Risk Factor Changes

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In a 2-year report of 282 men and 560 women, pooled from the surgically treated group and the control group, risk factor changes were examined as a function of weight change (15). Ten kilogram weight loss was enough to introduce clinically significant reductions in all traditional risk factors except total cholesterol (Figure 35.6). Although it is known that total cholesterol is reduced short term (1-6 months) by moderate weight losses (16,17), Figure 35.6 illustrates that 30 to 40 kg maintained weight loss is required to achieve a preserved reduction in total serum cholesterol after 2 years.

In another 2-year report on 767 surgically treated patients and 712 controls, the weight loss of the surgical group resulted in dramatic reductions in the incidence of hypertension, diabetes, hyperin-sulinaemia, hypertriglyceridaemia and low HDL cholesterol (4) (Figure 35.7). In the case of diabetes a 32-fold risk reduction was observed while the incidence of other risk conditions was reduced 2.6- to

Height Sex Factor

Figure 35.6 Adjusted risk factor changes (%) in relation to body weight changes (kg) over 2 years in 842 obese men and women pooled from the surgically treated group and the obese control group of the SOS Intervention study. The percentage change in each risk factor was adjusted for the basal value of that risk factor, initial body weight, sex, age and height. The number of subjects in each weight-changing class is shown at the top of the figure (as No). SBP and DBP, systolic and diastolic blood pressure; HDL, serum HDL cholesterol; CHOL, serum total cholesterol; TG, serum triglycerides; INS, serum insulin; URIC, serum uric acid; GLU, blood glucose. All serum samples collected after overnight fast. From C.D. Sjostrom et al. (14), with permission

Figure 35.6 Adjusted risk factor changes (%) in relation to body weight changes (kg) over 2 years in 842 obese men and women pooled from the surgically treated group and the obese control group of the SOS Intervention study. The percentage change in each risk factor was adjusted for the basal value of that risk factor, initial body weight, sex, age and height. The number of subjects in each weight-changing class is shown at the top of the figure (as No). SBP and DBP, systolic and diastolic blood pressure; HDL, serum HDL cholesterol; CHOL, serum total cholesterol; TG, serum triglycerides; INS, serum insulin; URIC, serum uric acid; GLU, blood glucose. All serum samples collected after overnight fast. From C.D. Sjostrom et al. (14), with permission

10-fold. In analogy with Figure 35.6, weight loss had no effect on the incidence of hypercholesterolemia (figure 35.7). To give a visual impression of the weight loss necessary to prevent development of diabetes, the surgically treated group and the control group were pooled and the diabetes incidence plotted by decentiles of weight change (18). As can be seen in Figure 35.8, weight changes close to zero were associated with a 2-year diabetes incidence of 7-9%. A Mean weight loss of 7% was still associated with a 2-year diabetes incidence of 3% while no new cases of diabetes were seen for mean weight losses 12% or larger.

In the 8-year follow up (12) the incidence of diabetes was still five times lower in the surgical group than in the control group (figure 35.9). However, there was no difference between the two groups with respect to the 8-year incidence of hypertension (Figure 35.9). This was the case with or without multiple adjustments in the completer population as well as in the intention-to-treat population (12).

In a follow-up study, the final blood pressure has been shown to be closely related to recent weight changes and the length of the follow-up but more weakly associated with initial weight and the initial weight loss (19).

Unpublished 10-year data from SOS show that insulin, glucose, triglycerides and HDL cholesterol are improved by surgical treatment while blood pressure and total cholesterol are not.

While short-term weight losses improve all cardiovascular risk factors (see Figure 35.6 and (16,17)), several observational epidemiological studies have shown an association between weight loss and increased total as well as cardiovascular mortality, even in those who were obese at baseline (20). This discrepancy has usually been explained by the inability of observational studies to separate intentional from unintentional weight loss. Williamson has provided some evidence for this in women (21) but not in men (22). The 8-year study discussed above (12) suggests another possibility: long term,

Figure 35.7 Two-year unadjusted incidence of indicated conditions in 712 obese controls (striped bars) and in 767 surgically treated completers (filled bars) from the SOS intervention study. Below bars, Odds Ratios (95% CI) adjusted for baseline values of age, sex, weight smoking and matching value of perceived health. P < 0.001 for all differences between groups except for hypercholesterolemia. Abbreviations as in Figure 35.6. From C.D. Sjostrom et al. (4), with permission

Figure 35.7 Two-year unadjusted incidence of indicated conditions in 712 obese controls (striped bars) and in 767 surgically treated completers (filled bars) from the SOS intervention study. Below bars, Odds Ratios (95% CI) adjusted for baseline values of age, sex, weight smoking and matching value of perceived health. P < 0.001 for all differences between groups except for hypercholesterolemia. Abbreviations as in Figure 35.6. From C.D. Sjostrom et al. (4), with permission

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