Primary prevention of coronary heart disease in general practice: a cross sectional population study

The aim of this study was to assess the interventions by general practitioners on cardiovascular risk factors among persons without a history of cardiovascular disease attending for a cardiovascular check-up. All inhabitants of three Belgian towns aged between 45 and 64 years were invited for a cardiovascular check-up and blood test. Of all the attending persons without a history of cardiovascular disease (n = 898), 51% received at least one prescription, diet or health advice: 28% for hyperlipidaemia, 23% for physical activity, 22% for caloric intake, 9% for blood sugar, 5% for blood pressure and 4% for smoking. Interventions on lipoproteins, blood sugar and smoking habits were significantly more often proposed to persons with a medium or high cardiovascular risk compared to those at low cardiovascular risk. For persons at low cardiovascular risk, therapeutic lifestyle changes are often not advised, and isolated risk factors often remain untreated.

Assessing the impact of complications on the costs of Type II diabetes

AIMS/HYPOTHESIS

'The Cost of Diabetes in Europe-Type II (CODE-2) study' provides the first coordinated attempt to assess the total costs of managing people with Type II (non-insulin-dependent) diabetes mellitus in Europe. Type II diabetes is associated with a number of serious long-term complications, which are a major cause of morbidity, hospitalisation and mortality in diabetic patients.

METHODS

Patients were divided into four broad categories defining their complication status in terms of no complications, one or more microvascular complications, one or more macrovascular complications or one or more of each microvascular and macrovascular complication. The prevalence of complications and associated costs were assessed retrospectively for 6 months.

RESULTS

In total, 72% of patients in the CODE-2 study had at least one complication, with 19% having microvascular only, 10% having macrovascular only and 24% of the total having both microvascular and macrovascular complications. Of patients with microvascular complications, 28% had neuropathy, 20% renal damage, 20% retinopathy and 6.5% required treatment for eye complications. Among the patients with macrovascular complications, 18% had peripheral vascular disease, 17% angina, 12% heart failure and 9% had myocardial infarction. Percutaneous transluminal coronary angioplasty, coronary artery bypass graft or stroke occurred in 3%, 4% and 5% of the patients, respectively. In patients with both microvascular and macrovascular complications, the total cost of management was increased by up to 250% compared to those without complications.

CONCLUSION/INTERPRETATION

Complications have a substantial impact on the costs of managing Type II diabetes. This study has confirmed that the prevention of diabetic complications will not only benefit patients, but potentially reduce overall healthcare expenditure.

Nateglinide improves glycaemic control when added to metformin monotherapy: results of a randomized trial with type 2 diabetes patients

AIMS/HYPOTHESIS

This study evaluated the addition of nateglinide, a d-phenylalanine derivative that restores early phase insulin release, to metformin in type 2 diabetes patients stabilized on high-dose metformin.

METHODS

This multicentre, double-blind, parallel group trial included 467 metformin-treated patients with glycosylated haemoglobin (HbA1c) between 6.8% and 11%. Patients were randomized to add nateglinide 60 mg, 120 mg or placebo before three meals to metformin 1000 mg b.i.d. for 24 weeks.

RESULTS

HbA1c was significantly reduced with nateglinide 60 mg and 120 mg plus metformin compared with metformin control (-0.36%, p = 0.003; -0.59%, p < 0.001 respectively). Greater benefits occurred if patients had elevated HbA1c at baseline (-1.38% with nateglinide 120 mg in patients with HbA1c > 9.5%). A modest fasting plasma glucose reduction was observed. Most symptoms suggestive of hypoglycaemia occurred in patients with low HbA1c levels (<or= 8%) at baseline, although no confirmed cases of hypoglycaemia occurred with nateglinide 60 mg in this patient group. Events suggestive of hypoglycaemia were confirmed in 1.1% of cases (plasma glucose <or= 3.3 mmol/l). Weight gain over 24 weeks was 0.9 kg with nateglinide 120 mg vs. metformin alone, and plasma lipids remained unchanged.

CONCLUSIONS/INTERPRETATION

In patients stabilized on high-dose metformin, the addition of nateglinide improved glycaemic control. The combination of these agents was well tolerated and both doses of nateglinide proved effective. The efficacy of nateglinide 60 mg and the low rate of hypoglycaemia observed at this dose make it suitable for patients close to their therapeutic target on metformin monotherapy.

The effects of orlistat on weight and on serum lipids in obese patients with hypercholesterolemia: a randomized, double-blind, placebo-controlled, multicentre study

OBJECTIVE

Assessment of the effects of orlistat 120 mg three times daily vs placebo on weight loss and serum lipids in obese hypercholesterolemic patients.

DESIGN

A 24 week multicentre, double-blind, randomized, placebo-controlled trial. After a 2-week single-blind run-in period (placebo+diet (-600 kcal/day; < or =30% of calories as fat)), 294 patients were submitted to the hypocaloric diet and randomly assigned to either orlistat 120 mg or placebo three times daily. Patients who completed the double-blind study (n=255) were eligible for participation in a subsequent 24 week open-label orlistat extension phase.

SUBJECTS

Patients with body mass index (BMI) 27-40 kg/m2 and hypercholesterolemia (low-density-lipoprotein cholesterol, LDL-C, 4.1-6.7 mmol/l).

MEASUREMENTS

Efficacy assessments included weight loss, lipid levels, other cardiovascular risk factors and anthropometric parameters. Safety assessments.

RESULTS

Weight loss during run-in was similar in both groups. After randomization, orlistat-treated patients lost significantly more weight than placebo recipients: mean percentage weight loss from start of run-in to week 24 was-6.8% in the orlistat group and -3.8% in the placebo group (P<0.001). Moreover, more patients in the orlistat group than in the placebo group achieved clinically meaningful weight loss of > or =5% (64 vs 39%) or > or =10% (23 vs 13%) at week 24. Treatment with orlistat was associated with significantly greater changes in total cholesterol (-11.9% vs -4.0%; P<0.001) and LDL-C (-17.6 vs -7.6%; P<0.001). For any category of weight loss during the double-blind treatment period, change in LDL-C was more pronounced in orlistat-treated patients than in placebo recipients, indicating that orlistat had a direct cholesterol-lowering effect that was independent of weight reduction (P<0.001). Adjunction of orlistat during the extension phase in patients who initially received placebo induced a further decrease in weight, total cholesterol and LDL-C. Orlistat was generally well tolerated with a safety profile comparable to placebo, with the exception of a higher incidence of gastrointestinal events (> or =1 event in 64 vs 38% of patients).

CONCLUSION

Orlistat as an adjunct to dietary intervention promotes weight loss and reduces LDL-C beyond the effect of weight loss in overweight or obese patients with concomitant hypercholesterolemia.

Visceral fat is a determinant of PAI-1 activity in diabetic and non-diabetic overweight and obese women

Plasminogen activator inhibitor type 1 (PAI-1), an inhibitor of fibrinolysis and an important and independent cardiovascular risk factor, has been shown to be elevated in obesity and type 2 diabetes. Recent study results have suggested that adipose tissue--visceral fat in particular--could play an important role in the fibrinolytic process.In order to assess the specific role of this fat distribution, we measured PAI-1 activity (AU/ml) and visceral fat (CT-scan at level L4-L5) in 2 groups of 30 overweight and obese diabetic and overweight and obese non-diabetic women. Subjects were matched for age, weight, body mass index, fat mass and total abdominal fat. Visceral adipose tissue and PAI-1 were significantly higher in diabetic women (p = 0.022 and p = 0.004 respectively) than in non-diabetic patients. Visceral fat correlated significantly with PAI-1 activity, even after correction for insulin and triglycerides (r = 0.28, p = 0.034). Stepwise regression analysis showed visceral fat as the most important determinant factor for PAI-1 in the whole group and in the non-diabetic group. In the diabetic group, fasting insulin was the most important determinant. These results show that visceral fat is more important than BMI or total body fat in the determination of PAI-1 levels. Furthermore, the increased amount of visceral fat in type 2 diabetics may contribute to the increase of PAI-1 activity levels and the subsequent increased risk for thrombovascular disease, regardless of BMI and total fatness.

Miglitol combined with metformin improves glycaemic control in type 2 diabetes

AIM

To investigate the efficacy and safety of miglitol vs. placebo in type 2 diabetic outpatients insufficiently controlled (HbA1c between 7.5 and 10.5%) with diet and metformin.

METHODS

Patients treated with diet and metformin (1500-2250 mg/day) were randomized to receive additional treatment with either miglitol or placebo for 32 weeks. The dosages were force-titrated: 4 weeks at 25 mg miglitol t.i.d., 12 weeks at 50 mg miglitol t.i.d., and 16 weeks at 100 mg miglitol t.i.d. or matching placebo. If the highest dosage could not be tolerated, patients could be down-titrated to 50 mg t.i.d. The primary efficacy criterion was the change in glycated haemoglobin (HbA1c). Secondary efficacy parameters included fasting and 1 h postprandial blood glucose, serum insulin, and fasting and 1 h postprandial triglyceride levels. Safety and tolerability were evaluated by the incidence of adverse events and changes in vital signs or routine biochemical and haematological parameters.

RESULTS

One hundred and fifty-two patients were valid for the intent-to-treat (ITT) analysis. There was a significant decrease in HbA1c on adding miglitol to metformin compared to adding placebo (miglitol treatment effect, - 0.21%; placebo treatment effect, + 0.22%; p = 0.011). Postprandial blood glucose declined in both the miglitol/metformin and placebo/metformin groups with a statistically significant difference in favour of miglitol/metformin (end of treatment adjusted means 13.8 mmol/l for miglitol vs. 15.8 mmol/l for placebo, p = 0.0007). Adverse events (AEs) were reported by only 8% more patients in the miglitol/metformin group than placebo/metformin. No cases of hypoglycaemia were reported.

CONCLUSIONS

Miglitol can safely and effectively be added to diet and metformin in patients whose type 2 diabetes is insufficiently controlled, and improves glycaemic control by significantly reducing HbA1c and postprandial blood glucose levels.

Leptin receptor gene polymorphisms are associated with insulin in obese women with impaired glucose tolerance

Leptin receptors are present on beta-cells as well as on muscle and fat cells, thus enabling leptin to modulate both insulin secretion and insulin action. Leptin inhibits especially the glucose-stimulated insulin secretion from pancreatic cells. The leptin receptor (LEPR) gene could thus play a role in the regulation of glucose and insulin after an oral glucose load. Therefore, the relationship between LEPR polymorphisms and glucose and insulin response to an oral glucose tolerance test (OGTT) was investigated. Three LEPR polymorphisms (Lys(109)Arg, Gln(223)Arg, and Lys(656)Asn) were typed on genomic DNA of 358 overweight and obese women, aged 18-60 yr. Based on an OGTT, 269 subjects were defined with normal glucose tolerance, and 89 with impaired glucose tolerance (IGT). Associations between genotypes and glucose metabolism were analyzed with a general linear models procedure in pre- and postmenopausal women separately, after adjusting the data for age and fat mass. In postmenopausal women with IGT (n = 24), associations were found with Lys(109)Arg and Lys(656)Asn for fasting insulin (P = 0.05) and with Lys(109)Arg and Gln(223)Arg for the insulin response to an OGTT (P < 0.02). In the same group, trends were found with Lys(656)Asn for fasting glucose as well as in response to the OGTT. In premenopausal women with IGT (n = 65), associations were found with Lys(109)Arg and Lys(656)Asn for overall glucose response to the glucose load. In contrast, no associations with insulin or glucose were found in women with normal glucose tolerance. In conclusion, these data indicate that LEPR polymorphisms are associated with insulin and glucose metabolism in women with impaired glucose homeostasis.

Predictors of weight loss and maintenance during 2 years of treatment by sibutramine in obesity. Results from the European multi-centre STORM trial. Sibutramine Trial of Obesity Reduction and Maintenance

BACKGROUND

In this report we assess pre-treatment determinants of weight loss and maintenance outcome in The Sibutramine Trial of Obesity Reduction and Maintenance (STORM), a 2 y randomized, double-blind, placebo-controlled, European multicenter study examining the effect of sibutramine (Sib) on inducing and maintaining weight loss in obese subjects.

MATERIAL

A total of 605 obese patients (BMI: 30-45 kg/m2) of both gender were included from eight European centers and treated for 24 months. The patients were treated for the initial 6 months by Sib (10 mg/day) and a low-fat low-energy, individualized diet (600 kcal/day deficit). The 467 patients who achieved >5% weight loss after 6 months were randomized 3&ratio;1 to Sib (10 mg/day) (Sib/Sib) and placebo (Sib/Pla) for weight maintenance over a further 18 months. MAIN OUTCOME AND ANALYSES: Pre-treatment individual characteristics were assessed as predictors of 6 months weight loss (kg) and 24 months weight maintenance using simple and multivariate correlation and regression analyses.

RESULTS

In univariate analyses, the 6 month weight loss (n=505) was positively associated with pre-treatment body weight (r=0.27), height (r=0.18), fat-free mass (r=0.21) (all P<0.001), fat mass (r=0.13, P<0.03), and resting metabolic rate (r=0.13, P<0.003). However, no relation was found with age, gender, smoking status, age at onset of obesity, or number of previous slimming attempts. The same predictors were found for weight change to endpoint in the Sib/Sib group (n=350), while no predictors were identified in the Sib/Pla (n=114). In the multivariate regression analysis only pre-treatment body weight predicted weight loss at 6 months (P<0.001). Weight change (kg) to 24 month was predicted by: 4.34+0.07*body weight (kg)-4*treatment (Sib=1, Pla=0)-0.06*age (y), (r2=8%, P<0.001).

CONCLUSION

Only pre-treatment body weight seems to be an important independent predictor of 6 months weight loss and 24 month weight maintenance in this study on diet and Sib. As only 8% of the variation in 24 months weight change could be explained by the predictors, the clinical value of this information is limited.

Mutation analysis of the MEN1 gene in Belgian patients with multiple endocrine neoplasia type 1 and related diseases

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder characterized by tumors in parathyroids, enteropancreatic endocrine tissues, anterior pituitary, and other tissues. The gene for MEN1 has recently been cloned and shown to code for a 610-amino acid protein of enigmatic function which probably acts as a tumor suppressor. Several mutations causing the MEN1 phenotype have been recently identified. In order to determine the spectrum of MEN1 gene mutations in a sample of 25 Belgian patients, we have systematically screened the 10 exons and adjacent sequences of the MEN1 gene by means of an automatic sequencing protocol. Twelve different mutations were identified including nonsense, frameshift, splicing, and missense mutations. Two of these mutations (D172Y and 357del4) occurred more than once. A missense mutation was also found in a kindred with familial hyperparathyroidism. We observed no significant correlation between the nature or position of mutation and the clinical status. We have also detected 6 intragenic polymorphisms and DNA sequence variants and have analyzed their frequencies in our population.

Associations of leptin with body fat distribution and metabolic parameters in non-insulin-dependent diabetic patients: no effect of apolipoprotein E polymorphism

Leptin levels have been shown previously to be associated with anthropometric parameters such as the body mass index (BMI), total body fat, and subcutaneous fat. Since apolipoprotein E (apoE) polymorphism is known to be a genetic marker affecting the relationship between certain anthropometric and metabolic parameters, we evaluated whether the leptin level and/or associations between the leptin level and body composition in non-insulin-dependent diabetic patients could be determined by apoE polymorphism. In 171 type 2 diabetic patients (105 male and 66 female), body composition (BMI, waist to hip ratio [WHR], fat mass, and visceral fat) was measured and fasting blood samples were obtained to determine the apoE genotype, leptin, glucose, and insulin levels, and the lipid profile. The mean leptin level for the whole group was 11.7 +/- 9.3 ng/mL, with a significant difference (P < .001) between men (7.1 +/- 4.9 ng/mL) and women (19.0 +/- 10.1 ng/mL). No difference was found for leptin levels or anthropometric variables between the 3 different apoE genotypes (E3/E3 homozygotes, E2 carriers, and E4 carriers). Only low-density lipoprotein (LDL) cholesterol was significantly different between the 3 apoE subgroups. The correlations of leptin with anthropometric variables, especially visceral fat, tended to be different between the 3 apoE groups, but this was not independent and no effect was found after controlling for the other parameters in the model. A multiple regression model containing gender, subcutaneous fat, fasting glucose, triglycerides, and high-density lipoprotein (HDL) cholesterol explained 81% of the variance in leptin levels. We conclude that apoE polymorphism has no effect on the leptin level or its associations with other anthropometric and metabolic parameters.

High frequency of persisting or increasing islet-specific autoantibody levels after diagnosis of type 1 diabetes presenting before 40 years of age. The Belgian Diabetes Registry

OBJECTIVE

To study the presence and levels of GAD65 antibodies (GADA), IA-2 antibodies (IA-2-A), and islet cell antibodies (ICA) during the first years after clinical onset of type 1 diabetes in relation to age at diagnosis.

RESEARCH DESIGN AND METHODS

Type 1 diabetic patients (n = 194) <40 years of age were consecutively recruited at the time of diagnosis by the Belgian Diabetes Registry and followed during the first 4 years of insulin treatment. ICA were determined by indirect immunofluorescence assay and IA-2-A, GADA, and insulin autoantibodies by a radioligand assay.

RESULTS

Overall, 94% of initially antibody-positive patients (n = 180) remained positive for at least 1 antibody type 4 years after diagnosis. In the case of diagnosis after 7 years of age, GADA, IA-2-A, and ICA persisted in 91, 88, and 71%, respectively, of the initially antibody-positive patients. Antibody persistence was lower in those diagnosed at <7 years of age, amounting to 60% for GADA, 71% for IA-2-A, and 39% for ICA. In 57% of the initially antibody-positive patients, at least 1 type of autoantibody reached peak values after diagnosis. This occurred more frequently for clinical onset after 7 years of age and more often for GADA (49%) than for IA-2-A (29%) or ICA (19%). Of the patients, 24% that were negative for GADA at onset became GADA-positive during the following 4 years. Among the 7% initially antibody-negative patients, 2 of 14 subjects developed antibodies after clinical onset.

CONCLUSIONS

In particular, for diagnosis after 7 years of age, islet cell-specific autoantibodies generally persist for many years after diagnosis. There is also a high frequency of increasing antibody levels and of conversion to antibody positivity in the first 4 years after diagnosis and start of insulin treatment. Thus, determination of antibodies at diagnosis can underestimate the number of cases with autoimmune type 1 diabetes, in particular with assays of lower sensitivity. The divergent temporal patterns of ICA, GADA, and IA-2-A suggest that the ICA test recognizes other antibody specificities besides GADA and IA-2-A and reflects other autoimmune processes; it also indicates that GADA assays have a higher diagnostic sensitivity in the period after clinical onset.

Gender differences in leptin levels and physiology: a role for leptin in human reproduction

Leptin, an adipocyte-derived hormone known to play an important role in body-weight regulation, has been shown to be expressed differentially in men and women. These observations are potentially important for the understanding of differences between men and women in regulation of food intake, weight gain, and body fat distribution. Leptin is also involved in female fertility, especially in pubertal development. It may well be the triggering signal for the onset of puberty in girls. Although the exact mechanisms and interactions with sex steroids are not yet fully established, it is clear that leptin plays a role as an endocrine mediator in sexual development and reproduction.

Carbohydrate-induced thermogenesis in obese women. Effect of insulin and catecholamines

Results of studies on diet-induced thermogenesis in obese persons are contradictory. A number of factors have been postulated to mediate the obligatory and facultative component of thermogenesis. This study was designed to investigate some further factors mediating the carbohydrate-induced thermogenesis in obese women. In 13 obese women, thermogenic responses to glucose and fructose were compared and related to subsequent hormonal changes. The thermogenic effect after fructose ingestion was significantly (p<0.006) higher in comparison with glucose, despite lower values for both glucose and insulin concentrations. Carbohydrate oxidation was significantly higher after fructose (81+/-7 E% vs 62+/-10 E% p<0.01) while oxidation of fat was lower (10+/-9 E% vs 21+/-12 E% p<0.01). These effects may partly be due to the de novo lipogenesis and/or to changes in cellular metabolism. No clear relationship could be found between thermogenesis and the activity of the sympathetic nervous system, as expressed by urinary catecholamine levels. These results indicate that not insulin but the cellular rate of carbohydrate metabolism is responsible for the thermogenic response to different carbo-nutrients.

Are leptin levels dependent on body fat distribution in obese men and women?

Leptin levels are strongly related to total body fat. It is however not yet clear if leptin is also related to visceral fat accumulation or not. In this study, we investigated whether leptin is also associated with body fat distribution and if this association is different in men and women. Leptin was measured in 143 obese subjects (118 women and 25 men) with a body mass index (BMI) greater than 28. Also weight, skinfolds, waist-to-hip ratio (WHR), fat mass by bioimpedance analysis (BIA) were measured, and abdominal visceral and subcutaneous fat were determined by CT scan. Leptin levels were significantly related with BMI, with fat mass (in kg and percentage body fat) as measured by BIA and skinfolds, and with total abdominal fat mass and subcutaneous fat measured by CT scan. No association was found with visceral fat, waist circumference or WHR. In men and women separately, however, a correlation with visceral fat existed. After correction for total body fat, the correlation remained significant only with subcutaneous fat in women. Multiple regression analyses pointed out that percentage body fat was the most important determinant of leptin for all subjects, while for women subcutaneous fat was the most important parameter, and for men alone total abdominal fat. These results suggest that subcutaneous fat seems to be an important factor related to leptin levels.

Role of hepatic arterial embolisation in the treatment for metastatic insulinoma. Report of two cases and review of the literature

Malignant insulinomas are very rare. They have typical clinical and biochemical characteristics that allow an early detection and distinction from other sorts of islet cell carcinoma. As a result a curative resection can occasionally be managed. Nevertheless, for more advanced stages the same treatment options as for other metastatic neuroendocrine tumours must be considered: palliative surgery, medical treatment, chemotherapy and hepatic arterial (chemo-) embolisation. Especially the last kind of treatment has recently gained interest. We report two cases of metastatic insulinoma treated in this way. In the first case we are able to record an unusually long survival through the single use of sequential embolisation, following palliative resection of the primary tumour. In the second case we describe the current way to use this technique, i.e. in combination with chemotherapy. We argue that it might be more important in the treatment of metastatic insulinoma to combine hepatic arterial embolisation with other types of local or systemic therapy, rather than the choice of this most efficient technique on its own.

The use of multi-frequency impedance to determine total body water and extracellular water in obese and lean female individuals

OBJECTIVE

To validate the assessment of total body water (TBW) and extracellular water (ECW) by multi-frequency bioelectrical impedance.

SUBJECTS

Twenty-five overweight but otherwise healthy subjects and 20 lean subjects.

DESIGN

Cross-sectional.

MEASUREMENTS

TBW and ECW were determined by dilution techniques. Prediction equations from the literature were used to calculate TBW and ECW from measured impedance at 100 and 50 kHz or 1 and 5 kHz, respectively. In 18 of the obese subjects, impedance was also measured with the electrodes placed at proximal sites.

RESULTS

In lean and obese subjects, significant correlations were observed between the impedance index (H2/Z) at high frequencies with TBW (r = 0.90, P < 0.001 in lean and r = 0.80, P < 0.001 in obese subjects) and at low frequencies with ECW (r = 0.87, P < 0.001 and r = 0.77, P < 0.001 respectively). Proximal placement of electrodes slightly improved the correlation between the impedance index and TBW (from r = 0.83 to r = 0.90 at 50 kHz and from r = 0.85 to r = 0.90 at 100 kHz) and ECW (from r = 0.77 to r = 0.83 at 1 kHz and from r = 0.79 to r = 0.85 at 5 kHz). The association of ECW and TBW with H2/Z was different for obese and lean subjects: in obese subjects a given amount of TBW or ECW corresponded with a lower index. An equation consisting only of the impedance index could predict TBW and ECW with small mean errors in lean (1.3 and 0.8 kg respectively) and obese subjects (0.1 and 0.0 kg respectively). Applying a more specific equation, including other subject characteristics, resulted in larger prediction errors in obese subjects, illustrating the population specificity of prediction equations. Furthermore an association was observed of the prediction bias of TBW and ECW with TBW (r = 0.48, P < 0.01) and ECW (r = 0.70, P < 0.001) respectively, and with body water distribution (r = -0.38 and r = 0.33 respectively, P < 0.05). TBW and ECW were also associated with weight (r = 0.76 and r = 0.71 respectively, P < 0.001) and body mass index (BMI) (r = 0.54 and r = 0.53 respectively, P < 0.001).

CONCLUSION

It appeared from this study that the accuracy of TBW and ECW estimation with the impedance technique is dependent on the absolute amount of TBW and ECW. A higher amount of TBW and ECW in obese subjects may contribute to a difference in prediction error between lean and obese individuals.

Effects of initial BMI and on-treatment weight change on the lipid-lowering efficacy of fibrates

OBJECTIVE

To assess the effects of BMI at baseline and on-treatment weight change on the lipid-lowering efficacy of diet plus fibric acid derivatives (fibrates) in hypercholesterolemic adults.

SUBJECTS

6003 participants in a Belgian General Practitioners Trial, an open-label, prospective study conducted in a primary care setting.

MEASURES

Effect of initial BMI, on-treatment weight change, or lipid values at baseline on percentage changes in low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG). Multiple linear regression models, including initial BMI, on-treatment weight change, age, gender, and baseline lipid values, were fitted to control the influences exerted by these variables on each other.

RESULTS

Reductions in LDL-C after diet plus fibrate treatment for 12 weeks were inversely related to initial BMI and to TG levels at baseline, and were positively associated with baseline LDL-C concentrations and with on-treatment weight change (P < 0.001 for all analyses). Decreases in TG related negatively with initial BMI (P = 0.012), and positively with weight loss (P = 0.011) and TG at baseline (P < 0.001). Increases in HDL-C were negatively associated with initial BMI (P = 0.012) and with baseline TG (P < 0.001).

CONCLUSIONS

The LDL-C lowering efficacy of fibrates is inversely related to initial BMI, and is positively associated with on-treatment weight loss.

Usefulness of fluoxetine in obese non-insulin-dependent diabetics: a multicenter study

Weight reduction is essential in the management of most non-insulin-dependent diabetics, but this therapeutical goal is difficult to obtain. In this double-blind parallel study, 82 non-insulin-dependent diabetics, moderately obese (BMI = 30 - 39 kg/m2), were given for an 8-week period either placebo (P) or fluoxetine (F), a specific serotonin reuptake inhibitor, in addition to their usual antidiabetic treatment. Thirty-nine of them received 60 mg fluoxetine a day and 43 were given the placebo. At admission, both groups had similar weight excess, metabolic control and serum lipid values. In comparison with the P-treated subjects, those treated with fluoxetine (F) lost more weight after 3 weeks (-1.9 vs. -0.7 kg, p < -0.0009) and after 8 weeks (-3.1 vs. -0.9 kg, p < 0.0007). Fasting blood glucose decreased in group F after 3 weeks (-1.5 vs -0.4 mmol/L, p < 0.003) and after 8 weeks (-1.7 vs. -0.02 mmol/L, p < 0.0004). HbAlc decreased from 8.5% to 7.7% in group F and from 8.6% to 8.3% in group P (p = 0.057). Mean triglyceride level was also reduced in group F after 8 weeks (p = 0.042). Fasting C-peptide did not change in either group, but fasting insulin values decreased in group F after 3 weeks (p < 0.02) and after 8 weeks (p < 0.05). The insulin/C-peptide molar ratio decreased significantly in group F after 3 weeks (p < 0.04) and after 8 weeks (p < 0.05) in comparison with group P. The drug was generally well tolerated and no major side effects were reported. In conclusion, the addition of fluoxetine to the usual oral hypoglycemic agent therapy might be beneficial in obese non-insulin-dependent diabetics, at least on a short-term basis.

Effects of pravastatin on lipid levels, in vitro oxidizability of non-HDL lipoproteins and microalbuminuria in IDDM patients

The effects of pravastatin on plasma lipid levels, in vitro oxidizability of the non-HDL fraction, metabolic control, urinary albumin excretion, and four serum enzymes (SGPT, SGOT, GT and CPK) were studied in 20 insulin-dependent diabetic patients (IDDM) with incipient nephropathy. The patients were divided into two groups and the study was carried out by a crossover design. After 12 weeks pravastatin treatment (20 mg daily), plasma cholesterol, LDL-cholesterol and apolipoprotein B (Apo B) decreased by 22, 19 and 15%, respectively. The thiobarbituric acid reactive substances (TBARS) formation and the oxidation lagtime of the non-HDL fraction during the in vitro incubation with copper were not changed before and after treatment. The HbA1c and blood glucose levels, urinary albumin excretion, SGOT, SGPT and GT were not influenced by pravastatin treatment. CPK activity was elevated after 12 weeks of pravastatin treatment, and this elevation persisted even after the 12 weeks placebo period. So, pravastatin could be used as an effective drug for IDDM patients with incipient nephropathy, but close monitoring of the CPK activity is recommended.

Lipid and lipoprotein changes after long-term weight reduction: the influence of gender and body fat distribution

OBJECTIVES

This study was designed: 1) to evaluate the effect of weight loss on body fat distribution, 2) to determine whether indices of body fat distribution can be considered as a prognostic indicator for the ability to lose weight and 3) to evaluate whether a change of body fat distribution is associated with changes in plasma glucose, lipids and lipoproteins in both sexes in order to evaluate a gender difference.

METHODS

63 obese subjects (41 women and 22 men) were treated on an outpatient basis with an energy-reduced, protein-enriched low calorie diet (3150-4200 kJ/day) for a 6-month period. They were divided in different groups according to gender and body fat distribution using the waist-to-hip circumference ratio.

RESULTS

Body fat topography can be altered by dieting, but not by more than it increases when a person gains weight. Body fat distribution seems to be a significant prognostic indicator for the ability to lose weight in women but not in men. Although body weight and the waist-to-hip circumference decreased significantly, no relationships were found between percent decrease in these parameters and percent changes in plasma glucose, lipids and lipoproteins.

CONCLUSION

We conclude that an important caloric deficit may lead to a series of metabolic improvements but that gender and the type of fat distribution are important confounding factors in the prediction of metabolic success.

Assessment of body composition by skinfold anthropometry and bioelectrical impedance technique: a comparative study

Both skinfold anthropometry and bioelectrical impedance are indirect, simple bedside methods to assess body composition. It is not clear, however, whether the results of these methods are comparable. In this study, body composition was determined in 449 subjects by skinfold anthropometry and by bioelectrical impedance. Percentage of body fat ranged from 8.0% to 47.5% with the skinfold technique and from 0.6% to 78.5% with bioelectrical impedance. Linear regression analysis showed a significant positive correlation (r = .84; p < .0001) between the results of both techniques. However, plot analysis showed that, in comparison with bioelectrical impedance, skinfold measurements overestimate fat mass in the lower weight range and underestimate it in obese subjects. We conclude that the results of skinfold anthropometry and bioelectrical impedance are not comparable, especially in the extreme ranges of body fat. At the present time, other, more rigorous techniques are necessary to assess body composition accurately, in the extreme ranges of body fat in particular.

Operations for failed vertical banded gastroplasty

Although vertical banded gastroplasty is considered as a safe and efficient bariatric procedure, reoperation rates either because of failure, or the induction of unacceptable side effects are important. In this study we evaluated 54 obese subjects with a history of vertical banded gastroplasty. One patient (2%) died postoperatively due to pulmonary embolism. Seven patients (13%) underwent a reoperation. A new vertical banded gastroplasty because of dilatation of the pouch with weight regain resulted in a loss of 26% of the initial weight after 3 years (1 patient). The vertical staple line disrupted in 4 patients: restapling failed after 1.5 year (1 patient), conversion into a gastric bypass resulted in a loss of only 12% of the initial weight after 3 years (1 patient), conversion into a biliopancreatic diversion resulted in a loss of 43 and 32% of body weight after 18 and 6 months, respectively (2 patients). In 2 cases a Nissen fundoplication was performed with good result for reflux oesophagitis. Since regastroplasty was not entirely successful in our hands, we consider biliopancreatic diversion as the method of choice for failed vertical banded gastroplasty.

A rapid and simple method for measuring the susceptibility of low-density-lipoprotein and very-low-density-lipoprotein to copper-catalyzed oxidation

Much evidence has accumulated to suggest a role for the oxidation of low-density-lipoprotein (LDL) and very low-density-lipoprotein (VLDL) in the pathogenesis of atherosclerosis. The susceptibility of lipoprotein to copper-catalyzed oxidation is often used to evaluate its oxidizability. A method was developed which isolates the non-high-density lipoprotein (non-HDL) fraction and removes EDTA by a dextran-magnesium precipitation method. The oxidizability of this fraction is evaluated by monitoring the fluorescence and measuring thiobarbituric acid reactive substances (TBARS) at different intervals of incubation. Those parameters reflect apolipoprotein B (apo B) modification and lipid degradation during LDL and VLDL oxidation. Our assay is sensitive enough to study factors which can influence the oxidizability of LDL and VLDL. The method is simple, rapid and can be easily conducted in a routine laboratory.

Insulin antibodies before and 1 year after the change-over from U40 to U100 insulin preparations in Belgium

In 1991, Belgium realized, on a national level, a change-over from U40 to U100 insulin. We took advantage of this evolution to investigate the consequences of changing the concentration of insulin. The patients' weight, daily insulin dosis, insulin binding-capacity of plasma and glycated hemoglobin HbA1c were registered before, and after the change of concentration. Overall, none of these parameters underwent an obvious change, except for the percentage of insulin binding that significantly decreased after the adaptation. Especially in the range of 40% or more insulin binding, the decrease becomes very pronounced. In conclusion, changing the insulin concentration from U40 to U100, did not lead to any harmful clinical consequence. On the contrary, a positive influence of this adaptation, in terms of decreased amount of insulin antibodies was suggested. Probably this decrease is not clinically relevant, since neither the glycated hemoglobin, nor the total daily insulin dose underwent a similar change.

Fluoxetine therapy in obese diabetic and glucose intolerant patients

A double-blind placebo-controlled trial was conducted, involving 97 obese diabetic and glucose intolerant patients receiving either 60 mg fluoxetine daily (47 patients) or a placebo (50 patients); a similar calorie-restricted diet was prescribed to all patients. Weight loss was significantly higher in the fluoxetine-treated patients, whose diabetic status improved. Drop-out rate was not significantly different for both groups of patients.

Impact of obesity on resting metabolic rate and glucose-induced thermogenesis in non-insulin dependent diabetes mellitus

Previous studies have shown that patients with non-insulin dependent diabetes mellitus (NIDDM) have a higher metabolic rate (RMR) and lower thermogenesis in comparison with persons with normal glucose tolerance. It is not clear whether this impairment is due to the diabetic state per se or to the association of the diabetic and obese state. The impact of obesity on RMR and glucose-induced thermogenesis (GIT) was studied in seven non-obese and 12 obese men with NIDDM; the results are compared with a group of six obese men with normal glucose tolerance. RMR was significantly higher for the obese subjects (P < 0.02) but this difference disappeared after correction for fat-free mass. Mean GIT was significantly lower (P < 0.01) in the diabetic patients, whether they were obese or non-obese. The results of this study indicate that for patients with NIDDM, the impact of obesity on both RMR and GIT is rather limited. On the other hand, a significant influence of glucose tolerance on GIT in obese patients could be demonstrated.

Magnesium and obesity: influence of gender, glucose tolerance, and body fat distribution on circulating magnesium concentrations

Obesity is characterized by a high risk for glucose intolerance and cardiovascular disease. Since magnesium deficiency or depletion have often been associated with both pathologies, is of interest to study magnesium status in severely obese subjects before any form of treatment. Negative magnesium balances have been described in overweight persons submitted to total starvation, hypocaloric diets, and obesity surgery. For this reason 80 non-diabetic obese men and 118 age-matched obese women were studied. Serum and erythrocyte magnesium concentrations were significantly higher in the male population but the mean values were not suggestive of a magnesium deficit before any form of treatment was started. Since metabolic abnormalities and cardiovascular risk are greater in patients with upper body fat distribution (UBFD) both sexes were subdivided according to "waist-to-hip" circumference ratio. No difference could be shown in the obese men but in women, UBFD subjects showed higher basal insulin levels and increased erythrocyte magnesium concentration as compared to those with classical gynoid fat distribution. A 75 g oral glucose tolerance test enabled the subjects to be subdivided into those with normal or impaired glucose tolerance (IGT). The IGT group in both sexes was older and more obese. Mean values of serum magnesium and erythrocyte magnesium were not decreased despite the more pronounced insulin resistance in the IGT group. However a significant negative correlation was found between fasting blood sugar/insulinaemia and erythrocyte magnesium, showing that this middle-aged obese population can maintain normal circulating levels of magnesium, in contrast to type II diabetics or older subjects where for other reasons (urinary losses or decreased intake) magnesium status is interfered with.

Effects of acarbose on carbohydrate metabolism, electrolytes, minerals and vitamins in fairly well-controlled non-insulin-dependent diabetes mellitus

The alpha-glucosidase inhibitor acarbose induces a reversible delay of carbohydrate digestion. This action represents a new therapeutic option for the treatment of diabetes mellitus. The current investigation is a prospective, randomized double-blind crossover trial in 24 non-insulin dependent diabetics, fairly well controlled on diet alone or diet plus sulphonylurea. In periods of 10 weeks, the patients received successive treatment with acarbose and placebo in random order. A significantly lower HbA1 level and urinary glucose excretion were shown during acarbose as compared to placebo. The other parameters of diabetic control remained unchanged. Acarbose induced no significant alterations in the concentrations of important electrolytes, iron, vitamin B12 and folic acid. Although no major side effects occurred, meteorism and flatulence were frequent complaints. These data suggest that acarbose, in a dosage of 3 x 100 mg/day, is a safe drug, with slight beneficial effect on diabetic metabolic control.

Importance of glucagon as a determinant of resting metabolic rate and glucose-induced thermogenesis in obese women

The long-term results of dietary treatment for obesity are often very poor. To predict the effect of a hypocaloric diet, it may be important to consider factors that could influence energy expenditure, especially those altered in obesity. Elevated plasma levels of glucagon are associated with obesity. In this study, the relationship of glucagon to resting metabolic rate (RMR) and glucose-induced thermogenesis (GIT) has been investigated. RMR and GIT, after ingesting 100 g glucose, were measured by indirect calorimetry in 25 obese premenopausal women (body mass index [BMI], 37.2 +/- 4.7 kg.m-2). RMR was significantly related to fat-free mass (FFM) (r = .50, P less than .005). A significant relation could be found between RMR and fasting glucagon levels (r = .36, P less than .05). Plasma glucose and insulin levels were not predictive for RMR. Mean GIT increased with increasing waist-hip circumference ratio (WHR) (r = .71, P less than 0.0001), confirming previous findings of our group. No relation was found between GIT and glucagon levels, neither in the basal state nor after glucose. The only important metabolic determinant was area under the curve (AUC) for glucose (r = .45, P less than .01), suggesting a higher GIT in obese women with impaired glucose intolerance. This suggests that the control of energy metabolism by the concentration of glucagon may be more important in the fasting state than after a meal. Plasma glucagon concentration should be considered in the evaluation of RMR.

Decreased hepatic insulin extraction in upper body obesity: relationship to unbound androgens and sex hormone binding globulin

Hyperinsulinemia is a well-recognized entity of simple obesity. It is demonstrated that hyperinsulinemia is associated with upper body fat and fat cell hypertrophy. Androgen excess and lower levels of sex hormone binding globulin (SHBG) may produce fat cell hypertrophy and hyperinsulinemia as well. We measured serum insulin and C-peptide levels during an OGTT in two groups of obese premenopausal women to determine whether the hyperinsulinemia is due to hypersecretion or due to a diminished hepatic extraction of insulin. In this study, we found no correlation between the insulin and C-peptide levels or their ratio and the degree of obesity. However, a significant correlation was found between the waist-to-hip circumference ratio (WHR), used as an index of body fat distribution, and the areas of insulin (r = 0.55; P less than 0.001) and C-peptide (r = 0.51; P less than 0.001). SHBG and free androgen index (FAI) were also significantly related to these areas. The peripheral C-peptide/insulin molar ratio has been assumed to reflect changes in hepatic insulin extraction while the corrected C-peptide response reflects beta-cell function. WHR was negatively related to this ratio (r = -0.44; P less than 0.005) and SHBG showed a positive correlation (r = 0.34; P less than 0.05). Stepwise multiple regression analysis revealed that the 2-h insulin and C-peptide values and both curve areas can be explained up to 40-80% by sex hormones and anthropometric variables. Also the C-peptide/insulin molar ratio is dependent in a first step on WHR (r2 = 0.23; P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Forty years of neuroglycopenia: neuropsychiatry for the internist

The case of a 65-year-old patient with an insulin-secreting pancreatic tumour and a 40-year history of neuropsychiatric disease is reported. The physiopathology and clinical features of acute, subacute, and chronic neuroglycopenia in patients with endogenous insulin hypersecretion are discussed.

Blood rheology during an intensified conventional insulin treatment (ICIT) in insulin-dependent diabetes

Fifteen insulin-dependent diabetes mellitus (IDDM) patients with minor diabetic complications underwent an intensified conventional insulin treatment (ICIT) program consisting of multiple daily insulin injections with an insulin pen. Blood viscosity parameters were measured before the start, after 6 weeks, 1 and 2 years with a Contraves LS30 viscosimeter. At the start several rheological parameters were disturbed in the diabetic subjects. Mean total hemoglobin A1 (HbA1) significantly (at least P less than 0.05) decreased while the plasma free insulin level significantly increased (at least P less than 0.05) under ICIT. During the first 6 weeks hematocrit (P less than 0.01), plasma (P less than 0.05), whole blood (P less than 0.05) and erythrocyte (P less than 0.01) viscosities significantly decreased but they increased again at 1 year of ICIT. Only plasma viscosity (P less than 0.05) remained below the starting value after 1 and 2 years. Normalization of the blood sugar level improved plasma and whole blood viscosity by an insulin-induced dilution phenomenon after 6 weeks. The persisting decrease in plasma viscosity was accompanied by a significant alteration of the plasma protein profile. These findings suggest that metabolic status influences blood rheology in IDDM patients but by different mechanisms on a short- or long-term basis.

Effect of oral antidiabetic drug withdrawal in type 2 diabetes

Oral hypoglycaemic agents were withdrawn in 22 Type 2 diabetic patients to establish whether long-term use of these products is really necessary. Discontinuation of the drugs resulted in significant increases of HbA1 (8.1 +/- 1.1 to 11.3 +/- 2.4%) and fasting (9.1 +/- 2.1 to 13.6 +/- 4.0 mmol l-1) and postprandial (12.3 +/- 3.0 to 18.7 +/- 5.7 mmol l-1) plasma glucose levels after 12 weeks (all p less than 0.01). This was associated with a reduction of fasting (12.4 +/- 6.2 to 8.0 +/- 3.4 mU l-1) and postprandial (35.7 +/- 13.2 to 19.3 +/- 13.4 mU l-1) serum insulin concentrations, and fasting (0.8 +/- 0.4 to 0.5 +/- 0.2 nmol l-1) and postprandial (1.8 +/- 0.6 to 1.0 +/- 0.5 nmol l-1) serum C-peptide concentrations (all p less than 0.01). Only one patient did not show metabolic deterioration after drug withdrawal. In multivariate analysis no significant correlations could be found between measures of baseline diabetic control and the deterioration after drug withdrawal.

Effect of a long term very low calorie diet on glucose/insulin metabolism in obesity. Influence of fat distribution on hepatic insulin extraction

Hyperinsulinemia is a well-recognized entity of simple obesity. In upper body obesity a diminished hepatic extraction of insulin contributes to the hyperinsulinemia. SHBG levels correlate (r = 0.34, P less than 0.05) with the c-peptide/insulin molar ratio. After long term weight reduction by very low calorie dieting, not only fasting and total area insulin decreased significantly, also hepatic insulin extraction improved markedly. This observed change was related to an increase in SHBG both for men and women.

Short and long term effects of a very low calorie diet on resting metabolic rate and body composition

Short and long term effects of a protein sparing modified fast (PSMF) diet on resting metabolic rate (RMR) and body composition were investigated. During a period of 6 months on diet, RMR decreased significantly, both in absolute value and after correction for fat-free mass (FFM). Short term evaluation with this type of diet showed no decrease in RMR. The results from this study indicate that the fall in RMR associated with a PSMF diet (weight loss) is not due to an acute adaptation to the lower energy intake. Changes in FFM are important in the change in RMR, but other factors have to be involved.

Apolipoprotein concentrations in obese subjects with upper and lower body fat mass distribution

In order to assess the relationship between obesity and serum lipids, a homogenous group of adult men and premenopausal women is assessed for body mass index, body fat distribution reflected by the waist/hip ratio (WHR), serum lipid parameters and apolipoproteins. Body fat distribution is distinguished in an abdominal and gluteal-femoral type using a cut-off point of 1.00 for the ratio of waist-to-hips girth for men. In women the cut-off value is considered as 0.80 but was also evaluated when considered as 0.85. In the next step tertiles for WHR are created to show a graded relationship between WHR and lipoprotein fraction. The results indicate that WHR is an important determinant for most atherosclerosis-related lipids and apoproteins: in both men (P less than 0.05) and women (P less than 0.005) WHR is significantly correlated with apolipoprotein B. Using multiple regression analysis, in women WHR seems to be the most important dependent variable, where body mass index is not significantly contributing to the explained variance. In men, however, besides WHR age is the most significant variable, although age distribution is similar in men and women. Using tertiles of WHR, we show a clear graded relationship with most lipids and lipoproteins; this gives additionally an argument to confirm that in women WHR = 0.80 is the most accurate cut-off value for abdominal obesity. This study demonstrates that both obese men and women with an abdominal fat mass distribution show a lipid and apoprotein profile that is less favorable than that seen in gluteal-femoral obese subjects insofar as the risk of coronary artery disease is concerned.

Relationship of body fat distribution pattern to atherogenic risk factors in NIDDM. Preliminary results

Because recent knowledge indicates that the distribution of fat deposits in men may be a better predictor of cardiovascular disease than the degree of obesity alone, some risk factors for atherosclerosis were evaluated in 51 middle-aged men with non-insulin-dependent diabetes mellitus. Abdominal adiposity (waist/hip ratio, WHR) was related to parameters of metabolic control, lipid parameters, and known vascular complications in three different groups. In groups with abdominal obesity, mean annual hemoglobin A1 was significantly (P less than .01) higher than in patients without an abdominal fat distribution. Atherogenic index was significantly increased in the group with the highest WHR and high-density lipoprotein cholesterol (HDL-chol) levels were significantly decreased in both groups with upper-body fat distribution. The frequency of peripheral vascular disease, coronary ischemic heart disease, and hypertension was most prominent in diabetic subjects with an abdominal fat mass distribution. A highly significant (P less than .001) correlation was present between WHR and HDL-chol and WHR and the total-cholesterol/HDL-chol ratio; this significant correlation remains after correction for body mass index. A similar correlation could be found between WHR and systolic and diastolic blood pressures. These results demonstrate an association of excess abdominal fat, even without manifest obesity, with worse diabetes metabolic control, cardiovascular complications, and blood lipid levels actually considered to play an important role in atherogenesis.

Evaluation of magnesium before and after jejuno-ileal versus gastric bypass surgery for morbid obesity

Jejuno-ileal bypass surgery for morbid obesity can cause metabolic and electrolyte imbalances. Another case of severe, symptomatic magnesium deficiency after jejuno-ileal bypass surgery is described. This complication was not encountered in a prospective evaluation of the magnesium status after gastric restrictive bypass surgery. Significant (p less than 0.005) body weight decrease was not accompanied by any (serum, erythrocyte or urinary) evidence of magnesium loss for 12 months after surgery.

Changes in vitamin E status during obesity treatment

The effects of vitamin E on platelet function and erythrocyte membrane rigidity are extensively described. Little is known, however, about the vitamin E status in an obese population and about the effect of weight loss on it. This study evaluates the changes in vitamin E status during obesity treatment in 8 morbidly obese females. They received a protein-sparing modified fast (PSMF) diet for a period of 5 weeks; mean vitamin E supplementation did not exceed the recommended daily allowance (8 mg of alpha-tocopherol equivalents). During the investigated period plasma vitamin E levels increased (p less than 0.02), while there was a slight decrease in plasma cholesterol. The rise in total tocopherol/total cholesterol ratio was highly significant (p less than 0.002). Both the experimental design and the results are comparable with previously reported data in hypothalamic obese mice. It is, therefore, suggested that the hypothalamic obese mouse is a convenient animal model for the study of vitamin E nutritional status in obesity.

[Effects of the relative enrichment of polyunsaturated fatty acids in insulin-dependent diabetic patients]

Twenty seven insulin-dependent (type I) diabetic patients (mean +/- SD; age: 30 y +/- 12; duration of diabetes 12 y +/- 2.5) were treated for at least 12 weeks with two regimens differing only in their fatty acid composition. The energy in the diabetic diet was contributed 50%-55% by carbohydrates, 15%-20% proteins and 30% by lipids. The diet high in poly-unsaturated-fatty-acids (PUFA) contained 61% PUFA and 17% of saturated fatty acids (SFA) while the diet low in PUFA was composed of only 4% PUFA and of 65% SFA. Group I followed the diet high in SFA for six weeks and then switched to the diet high in PUFA. Group II followed the diets in the reverse order. After six weeks of treatment with the high PUFA diet, total serum cholesterol decreased from 195 mg % +/- 11.1 mg % in group I and 179 mg% +/- 12.1 % in group II to 169 mg +/- 10.2 and 142 mg % +/- 8.1 respectively. This fall was mainly due to highly significant decrease in LDL-Cholesterol. VLDL-cholesterol and HDL-cholesterol in both groups remained almost unchanged. In group I a significant decrease in serum triglyceride from 88 mg % +/- 9.2 to 70 mg % +/- 10.9 was found after six weeks of treatment with the high PUFA diet. The atherogenic index decreased significantly in both groups. Six weeks of treatment with the high SFA diet reversed these results. Serum cholesterol increased mainly due to the highly significant increase in LDL-cholesterol, VLDL-cholesterol, HDL-cholesterol and triglycerides remaining unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

A lesson from IVF endocrinology: the importance of the follicular phase to success and failure in non-IVF cycles

Sixty-three patients treated with exogenous gonadotropins for a total of 232 non-IVF cycles were monitored by serum E2 and/or total urinary estrogen excretion. The endocrine profile of follicular phase during HMG-HCG stimulation was evaluated with regard to an effect on the pregnancy rate. Six different follicular phase patterns were observed: A-profiles (daily exponential increase of sE2 or total urinary estrogen values followed by a sustained exponential increase on the day after HCG injection) seem to be necessary to obtain pregnancy, being followed by conception in 21.5% of all cases. Other profiles have lower conception rate (10%); no conception occurred when non exponential E2 rise was observed. The different responses are not related to total dosage of HLG administered. Patients who were treated for hypogonadotropic hypogonadism had a high pregnancy rate (80%) even in absence of post-HCG estrogen rise (G-endocrine profiles. Women aged 35 years must have significantly higher doses of gonadotropins to obtain A-profiles. Monitoring by E2 seems to be more adequate than the TUE only (conceptual pregnancy rate/cycle of 15.25%, versus 10.34%). In conception cycle, midluteal E2/P ratio never exceeds 50.