Changes in alcohol metabolism after gastric bypass ... - The Lancet

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Aug 27, 2011 - Portion size is of course paramount in all diets, as US First Lady .... surgery: a case-crossover trial. J Am Coll Surg. 2011; 212: 209–14.
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Charrouf Z, Guillaume D. Should the Amazigh diet (regular and moderate argan-oil consumption) have a beneficial impact on human health? Crit Rev Food Sci Nutr 2010; 50: 473–77.

Authors’ reply The central point of our Comment was the cultural context of the Mediterranean diet and of food and diets in general. Apparently only food itself is “natural”.1,2 The choice and the preparation of food are highly cultural activities. As opposed to animals, man does not necessarily eat what he finds in nature but transforms the natural ingredients—and therefore produces and creates. Furthermore, although he could eat all that is edible, man chooses his food following criteria related to practical and economic reasons but also to symbolic values. Therefore, food accessibility is only one of the determinants of diet. Bread is the most typical (although obviously not the only) example of this concept and of the symbolic content that can be attributed to food. The sacred value of bread can be found in many religions preceding Christianity. In the second millennium BC, for example, as we can read in the Epic of Gilgamesh,3 bread was offered to the Babylonian gods as a sacred product. On many occasions, the Old Testament tells of sacred uses of bread (albeit unleavened) among the Jewish population. In Christianity, however, all three pillars of the Mediterranean food culture (bread, wine, and oil) acquire a symbolic and sacred value. For these reasons we mentioned Christianity in our paper. Obviously this does not mean that a culture that does not attribute the same symbolic value to bread is inferior. Historical facts must not be confused with value judgments. The governing and intellectual class of the Roman republic considered frugality a very important value (which is not to say that nobody enjoyed large portions or a high-calorie diet). From the fall of the Roman Empire, however, the consumption of animal meat began to be regarded as a value www.thelancet.com Vol 378 August 27, 2011

that characterised leaders and men of power. Iulius Capitolinus, biographer of Maximinus Thrax, in order to exalt the leader’s charisma wrote: “Apparently he could eat 40 or even 60 pounds of meat and he never tasted vegetables”.4 Once again we are considering the symbolic value awarded by a certain culture to a certain type of diet; there is no moral judgment. Portion size is of course paramount in all diets, as US First Lady Michelle Obama recently reiterated in unveiling the “MyPlate” campaign as part of her healthier eating initiative.5 In conclusion, no diet remains fixed and constant in time, as no culture remains untouched by the outside world. To paraphrase an Italian scholar in food history,2 the table is truly the place of identity (of a culture) but also of exchange (between cultures), and the contamination between cuisines (and cultures) is the basis of progress and harmony between peoples. We declare that we have no conflicts of interest.

*Roberto Ferrari, Claudio Rapezzi [email protected] Department of Cardiology, University of Ferrara, Ferrara 44121, Italy (RF); Salvatore Maugeri Foundation, IRCCS, Lumezzane, Italy (RF); and Institute of Cardiology, University of Bologna, Policlinico S Orsola-Malpighi, Bologna, Italy (CR) 1 2 3 4 5

Levi-Strauss C. Mythologiques I: le cru et le cuit. Paris: Plon, 1964. Montanari M. Food is culture. New York: Columbia University Press, 2006. Anon. The epic of Gilgamesh. London: Penguin Classics, 2003. Syme R. Historia Augusta: emperors and biography. London: Penguin, 1971. United States Department of Agriculture. ChooseMyPlate.gov. http://www. choosemyplate.gov/ (accessed Aug 10, 2011).

Changes in alcohol metabolism after gastric bypass surgery I was recently made aware of a misadventure in a patient who had undergone Roux-en-Y gastric bypass several years previously. After a minor traffic accident in which the police

were involved, the patient was given a breathalyser test for alcohol and, to his surprise, a level consistent with moderate intoxication was found. The patient admitted to drinking one glass of wine many hours previously. A review of published studies on alcohol metabolism after gastric bypass surgery indicates that such patients should be very concerned about elevated blood (and breath) alcohol concentrations out of proportion to intake. For many years, it has been known that bacteria accumulating in stagnant loops of intestine can produce ethanol from ingested carbohydrate substrates.1 Small amounts of alcohol have been detected in the blood of patients after jejunoileal bypass surgery2 and in obese women.3 Bacterial accumulation can occur in the bypassed duodenal-jejunal loop in bypassed patients, potentially resulting in production of alcohols. Furthermore, abnormal handling of small amounts of alcohol has been directly shown in a study of alcohol concentrations in breath before and 3 and 6 months after gastric bypass surgery for obesity.4 That study showed significantly elevated peak alcohol concentrations (reaching 0·08%) and a significant delay in the return of alcohol to baseline concentrations after drinking one glass of wine 6 months postoperatively. Patients who have had gastric bypass have also reported greater sensitivity to small amounts of alcohol with more rapid intoxication and lower intolerance than before surgery.5 Obesity surgery has become one of the commonest operations in western countries. These data mandate that patients undergoing Roux-en-Y gastric bypass surgery be warned that they could experience a major difference in their capacity to handle alcohol after their surgery and that they should consider not driving after drinking any alcohol at all. I declare that I have no conflicts of interest.

Peter R Holt [email protected]

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Rockefeller University, Laboratory of Biochemical Genetics and Metabolism, New York, NY 10065, USA 1

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Nosova T, Jokelainen K, Kaihovaara P, et al. Aldehyde dehydrogenase activity and acetate production by aerobic bacteria representing the normal flora of human large intestine. Alcohol Alcohol 1996; 31: 555–64. Mezey E, Imbembo AL, Potter JJ, Rent KC, Lombardo R, Holt PR. Endogenous ethanol production and hepatic disease following jejunoileal bypass for morbid obesity. Am J Clin Nutr 1975; 28: 1277–83. Nair S, Cope K, Risby TH, Diehl AM. Obesity and female gender increase breath ethanol concentration: potential implications for the pathogenesis of nonalcoholic steatohepatitis. Am J Gastroenterol 2001; 96: 1200–04. Woodard GA, Downey J, Hernandez-Boussard T, Morton JM. Impaired alcohol metabolism after gastric bypass surgery: a case-crossover trial. J Am Coll Surg 2011; 212: 209–14. Ertelt TW, Mitchell JE, Lancaster K, Crosby RD, Steffen KJ, Marino JM. Alcohol abuse and dependence before and after bariatric surgery: a review of the literature and report of a new data set. Surg Obes Relat Dis 2008; 4: 647–50.

Continued neglect of ageing of HIV epidemic at UN meeting AFP/Getty Images

On June 10, 2011, the UN HIV/AIDS meeting in New York, USA, concluded with a set of commitments including to redouble efforts to achieve universal access to prevention, treatment, and care. As you report (June 18, p 2055),1 integration was highlighted as the way forward for the epidemic’s response. The declaration, however, missed an opportunity to acknowledge the integration needed to address the reality that, as more people are put on treatment and as survival on treatment is enhanced around the world, a growing proportion of people living with HIV will be classified as elderly.2 UN data have focused on those aged 15–49 years but, across the world, the epidemic is affecting those aged 50 years and older more than ever before. By 2015, at least half of those living with HIV in the USA will be aged 50 years and older. In sub-Saharan Africa, there are 3 million people living 768

with HIV aged 50 years and older, representing more than 13% of the region’s HIV cases.3 With the ageing of the epidemic, HIV/AIDS has become a complex chronic disease characterised by increasing rates of comorbid conditions including liver and renal disease, cancers, osteoporosis, and neurocognitive and cardiovascular diseases.4 The vertical AIDS funding approach has meant that AIDS clinics have training and resources to deal with AIDS-specific conditions, but lack access to effective diagnostics and treatments for these comorbid disorders. The UN meeting was tasked with charting the future course of the global HIV response, yet failed to mention the ageing of the pandemic. It acknowledged the need for a more integrated approach, but centred mainly on infectious diseases and reproductive and child health. The call for integration is appropriate, but should focus on strengthening the response to non-communicable diseases in developing countries, building on existing efforts to develop HIV chronic-care models.5 We declare that we have no conflicts of interest.

*Joel Negin, Edward J Mills, Rachel Albone [email protected] School of Public Health, University of Sydney, Sydney, NSW 2006, Australia (JN); British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, BC, Canada (EJM); Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada (EJM); and HelpAge International, London, UK (RA) 1 2

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The Lancet. A strategic revolution in HIV and global health. Lancet 2011; 377: 2055. Mills EJ, Rammohan A, Awofeso N. Ageing faster with AIDS in Africa. Lancet 2010; 377: 1131–33. Negin J, Cumming RG. HIV infection in older adults in sub-Saharan Africa: extrapolating prevalence from existing data. Bull World Health Organ 2010; 88: 847–53. Justice AC. HIV and aging: time for a new paradigm. Curr HIV/AIDS Rep 2010; 7: 69–76. Rabkin M, El-Sadr WM. Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases. Glob Public Health 2011; 6: 247–56.

Further analyses of the Myeloma IX Study Athanassios Kyrgidis and Thrasivoulos-George Tzellos (June 25, p 2177)1 and Tetsuya Tanimoto and colleagues (June 25, p 2178)2 make important comments on our paper3 reporting the results of the Medical Research Council (MRC) Myeloma IX Study. In response to Kyrgidis and Tzellos, the statistical analyses were done as prospectively planned for the MRC Myeloma IX Study. The additional exploratory analyses were done to verify that the overall survival model was valid despite a model violation detected for one treatment centre (model omitting stratification by treatment centre) and to test a hypothesis that the effect of zoledronic acid on survival was simply due to prevention of skeletal-related events, which was found not to be the case. The outcome from this latter model was consistent when treatmentcentre stratification was omitted, although the comparison then fell just short of significance (p=0·0515). The overall survival benefit with zoledronic acid versus clodronic acid seen in the overall population in Myeloma IX was also consistent (though statistically underpowered) when the intensive and non-intensive pathways were analysed separately. The intention of the different curves presented in figure 2 was not, as implied, to present a favourable impression for zoledronic acid. The overall and progression-free survival curves were initially generated for the entire time course (figures 2A and 2C) per the study protocol. Given the lower rates of early death and generally favourable response profiles in patients treated with zoledronic acid, the first 4 months on study (ie, during chemotherapy) were analysed separately and revealed striking differences. The cumulative incidence of osteonecrosis of the jaw in patients treated with zoledronic acid was 3–4% across a median follow-up of 3·7 years. www.thelancet.com Vol 378 August 27, 2011