To the Editor.—
The article by Dr Ames et al on liver dysfunction (235:1249, 1976) points up a problem in the long-term postoperative follow-up of intestinal bypass patients, which is, at best, poorly understood and often ignored, sometimes with serious consequences. Thus, hepatic failure is considered a serious risk to intestinal bypass for morbid obesity.There is reason to believe that hepatic steatosis is a consequence of carbohydrate-protein imbalance, not a simple protein deficiency, probably exactly like the changes seen in the early stages of kwashiorkor disease. Simple starvation does not produce these changes. The morbidly obese already have some degree of hepatic steatosis at the time of their bypass, and this, in my experience, is not directly related to the degree of obesity but, I suspect, is related to the ratio of carbohydrate to protein these people have eaten to become so obese and to maintain their obesity. Carbohydrates