstrated that psoriasis was associated with an increased risk for ischaemic heart disease (odds ratio (OR) 1.4 95% confidence interval (CI) 1.0-1.8), diabetes mellitus (OR 1.5 95% CI 1.2-2.0), hypertension (OR 1.3 95% CI 1.0-1.7), obesity (OR 1.3 95% CI 1.0-1.7) and dyslipidaemia (OR 1.2 95% CI 1.0-1.6). Our findings demonstrate a possible association between psoriasis and the metabolic syndrome. Further studies are needed to establish this observation.

Two Patterns of Adipokine and Other Biomarker Dynamics in a Long-Term Weight Loss Intervention

OBJECTIVE Long-term dietary intervention frequently induces a rapid weight decline followed by weight stabilization/regain. Here, we sought to identify adipokine biomarkers that may reflect continued beneficial effects of dieting despite partial weight regain. RESEARCH DESIGN AND METHODS We analyzed the dynamics of fasting serum levels of 12 traditional metabolic biomarkers and novel adipokines among 322 participants in the 2-year Dietary Intervention Randomized Controlled Trial (DIRECT) of low-fat, Mediterranean, or low-carbohydrate diets for weight loss. RESULTS We identified two distinct patterns: Pattern A includes biomarkers (insulin, triglycerides, leptin, chemerin, monocyte chemoattractant protein 1, and retinol-binding protein 4) whose dynamics tightly correspond to changes in body weight, with the trend during the weight loss phase (months 0–6) going in the opposite direction to that in the weight maintenance/regain phase (months 7–24) (P < 0.05 between phases, all biomarkers). Pattern B includes biomarkers (high molecular weight adiponectin, HDL cholesterol [HDL-C], high-sensitivity C-reactive protein [hsCRP], fetuin-A, progranulin, and vaspin) that displayed a continued, cumulative improvement (P < 0.05 compared with baseline, all biomarkers) throughout the intervention. These patterns were consistent across sex, diabetic groups, and diet groups, although the magnitude of change varied. Hierarchical analysis suggested similar clusters, revealing that the dynamic of leptin (pattern A) was most closely linked to weight change and that the dynamic of hsCRP best typified pattern B. CONCLUSIONS hsCRP, HDL-C, adiponectin, fetuin-A, progranulin, and vaspin levels display a continued long-term improvement despite partial weight regain. This may likely reflect either a delayed effect of the initial weight loss or a continuous beneficial response to switching to healthier dietary patterns.

Abdominal Superficial Subcutaneous Fat: A putative distinct protective fat subdepot in type 2 diabetes

OBJECTIVE Unlike visceral adipose tissue (VAT), the association between subcutaneous adipose tissue (SAT) and obesity-related morbidity is controversial. In patients with type 2 diabetes, we assessed whether this variability can be explained by a putative favorable, distinct association between abdominal superficial SAT (SSAT) (absolute amount or its proportion) and cardiometabolic parameters. RESEARCH DESIGN AND METHODS We performed abdominal magnetic resonance imaging (MRI) in 73 patients with diabetes (mean age 58 years, 83% were men) and cross-sectionally analyzed fat distribution at S1-L5, L5-L4, and L3-L2 levels. Patients completed food frequency questionnaires, and subgroups had 24-h ambulatory blood pressure monitoring and 24-h ambulatory electrocardiography. RESULTS Women had higher %SSAT (37 vs. 23% in men; P < 0.001) despite a similar mean waist circumference. Fasting plasma glucose (P = 0.046) and HbA1c (P = 0.006) were both lower with increased tertile of absolute SSAT. In regression models adjusted for age, waist circumference, and classes of medical treatments used in this patient population, increased %SSAT was significantly associated with decreased HbA1c (β = −0.317; P = 0.013), decreased daytime ambulatory blood pressure (β = −0.426; P = 0.008), and increased HDL cholesterol (β = 0.257; P = 0.042). In contrast, increased percent of deep SAT (DSAT) was associated with increased HbA1c (β = 0.266; P = 0.040) and poorer heart rate variability parameters (P = 0.030). Although total fat and energy intake were not correlated with fat tissue distribution, increased intake of trans fat tended to be associated with total SAT (r = 0.228; P = 0.05) and DSAT (r = 0.20; P = 0.093), but not with SSAT. CONCLUSIONS Abdominal SAT is composed of two subdepots that associate differently with cardiometabolic parameters. Higher absolute and relative distribution of fat in abdominal SSAT may signify beneficial cardiometabolic effects in patients with type 2 diabetes.

Renal Function Following Three Distinct Weight Loss Dietary Strategies During 2 Years of a Randomized Controlled Trial

OBJECTIVE This study addressed the long-term effect of various diets, particularly low-carbohydrate high-protein, on renal function on participants with or without type 2 diabetes. RESEARCH DESIGN AND METHODS In the 2-year Dietary Intervention Randomized Controlled Trial (DIRECT), 318 participants (age, 51 years; 86% men; BMI, 31 kg/m2; mean estimated glomerular filtration rate [eGFR], 70.5 mL/min/1.73 m2; mean urine microalbumin-to-creatinine ratio, 12:12) with serum creatinine <176 μmol/L (eGFR ≥30 mL/min/1.73 m2) were randomized to low-fat, Mediterranean, or low-carbohydrate diets. The 2-year compliance was 85%, and the proportion of protein intake significantly increased to 22% of energy only in the low-carbohydrate diet (P < 0.05 vs. low-fat and Mediterranean). We examined changes in urinary microalbumin and eGFR, estimated by Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration formulas. RESULTS Significant (P < 0.05 within groups) improvements in eGFR were achieved in low-carbohydrate (+5.3% [95% CI 2.1–8.5]), Mediterranean (+5.2% [3.0–7.4]), and low-fat diets (+4.0% [0.9–7.1]) with similar magnitude (P > 0.05) across diet groups. The increased eGFR was at least as prominent in participants with (+6.7%) or without (+4.5%) type 2 diabetes or those with lower baseline renal function of eGFR <60 mL/min/1.73 m2 (+7.1%) versus eGFR ≥60 mL/min/1.73 m2 (+3.7%). In a multivariable model adjusted for age, sex, diet group, type 2 diabetes, use of ACE inhibitors, 2-year weight loss, and change in protein intake (confounders and univariate predictors), only a decrease in fasting insulin (β = −0.211; P = 0.004) and systolic blood pressure (β = −0.25; P < 0.001) were independently associated with increased eGFR. The urine microalbumin-to-creatinine ratio improved similarly across the diets, particularly among participants with baseline sex-adjusted microalbuminuria, with a mean change of −24.8 (P < 0.05). CONCLUSIONS A low-carbohydrate diet is as safe as Mediterranean or low-fat diets in preserving/improving renal function among moderately obese participants with or without type 2 diabetes, with baseline serum creatinine <176 μmol/L. Potential improvement is likely to be mediated by weight loss–induced improvements in insulin sensitivity and blood pressure.

Dietary treatment of hypercholesterolemia: do dietitians do it better? a randomized, controlled trial

PURPOSE Current guidelines of the National Cholesterol Education Program (NCEP) recommend initial dietary counseling by physicians for most patients with hypercholesterolemia; referral to a registered dietitian and lipid-lowering drugs are recommended only for patients who remain hypercholesterolemic. We evaluated the incremental value of detailed nutritional counseling by dietitians when added to general nutritional advice provided by physicians. SUBJECTS AND METHODS Hypercholesterolemic patients detected during a cholesterol screening project were randomly assigned to receive dietary counseling by a physician only (70 patients) or by a physician and a registered dietitian (66 patients). Patients were observed for 1 year to determine compliance with NCEP guidelines. RESULTS At 3 months, the mean (+/- SD) decrease in the serum low-density lipoprotein (LDL) cholesterol level was 7% +/- 11% in the physician group and 12% +/- 10% in the dietitian group (P <0.004). A decrease of 10% or more in the LDL cholesterol level was seen in 25 patients (36%) in the physician group and 43 patients (65%) in the dietitian group (P <0.001). Only 40 (29%) of the patients in both groups achieved their NCEP target goals at 3 months. The majority of these were low-risk patients with an LDL cholesterol target goal of 160 mg/dL. At 12 months, both groups lost about half of the beneficial effects on LDL cholesterol levels, and the difference between the two groups diminished. CONCLUSIONS The short-term reduction in LDL cholesterol level achieved after counseling by dietitians is superior to that achieved by physicians. However, long-term compliance remains inadequate. For patients at high risk, consideration should be given to a more aggressive dietary approach and possibly earlier introduction of lipid-lowering medications.

Usefulness of lipoprotein changes during acute coronary syndromes for predicting postdischarge lipoprotein levels

The aim of our study was to evaluate the lipoprotein changes that occur during acute coronary events, and to determine the lipoprotein threshold levels that identify patients who require future statin therapy. Lipoprotein levels were measured at admission, at 6 hours, the morning after admission, before discharge, and 3 months after discharge in patients with myocardial infarction and unstable angina. Patients with myocardial infarction on thrombolytic therapy (n = 63) and patients with unstable angina (n = 33) had a decrease in low-density lipoprotein (LDL) cholesterol levels < or = 24 hours after admission (-12 +/- 20% and -6 +/- 23%, respectively), but these levels returned to baseline before discharge. In patients with myocardial infarction who did not receive thrombolytic therapy (n = 37), the decrease was more gradual and peaked before hospital discharge (-7 +/- 19%). There was good correlation between LDL cholesterol levels at admission and after discharge, especially in normotriglyceridemic patients. Over 90% of patients with LDL cholesterol > or = 125 mg/dl on the morning after admission were candidates for statin therapy after discharge. Thus, the need for future statin therapy can be predicted with fair reliability during the initial 24 hours after admission. However, elevated baseline triglyceride levels significantly affect these LDL cholesterol changes and complicate prediction of long-term lipoprotein levels.

Determinants of Long-Term Satisfaction after Vertical Banded Gastroplasty

Background: The long-term usefulness of vertical banded gastroplasty (VBG) in achieving weight loss is controversial, and adverse effects related to the procedure may attenuate patient satisfaction. Our objective was to evaluate patient satisfaction, and to identify parameters that are related to such satisfaction, 3 to10 years after VBG. Methods: All consecutive patients who underwent VBG in one surgical ward were invited for a follow-up study 3 to 10 years after surgery. Questions relating to symptoms and quality of life were evaluated in a personal interview using a structured questionnaire. Results: Of the 122 patients who underwent VBG from 1986 to 1992, 75 patients were located and agreed to participate in the follow-up study. The average time since surgery was 5.4 ± 1.8 years. The average weight loss was 24.9 ± 12.4%, representing an excess body-weight loss of 58.6 ± 30.4%. Overall, 65% of the patients were satisfied with the results of surgery while 19% expressed dissatisfaction. Significant improvement was seen in respiratory difficulties, ability to perform physical exercise, and mental status. Successful weight loss and the frequency of respiratory difficulties were the only independent parameters associated with patient satisfaction. Although vomiting, gastroesophageal reflux and difficulty in swallowing occurred in over two-thirds of the patients, their presence was not correlated with patient dissatisfaction. Conclusion: Despite the presence of a multitude of adverse effects, the majority of our patients were satisfied with the long-term results of VBG. Successful weight loss and improvement in respiratory difficulties were the major determinants of patient satisfaction.