Effect of diet-induced weight loss on plasma apelin and cytokine levels in individuals with the metabolic syndrome

BACKGROUND AND AIMS

Adipose tissue is an active endocrine organ that secretes signaling molecules involved in the regulation of insulin sensitivity, food intake and inflammation. Apelin is a peptide secreted by adipose tissue that has been shown to modulate cardiovascular tone in animals. The aim of this study was to measure abdominal fat, blood pressure and circulating apelin, adiponectin, leptin, ghrelin, TNF-alpha and IL-6 levels in patients with the metabolic syndrome after a diet-induced weight loss.

METHODS AND RESULTS

35 obese individuals with the metabolic syndrome underwent an 8-week very-low-calorie diet (VLCD) and a 6-month weight maintenance period (WM) with 120mg orlistat or placebo administered 3 times daily. VLCD and WM (-15.1+/-1.0kg) decreased mean arterial pressure (MAP), insulin, leptin, triglycerides and visceral and subcutaneous adipose tissue. Moreover, adiponectin increased in response to the weight loss. However, the overall changes in plasma apelin, TNF-alpha and IL-6 were non-significant. A correlation between plasma apelin and TNF-alpha was observed at baseline (0.41, p<0.05), and the minor changes in plasma apelin levels were associated with changes in BMI during VLCD and MAP and TNF-alpha during VLCD and WM periods.

CONCLUSION

Despite reductions in BMI, body adiposity, MAP and enhancement of glucose metabolism and adiponectin in response to weight loss, no significant changes in plasma apelin, TNF-alpha and IL-6 were observed. However, apelin significantly correlated with TNF-alpha and MAP. These results suggest that apelin may not be that strongly correlated with the fat mass as an adipokine like the more abundant adipokines adiponectin or leptin and it might be involved in the regulation of inflammation and cardiovascular tone.

11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study)

BACKGROUND

The introduction of second-generation antipsychotic drugs during the 1990s is widely believed to have adversely affected mortality of patients with schizophrenia. Our aim was to establish the long-term contribution of antipsychotic drugs to mortality in such patients.

METHODS

Nationwide registers in Finland were used to compare the cause-specific mortality in 66 881 patients versus the total population (5.2 million) between 1996, and 2006, and to link these data with the use of antipsychotic drugs. We measured the all-cause mortality of patients with schizophrenia in outpatient care during current and cumulative exposure to any antipsychotic drug versus no use of these drugs, and exposure to the six most frequently used antipsychotic drugs compared with perphenazine use.

FINDINGS

Although the proportional use of second-generation antipsychotic drugs rose from 13% to 64% during follow-up, the gap in life expectancy between patients with schizophrenia and the general population did not widen between 1996 (25 years), and 2006 (22.5 years). Compared with current use of perphenazine, the highest risk for overall mortality was recorded for quetiapine (adjusted hazard ratio [HR] 1.41, 95% CI 1.09-1.82), and the lowest risk for clozapine (0.74, 0.60-0.91; p=0.0045 for the difference between clozapine vs perphenazine, and p<0.0001 for all other antipsychotic drugs). Long-term cumulative exposure (7-11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0.81, 0.77-0.84). In patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted (HR for trend per exposure year 0.991; 0.985-0.997).

INTERPRETATION

Long-term treatment with antipsychotic drugs is associated with lower mortality compared with no antipsychotic use. Second-generation drugs are a highly heterogeneous group, and clozapine seems to be associated with a substantially lower mortality than any other antipsychotics. Restrictions on the use of clozapine should be reassessed.

FUNDING

Annual EVO Financing (Special government subsidies from the Ministry of Health and Welfare, Finland).

Plasma aldosterone to renin ratio predicts treatment response in primary aldosteronism: Is volume loading needed?

Volume loading is considered the golden standard of the confirmatory tests in the diagnostics of primary aldosteronism (PA). However, it is time-consuming, and it is unclear to what extent it improves the diagnostics of PA in comparison to simple screening tests. To study this question, the diagnostics with and without oral sodium loading (OSL) were evaluated by receiver operating characteristic curves analyses in 77 consecutive OSL patients. The final diagnosis was essential hypertension in 39 cases and PA in 38 cases, determined by review of the patient records, biochemical tests, imaging findings, and the response to therapy with spironolactone and/or operation. Plasma aldosterone-to-renin-activity ratio (ARR) and daily urinary aldosterone had a good diagnostic ability that did not significantly improve by accomplishing OSL. Cut-off values with optimal sensitivity and specificity were >or=1050 pmol/l per ng/ml/h for upright ARR, and >or=45 nmol/day for daily urinary aldosterone. To conclude, carefully conducted outpatient tests are sufficient for the diagnostics of PA, when the diagnosis is justified by the positive response to treatment. However, volume loading serves as an additional diagnostic tool in the most problematic cases, improving slightly the discriminative ability of urinary aldosterone determination.

Association of depressive symptoms and metabolic syndrome in men

OBJECTIVE

To explore the relationship between several indicators of depression and metabolic syndrome (MetS).

METHOD

A population-based sample with high (HMS group) or low (LMS group) levels of mental symptoms, including those of depression, in three follow-ups participated in a clinical examination in 2005 (n = 223). MetS was determined according to the NCEP criteria.

RESULTS

The prevalence of MetS was 49% in men and 21% in women. Men with MetS had higher rates of major depressive disorder than other men. They also displayed higher Hamilton Rating Scale for Depression (HDRS) scores and more often signs of suicidality. In logistic regression analyses, higher HDRS scores (OR 1.31, 95% CI 1.04-1.64) and belonging to the HMS group (OR 10.1, 95% CI 1.98-51.3) were independent associates for MetS but only in men.

CONCLUSION

The results highlight that there is an association between long-term depressive symptoms and the emergence of MetS, especially in men.

Leisure-time physical activity, cardiorespiratory fitness and feelings of hopelessness in men

BACKGROUND

Leisure-time physical activity (LTPA) and cardiorespiratory fitness contribute to mental health. Hopelessness has been linked to impaired mental health, cardiovascular events and mortality. Previous studies have focused on physical exercise and depression. We examined the associations of LTPA and cardiorespiratory fitness with feelings of hopelessness.

METHODS

In this cross-sectional study leisure-time physical activity, maximal oxygen uptake (VO2max), hopelessness and cardiovascular risk factors were assessed in a population-based cohort of 2428 men aged 42 - 60 years old at baseline.

RESULTS

Men feeling more hopeless about their future and reaching goals were less physically active, less fit and had a higher prevalence of many cardiovascular risk factors than men with lower levels of hopelessness. In a logistic regression model adjusted for age, smoking, alcohol consumption, cardiovascular disease and socioeconomic status, men engaging in less than 60 min/week of moderate-to-vigorous LTPA were 37% (95% CI 11 - 67%) more likely to feel hopeless than those engaging in at least 2.5 h/wk of LTPA. After further adjusting for elevated depressive symptoms the association of LTPA and hopelessness remained significant. VO2max was also associated with hopelessness, but not after adjustment for depressive symptoms.

CONCLUSION

Moderate and vigorous LTPA and cardiorespiratory fitness were inversely associated with hopelessness in these middle-aged men. These findings suggest that physical inactivity and poor cardiorespiratory fitness is an important associate of hopelessness, a distinct element of low subjective well-being.

Persistent pain at multiple sites--connection to glucose derangement

The aim of this study was to analyse the prevalence of prediabetes and diabetes among subjects with daily chronic widespread pain (DCWP). In the multivariate analysis, DCWP was significantly associated with prediabetes and diabetes. Persistent chronic pain at multiple sites may be an additional symptom of prediabetes and diabetes.

Hypogonadism, decreased sexual desire, and long-term depression in middle-aged men

INTRODUCTION

In middle-aged men, the associations between long-term depressive symptoms and circulating testosterone levels are poorly known, although it is known that testosterone levels decrease with age.

METHODS

A health questionnaire was mailed to a population-based sample from the National Population Register in 1998, 1999, and 2001. Based on their self-reported mental symptoms, a total of 116 men were selected for clinical examination in 2005. Half of them had high and the others low levels of adverse mental symptoms in all three previous follow-ups. A structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-IV was performed. Depressive symptoms were assessed with the Beck Depression Inventory (BDI) and the Hamilton Depression Rating Scale (HDRS). The Aging Males' Symptoms scale was also compiled and testosterone levels were determined.

RESULTS

In the entire study sample, serum free testosterone levels correlated negatively with both BDI and HDRS scores. In the hypogonadism group (based on free testosterone, 19.8% of the sample), clinically significant depression (BDI score > or = 13) was more than three times as frequent as in the other men (34.8% vs. 10.4%), the odds ratio after multiple adjustments being 4.98 (95% confidence interval 1.66-14.95). A decrease in sexual desire was common in hypogonadism (36%). Nevertheless, it also associated with clinically significant depression, irrespective of free testosterone levels.

DISCUSSION

Long-term and current depressive symptoms, a decreased sexual desire, and low serum free testosterone levels are associated in middle-aged men. Hypogonadism per se and as a cause of decreased sexual desire may be a contributory and possibly treatable factor underlying male depression.

CONCLUSIONS

The findings highlight the need for hormonal status assessment in middle-aged depressive men.

Hopelessness — novel facet of the metabolic syndrome in men

Aims: Recent studies have shown that lack of hope is linked to cardiovascular morbidity and mortality. Little is known, however, about the relationship of hopelessness and the metabolic syndrome. The aim of this study is to examine the association of hopelessness and the metabolic syndrome. Methods: This cross-sectional study examines the relationship between hopelessness and the metabolic syndrome as defined by the National Cholesterol Education Program in a population-based cohort of 1743 non-diabetic men aged 42, 48, 54 and 60 years old at baseline (1984—89). Hopelessness was measured by one's expectations about the future and reaching goals. Results: In simple age-adjusted univariate analyses the prevalence of the metabolic syndrome, many of its components and other cardiovascular risk factors were more common in men with higher levels of hopelessness. In a logistic regression model adjusted for age, smoking, alcohol consumption, cardiovascular disease, adult socioeconomic status and physical activity, men in the highest third were 2.1 (95% CI 1.3—3.2) times more likely to have the metabolic syndrome than those in the lowest third. After further adjusting for body mass index and elevated depressive symptoms the respective figures were 1.9 (95% CI 1.2—3.1) and 2.1 (95% CI 1.4—3.4). Conclusions: Hopelessness was strongly associated with the metabolic syndrome in these middle-aged men, independent of other depressive symptoms and traditional cardiovascular risk factors. These findings suggest that hopelessness is very closely related to the metabolic syndrome. Therefore lifestyle management of the metabolic syndrome should also take into account patients' expectations more thoroughly than hitherto acknowledged.

Downregulation of genes involved in NFkappaB activation in peripheral blood mononuclear cells after weight loss is associated with the improvement of insulin sensitivity in individuals with the metabolic syndrome: the GENOBIN study

AIMS/HYPOTHESIS

The transcription factor nuclear factor-kappa-B (NFkappaB) is implicated in inflammatory responses, obesity and the metabolic syndrome, while immune cells appear to play a central role in mediating insulin resistance and can be used as a model to study inflammation and its relationship with insulin resistance. In peripheral blood mononuclear cells of overweight participants with the metabolic syndrome, we evaluated (1) the effect of diet-induced weight loss on the expression of genes involved in NFkappaB activation and (2) their association with insulin sensitivity. The genes studied were: TNF receptors TNFRSF1A and TNFRSF1B, and IL1R1, TLR4, TLR2, ICAM1, CCL5 and IKBKB.

METHODS

We analysed data from 34 overweight participants with abnormal glucose metabolism and the metabolic syndrome, who were randomised to a weight-reduction (n = 24) or control group (n = 10) for 33 weeks. The mRNA expression was measured using real-time PCR. Measures of insulin and glucose homeostasis were assessed by IVGTT and OGTT.

RESULTS

In general, the genes studied were downregulated after weight loss intervention. The changes in TLR4, TLR2, CCL5 and TNFRSF1A mRNA expression were associated with an increase in insulin sensitivity index independently of the change in waist circumference (p < 0.05). The change in IKBKB expression correlated with most of the changes in gene expression in the weight-reduction group.

CONCLUSIONS/INTERPRETATION

These results suggest that proteins encoded by CCL5, TLR2 and TLR4, and TNFRSF1A might contribute to insulin-resistant states that characterise obesity and the metabolic syndrome.

TRIAL REGISTRATION

ClinicalTrials.gov NCT 00621205.

Electrocardiographic alterations during hyperinsulinemic hypoglycemia in healthy subjects

BACKGROUND

We evaluated the arrhythmogenic potential of hypoglycemia by studying electrocardiographic (ECG) changes in response to hyperinsulinemic hypoglycemia and associated sympathoadrenal counterregulatory responses in healthy subjects.

METHODS

The study population consisted of 18 subjects, aged 30-40 years. Five-minute ECG recordings and blood samplings were performed at baseline and during the euglycemic and hypoglycemic hyperinsulinemic clamp studies. PR, QT, and QTc intervals of electrocardiogram and ECG morphology were assessed from signal-averaged ECG.

RESULTS

Although cardiac beat interval remained unchanged, PR interval decreased (P < 0.01) and QTc interval (P < 0.001) increased in response to hyperinsulinemic hypoglycemia. Concomitant morphological alterations consisted of slight increases in R-wave amplitude and area (P < 0.01 for both), significant decreases in T-wave amplitude and area (P < 0.001 for both), and moderate ST depression (P < 0.001). Counterregulatory norepinephrine response correlated with amplification of the R wave (r =-0.620, P < 0.05) and epinephrine response correlated with flattening of the T wave (r =-0.508, P < 0.05).

CONCLUSIONS

Hyperinsulinemic hypoglycemia with consequent sympathetic humoral activation is associated with several ECG alterations in atrioventricular conduction, ventricular depolarization, and ventricular repolarization. Such alterations in cardiac electrical function may be of importance in provoking severe arrhythmias and "dead-in-bed" syndrome in diabetic patients with unrecognized hypoglycemic episodes.

Androgen receptor gene CAG repeat length in women with metabolic syndrome

OBJECTIVE

The length of the androgen receptor gene CAG repeat [AR (CAG)(n)] modulates the activity of the androgen receptor (AR), and this polymorphism has been shown to modulate body fat mass and serum concentrations of insulin in men. We hypothesized that shorter AR (CAG)(n) is associated with metabolic syndrome (MBS) or its components in women.

DESIGN, PATIENTS AND MEASUREMENTS

In a cross-sectional controlled study we studied 52 Finnish women aged 34-55 years with MBS and 69 age-matched controls. All participants were recruited from a sample of women drawn from the Finnish population register. We compared the mean AR (CAG)(n) in the two groups. Furthermore, we correlated the AR (CAG)(n) with serum testosterone, androstenedione, dehydroepiandrosterone sulfate and several parameters of glucose and lipid metabolism in each group and in all 121 women.

RESULTS

There was no difference in the biallelic mean AR (CAG)(n) between the MBS and the control group (21.6+/-0.2 vs. 21.8+/-0.2, not significant). The AR (CAG)(n) did not correlate significantly with any of the clinical or biochemical parameters of glucose or fat metabolism. However, it correlated negatively with serum testosterone (-0.195, p = 0.04) and androstenedione concentrations (-0.205, p = 0.03) in all studied women.

CONCLUSIONS

The AR (CAG)(n) is not a major determinant of MBS in women but it contributes to ovarian androgen production.

Analytical investigation: assay of D-lactate in diabetic plasma and urine

OBJECTIVE

In this study we developed a 96-micro plate enzymatic assay for D-lactate in plasma and urine.

METHODS

D-lactate was assayed enzymatically with a UV-spectrophotometer in plasma from 38 and in urine from 37 diabetics and from 42 non-diabetic controls.

RESULTS

The within-run coefficients of variations (CV) were 2.6% for plasma and 5.7% for urine. The between run CVs were 6.8% for plasma and 6.7% for urine. The mean recovery with standard deviation (S.D.) was 107.4+/-7.3% for plasma and 100.1%+/-6.7% for urine. The plasma D-lactate in diabetics were (mean+/-S.D.) 39.6+/-23.7 microM. We found significant difference between the urinary d-lactate in controls and diabetics (18.2+/-12.0 vs. 35.9+/-24.2 microM/mM creatinine, p<0.0001).

CONCLUSIONS

The assay proved reliable with acceptable precision and recovery. Results suggest that diabetics have elevated urinary and plasma D-lactate as compared to controls.

Glucose regulation and chronic pain at multiple sites

OBJECTIVE

To analyse how glucose regulation status is associated with chronic regional pain and chronic widespread pain (CWP) in the adult population.

METHODS

A structured interview and health examination study with 480 participants aged 30-65 yrs was carried out in Lapinlahti municipality in eastern Finland. The number of painful sites in the right or left upper and lower extremities, shoulders and hips, and in neck and back was summated. Those subjects with chronic pain in at least four sites were defined as having CWP. Diabetes and glucose tolerance status diagnosis were based on self-reported diagnoses, reimbursed medication and laboratory tests. Subjects with impaired fasting plasma glucose and/or elevated 2-h glucose level were combined into a group of impaired glucose regulation (IGR).

RESULTS

Of the total sample, 55 subjects (11%) had diabetes. The prevalence of CWP was 13% (n = 62) in all subjects. The corresponding percentages for subjects with normal glucose regulation, IGR and diabetes were 9, 18 and 28%. In the multivariate analysis, diabetes was associated with CWP (odds ratio = 2.99; 95% CI 1.19, 7.53; P = 0.020).

CONCLUSIONS

These results point to a significant association between diabetes and CWP in the adult population.

Cost-effectiveness of statins in the prevention of coronary heart disease events in middle-aged Finnish men

OBJECTIVE

This study evaluated the long-term cost-effectiveness of atorvastatin 20 mg, rosuvastatin 10 mg and simvastatin 40 mg in primary and secondary prevention of CHD in Finland.

RESEARCH DESIGN AND METHODS

The effect of statin therapy on the incidence of CHD and the expected total costs of the disease were described using a Markov state transition model. Due to the limited amount of evidence concerning mortality and morbidity for rosuvastatin, the model was used to transmute the efficiency data of all statins (decrease in total cholesterol) into long-term endpoints (myocardial infarction, death) using risk functions of the FINRISK and 4S studies. The study followed a characterized cohort of 55-year-old Finnish men with an average 3.3-6.6% baseline risk of dying from cardiovascular disease within a 10-year period.

MAIN OUTCOME MEASURES

Incremental cost-effectiveness ratios (ICERs) for atorvastatin and rosuvastatin, compared with simvastatin, measured as cost of life years gained (euro/LYG) and cost of quality adjusted life years gained (euro/QALY).

RESULTS

The use of rosuvastatin increased the life expectancy by 0.27 years on average (LYG) compared with simvastatin, producing additional 0.08 quality-adjusted life-years (QALYs). Compared with simvastatin, the cost of one LYG with rosuvastatin was euro10 834 and the cost of one QALY gained was euro36 548 (discount rate 5% per annum). Corresponding figures for atorvastatin were euro31 286/LYG and euro105 599/QALY.

CONCLUSIONS

If the decision makers' willingness to pay for a QALY gained is around euro40 000 there is a high probability (>50%) that rosuvastatin represents a cost-effective form of therapy in the prevention of CHD in middle-aged men with an average 3.3-6.6% risk of dying within 10 years from cardiovascular disease. However, the true clinical impact of these results needs confirmation from on-going clinical trials, as the role of rosuvastatin in reducing clinical events is pending, but for simvastatin and atorvastatin established.

Inflammation markers are modulated by responses to diets differing in postprandial insulin responses in individuals with the metabolic syndrome

BACKGROUND

Inflammation may be a mechanism by which high postprandial insulin and glucose responses increase the risk of type 2 diabetes mellitus.

OBJECTIVE

We hypothesized that dietary carbohydrates characterized by different postprandial insulin responses may differentially modify cytokine concentrations in plasma and gene expression in subcutaneous adipose tissue.

DESIGN

Individuals (n = 47) with the metabolic syndrome were randomly assigned to a 12-wk diet with oat and wheat bread and potato (high postprandial insulin response) or rye bread and pasta (low postprandial insulin response). Postprandial glucose and insulin responses to the oat and wheat bread meal and to the rye bread meal were determined in 19 individuals before intervention.

RESULTS

During the 12-wk diet, the change in the gene expression of interleukin (IL)-10 receptor alpha and tumor necrosis factor-alpha in subcutaneous adipose tissue differed between the groups (P = 0.002 and P = 0.083, respectively). Moreover, the change in fasting plasma concentrations of IL-1beta and IL-6 differed between the groups (P = 0.020 and P = 0.055, respectively). In the postprandial challenge, the insulin response to the rye bread meal was lower than that to the oat and wheat bread meal (P < 0.001), whereas there were no differences in the mean blood glucose response. In contrast, plasma glucose concentrations decreased more below fasting concentrations 2.5-3 h after the oat and wheat bread meal than after the rye bread meal. A late postprandial rebound of free fatty acids was detected after the oat and wheat bread meal (P = 0.048).

CONCLUSIONS

Long-term intake of cereal foods with differing postprandial insulin responses may be a factor that modulates the inflammatory status in individuals with the metabolic syndrome.

Dyslipidaemia as a predictor of hypertension in middle-aged men

AIMS

Dyslipidaemia and hypertension are features of the metabolic syndrome, but the role of dyslipidaemia in the development of hypertension is less clear. We assessed the association of dyslipidaemia with incident hypertension during a 7-year follow-up in a population-based cohort of middle-aged men without hypertension at baseline.

METHODS AND RESULTS

In all, 88 of 311 men developed hypertension during the follow-up. A 1-SD increment in triglyceride concentrations was associated with a 1.6-fold [95% CI(confidence interval) 1.2-2.3] increased risk of developing hypertension, independently of features related to the metabolic syndrome. In separate multivariable models, the triglyceride content of high-density lipoprotein (HDL) cholesterol and apolipoprotein B concentrations were also associated with new-onset hypertension. In a stepwise backwards logistic regression model, concentrations of low-density lipoprotein (LDL) cholesterol [odds ratio (OR) 1.3, 95% CI 1.0-1.7 for a 1-SD change] and triglyceride content of HDL cholesterol (OR) 1.5, 95% CI 1.1-1.9) were positively associated with incident hypertension, whereas HDL concentrations (OR 0.7, 95% CI 0.5-0.9) seemed protective. In factor analyses, elevated triglyceride levels and related disturbances in lipid and cholesterol metabolism were associated with new-onset hypertension.

CONCLUSION

Dyslipidaemia characteristic of the metabolic syndrome predicts the development of hypertension during a 7-year follow-up of eastern Finnish men, independently of features related to insulin resistance. The recognition of dyslipidaemia and initiation of lifestyle treatment even in the absence of hypertension is likely to reduce the long-term burden of cardiovascular disease.

Effect of weight loss on cytokine messenger RNA expression in peripheral blood mononuclear cells of obese subjects with the metabolic syndrome

Inflammation is associated with obesity, the metabolic syndrome, and diabetes. No data are available on the effect of weight reduction on the gene expression of cytokines in immune cells in obesity and the metabolic syndrome. We assessed how long-term weight loss affects expression of cytokines in peripheral blood mononuclear cells (PBMCs) in individuals with impaired glucose metabolism and the metabolic syndrome. Data from 34 subjects randomized to either a weight reduction or a control group for a 33-week period were analyzed. The messenger RNA (mRNA) expression of interleukins (ILs) in PBMCs was measured using real-time polymerase chain reaction. Measures of insulin and glucose metabolism (intravenous and oral glucose tolerance tests), body composition, and circulating adipokines and inflammatory markers were also assessed. Weight reduction resulted in a decrease in the mRNA expression of IL-1beta (IL1B), IL-1 receptor antagonist, and tumor necrosis factor alpha (P < .001) and an increase in expression of IL-6 (IL6) and IL-8 (P < .01). The increase in IL6 expression was associated with a decrease in fasting glycemia (r = -0.53, P < .01). Interestingly, the decrease in IL1B expression was correlated with an increase in insulin sensitivity index (r = -0.68, P < .01). In general, a decrease in circulating levels of adipokines and inflammatory markers was also observed after weight loss. Weight loss altered gene expression of cytokines related to inflammation and the immune response in PBMCs. Changes in IL6 mRNA expression were associated with changes in fasting glycemia. The decrease in IL-1 receptor antagonist expression after weight loss and the strong correlation between the decrease in IL1B expression and the increase in insulin sensitivity suggest a contribution of these genes to insulin-resistant states found in obesity and the metabolic syndrome.

Statins are effective in treating dyslipidemia among psychiatric patients using second-generation antipsychotic agents

Statins are widely used in the treatment of patients having high levels of serum total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C). However, there is little documentation on the ability of statins to treat dyslipidemia induced by second-generation antipsychotics (SGAs) and if so, to what extent. A goal of the present study was to evaluate these aspects among psychotic inpatients who were prescribed SGAs in a typical clinical setting. The study sample consisted of 28 psychotic male forensic psychiatric inpatients (mean age 44 years). All had sGA medication for their psychotic symptoms. secondary causes of dyslipidemia were excluded and statin therapy was initiated, according to the established guidelines. The change in TC, LDL-C, high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) levels were evaluated retrospectively and analysed by the Wilcoxon signed Ranks test. The lowering effectivity of statin treatment was 36% for TC, 49% for LDL-C and 29% for TG. Most of the patients (84%) achieved a target value for LDL-C of <3.0 mmol/L, and 54% achieved target value of <2.6 mmol/L, while HDL-C remained unchanged. These results were achieved with a low or moderate dose of statin during a period of 1 month. The effect of statins in lowering of TC, LDL-C and TG among dyslipidemic psychiatric patients that were treated with sGA was similar to the effectiveness of statin therapy in other clinical trial settings, and should be used when they are indicated.

Long-term repeatability of measures of early insulin secretion derived from an intravenous glucose tolerance test and conversion from impaired glucose tolerance to diabetes

AIM

We assessed the long-term repeatability of the acute insulin response (AIR) and sensitivity index (S(I)) derived from the frequently sampled intravenous glucose tolerance test (FSIGT).

METHODS

An FSIGT was performed in 20 women who participated in a 6.5-month rye- and wheat-bread intervention trial, 70 men and women with impaired fasting glycaemia (IFG) or impaired glucose tolerance (IGT) who participated in the Genobin study, and 81 men and women with IGT who participated in the Finnish Diabetes Prevention Study (DPS).

RESULTS

The correlation of AIR and S(I) at base-line with respective values after the 6.5-8.5-month trials was 0.86-0.88 and 0.71-0.84, and before and after 4 years in the DPS substudy, 0.86 and 0.53. In multivariate analyses, AIR (relative risk for a 1-SD change, 0.67; 95% confidence intervals 0.46-0.97) predicted the conversion from IGT to diabetes in the DPS substudy.

CONCLUSION

AIR is highly repeatable even after 4 years of follow-up. The long-term repeatability of S(I) is moderate. Our findings emphasize the importance of impaired early insulin secretion in the transition from IGT to diabetes, and the high degree of tracking of measures of early insulin secretion derived from the FSIGT.

Health-related quality of life in a population-based sample of men with long-term mental symptoms

It is not known whether somatic factors related to overall health and lifestyles or psychological factors, including confirmed psychiatric diagnoses, are associated with the health-related quality of life (HRQL) of men in a population-based sample. The aim of this study was to investigate socio-demographic, somatic and psychological factors associated with HRQL in men having mental symptoms during the 7 previous years. This cross-sectional sample of men (n=63) was investigated in 2004-05 and was based on a previous three-phase follow-up study that began in 1998. Blood pressure, body mass index, waist circumference, serum lipids and testosterone levels were measured. Psychiatric diagnoses were confirmed with using the Structured Clinical Interview for DSM-IV. Several mental symptoms were assessed with standardized scales. HRQL was measured with the RAND-36 using the physical (PCS) and mental component summary (MCS) scores. A poor HRQL in PCS was found in 73% of men and in MCS in 54%. Depressive symptoms, life dissatisfaction, male symptoms of aging and alexithymia were associated with both impaired PCS and MCS scores. Hopelessness, lifetime and current diagnoses of major depressive disorder and signs of suicidality only associated with a poorer MCS score. Somatic factors describing lifestyles and overall health only weakly associated with HRQL. In general, HRQL was poor in men having long-term mental symptoms. Mental health factors were strongly associated with PCS and MCS scores of HRQL. In improving HRQL in men, both physical and mental domains should be targeted in preventive and curative strategies.

Cholesterol metabolism and non-cholesterol sterol distribution in lipoproteins of type 1 diabetes: The effect of improved glycemic control

In type 1 diabetes, the ratios to cholesterol of serum absorption markers, e.g., cholestanol, are elevated and those of synthesis markers, e.g., lathosterol, are reduced suggesting perturbed cholesterol metabolism. We studied 17 subjects with type 1 diabetes in poor glycemic control at baseline to assess whether improvement of glycemic control affects lathosterol and cholestanol ratios to cholesterol and their distribution in lipoproteins. Cholesterol and the non-cholesterol sterols were assayed directly from serum, and free and ester fractions after thin-layer chromatographic separation of lipoprotein sterols with gas-liquid chromatography. After the 2-6 months follow-up, the mean value of HbA1(c) decreased from 10.8% to 8.6% (p=0.001). Even though the concentrations of serum and lipoprotein cholesterol remained unchanged, the serum lathosterol to cholesterol ratio increased by 28% (p<0.05) and the lathosterol/cholestanol proportion by 23% (p<0.05). The ratios of total and esterified lathosterol to cholesterol in serum, chylomicrons and LDL, and free lathosterol to cholesterol in serum and IDL, were negatively associated with HbA1(c) at baseline and after follow-up, suggesting that the better glycemic control, the higher was cholesterol synthesis. The absorption markers were less consistently associated with HbA1(c). About half of the serum lathosterol and cholestanol was carried in LDL and one-fourth to one-fifth in HDL, but the lathosterol ratios were roughly similar in all lipoproteins. In contrast, cholestanol accumulated in chylomicrons and HDL. Glycemic control did not affect the distributions of lathosterol and cholestanol. In conclusion, improvement in glycemic control increased cholesterol synthesis, but had no effect on cholesterol absorption as measured by the serum or lipoprotein cholestanol to cholesterol ratio. From a clinical point of view, the better the glycemic control, the more antiatherogenic cholesterol metabolism may be in type 1 diabetes.

Chronic pain, impaired glucose tolerance and diabetes: a community-based study

The aim of this study was to analyse how plasma glucose level and diabetes mellitus (DM) are associated with chronic pain in the adult population. A structured interview and health examination study with 480 participants aged 30-65 years was carried out in Lapinlahti municipality in Eastern Finland. Chronic pain (duration of at least 3 months) was graded according to frequency: being present less often than daily, or every day or continuously (daily chronic pain, DCP). Elevated plasma glucose was defined as a plasma glucose level 6.1 mmol/l. DM diagnosis was based on self-reported diagnoses, reimbursed medication or a health examination with laboratory tests. Glucose regulation status was defined according to fasting plasma glucose level and a two-hour glucose tolerance test. Of the total sample, 90 subjects (19%) had a plasma glucose level > or = 6.1 mmol/l and 55 subjects (11%) had diabetes. The prevalence of daily chronic pain was 21% (N = 101) in all the subjects. In the subjects with a normal plasma glucose level, the prevalence was 18%, while in those with an elevated plasma glucose level it was 38%. The corresponding percentages for non-diabetics and diabetics were 19% and 42%. In the multinomial multivariate logistic regression analysis, glucose level or diabetes was associated with DCP. The odds for DCP in the subjects with an elevated plasma glucose level was 2.37 (95% CI, 1.26-4.49), and in those with DM it was 2.53 (95% CI, 1.12-5.72). Elevated plasma glucose level and DM are associated with DCP in adults.

Weight reduction modulates expression of genes involved in extracellular matrix and cell death: the GENOBIN study

OBJECTIVE

Lifestyle and genetic factors interact in the development of obesity and the metabolic syndrome. The molecular mechanisms underlying the beneficial dietary modifications are, however, unclear. We aimed to examine the effect of the long-term moderate weight reduction on gene expression in adipose tissue (AT) and to identify genes and gene clusters responsive to treatment and thereby likely contributing to the development of the metabolic syndrome.

DESIGN

Randomized controlled and individualized weight reduction intervention.

SUBJECTS

Forty-six subjects with impaired fasting glycemia or impaired glucose tolerance and features of metabolic syndrome, aged 60+/-7 years were randomized either to a weight reduction (WR) (n=28) or a control (n=18) group lasting for 33 weeks.

MEASUREMENTS

Oral and intravenous glucose tolerance tests and subcutaneous AT biopsies were performed before and after the intervention. Gene expression of AT was studied using microarray technology in subgroups of WR (with weight reduction > or =5%, n=9) and control group (n=10). The results were confirmed using quantitative PCR.

RESULTS

In the WR group, glucose metabolism improved. Moreover, an inverse correlation between the change in S (I) and the change in body weight was found (r=-0.44, P=0.026). Downregulation of gene expression (P<0.01) involving gene ontology groups of extracellular matrix and cell death was seen. Such changes did not occur in the control group. The tenomodulin-gene was one of the most downregulated genes (-39+/-16%, P<0.0001). Moreover, its expression correlated with insulin sensitivity (r=-0.34, P=0.005) before the intervention and with body adiposity both before (r=0.42, P=0.007) and after (r=0.30, P=0.056) the intervention.

CONCLUSION

Genes regulating the extracellular matrix and cell death showed a strong downregulation after long-term weight reduction. This likely reflects a new stable state at the molecular level in AT. Further studies are warranted to elucidate the mechanisms of these genetic factors.

Multiple endocrine neoplasia type 1 in Northern Finland; clinical features and genotype phenotype correlation

OBJECTIVE

The existence of genotype-phenotype correlation in multiple endocrine neoplasia type 1 (MEN1) is controversial. Two founder mutations of the MEN1 gene in Northern Finland gave us an opportunity to compare clinical features among heterozygotes of different mutations.

DESIGN AND METHODS

Study cohort included 82 MEN1 heterozygotes who were tested for MEN1 during the years 1982-2001. Medical records were reviewed for manifestations of MEN1, other tumours and cause of death by the end of August 2003. Logistic regression analysis was used in evaluating the impact of age, gender and mutational status of affected heterozygotes on the likelihood of developing manifestations of MEN1.

RESULTS

Founder mutations 1466del12 and 1657insC were found in 39 and 29 individuals, and D418N, G156R and R527X mutations in 9, 3 and 2 individuals respectively. Except for pituitary adenoma and nonfunctional pancreatic tumour (NFPT), age was a risk factor for all the disease manifestations. For NFPT, frameshift/nonsense mutations (1657insC, R527X) gave an odds ratio (OR) of 3.26 (95% confidence intervals (CI), 1.27-8.33; P = 0.014) compared with in-frame/missense mutations (1466del12, D418N, G156R); including the founder mutation carriers (n = 68) only, the 1657insC mutation gave an OR of 3.56 (CI, 1.29-9.83; P = 0.015). For gastrinoma, in-frame/missense mutations predicted the risk with an OR of 6.77 (CI, 1.31-35.0; P = 0.022), and in the founder mutations group the 1466del12 mutation gave an OR of 15.09 (CI, 1.73-131.9, P = 0.014).

CONCLUSIONS

In this study population, NFPT was more common in the frameshift/nonsense or 1657insC mutation carriers, whereas gastrinoma was more common in the in-frame/missense or 1466del12 mutation carriers.

National type 2 diabetes prevention programme in Finland: FIN-D2D

OBJECTIVES

Current evidence shows that type 2 diabetes (T2D) can be prevented by life-style changes and medication. To meet the menacing diabetes epidemic, there is an urgent need to translate the scientific evidence regarding prevention of T2D into daily clinical practice and public health. In Finland, a national programme for the prevention of T2D has been launched. The programme comprises 3 concurrent strategies for prevention: the population strategy, the high-risk strategy and the strategy of early diagnosis and management. The article describes the implementation strategy for the prevention programme for T2D.

METHODS

The implementation project, FIN-D2D, is being conducted in 5 hospital districts, covering a population of 1.5 million, during the years 2003-2007. The main actors in the FIN-D2D are primary and occupational health care providers.

RESULTS

The goals of the project are (1) to reduce the incidence and prevalence of T2D and prevalence of cardiovascular risk factor levels; (2) to identify individuals who are unaware of their T2D; (3) to generate regional and local models and programmes for the prevention of T2D; (4) to evaluate the effectiveness, feasibility and costs of the programme; and (5) to increase the awareness of T2D and its risk factors in the population and to support the population strategy of the diabetes prevention programme. The feasibility, effectiveness and costs of the programme will be evaluated according to a specific evaluation plan.

CONCLUSIONS

Current research evidence shows that the type 2 diabetes can be effectively prevented in high-risk subjects by life-style changes, which include increased physical activity and weight reduction. FIN-D2D explores ways to implement these methods on a national level.

Is discordance in bone measurements affected by body composition or anthropometry? A comparative study between peripheral and central devices

Screening of osteoporosis using peripheral bone measurements has become more common, even though diagnostic discrepancies are known to exist between peripheral dual-energy X-ray (pDXA) or quantitative ultrasound (QUS) and central DXA measurements. Values of diagnostic parameters such as bone mineral density, speed of (ultra)sound, and broadband ultrasound attenuation are affected by bone size and soft tissue composition. However, their significance for the discordance between peripheral and central techniques is unclear. In this study, bone status and total body composition of 139 women (mean age 68.3 yr [1.7 SD], mean body mass index 26.5 kg/m2 [3.6 SD]) were assessed by 3 GE Lunar devices. Heel pDXA and heel QUS were conducted using peripheral instantaneous X-ray imaging (PIXI) and Achilles, respectively, and central DXA measurements were taken at the posterior-anterior lumbar spine (L2-L4) and at the left femoral neck using Prodigy. Positive significant associations were found between body height or fat (%) and most DXA or QUS parameters. The discordance between the site-dependent DXA or QUS T-score values typically increased (p<0.05) as a function of body weight or fat (%), but not with body height. On an average, body adiposity accounted for less than 11% of the differences between the techniques; however, increase of total body fat from 20% to 45% led to a discrepancy of one T-score between DXA(HEEL) and QUS(HEEL). To avoid diagnostic bias, comparative assessment of the devices using the same population is recommended.

Markers of absorption and synthesis of cholesterol in men with type 1 diabetes

BACKGROUND AND METHODS

Serum cholestanol and plant sterol ratios to cholesterol, surrogate markers of cholesterol absorption, are assumed to be high in type 1 diabetes (T1D), and the ratios of cholesterol precursor sterols (markers of synthesis) are assumed to be low reflecting downregulated cholesterol synthesis. To this end, we measured serum sterols with gas-liquid-chromatography in 56 men with T1D and in 18 controls to evaluate cholesterol metabolism. Subjects were categorised into tertiles by the cholestanol to cholesterol ratio of controls indicating low to high absorption of cholesterol.

RESULTS

The ratios of the synthesis markers were negatively related to the absorption markers in controls, but less consistently in T1D. The absorption markers were positively related to each other, but interrelation of the synthesis markers was less consistent in T1D. In the low absorbers the absorption markers were higher in T1D than in controls (e.g. sitosterol ratio 173 +/- 9 in T1D vs 135 +/- 11 10(2) x mmol/mol of cholesterol in controls, p < 0.05). In the high absorbers, the absorption markers were similar in T1D and controls, but the synthesis markers were higher in T1D than in controls (e.g. lathosterol ratio 154 +/- 10 in T1D vs 120 +/- 5 10(2) x mmol/mol of cholesterol in controls, p < 0.05).

CONCLUSIONS

Absorption and synthesis of cholesterol are less closely related to each other in T1D than in controls, but the markers of cholesterol absorption are interrelated also in T1D. Absorption of cholesterol is higher in T1D than in controls within the range of low absorption, but similar in those with relatively high cholesterol absorption.

Fortified mineral water improves folate status and decreases plasma homocysteine concentration in pregnant women

OBJECTIVES

There is no mandatory folic acid fortification of food in Finland. We investigated the effects of mineral water fortified with folic acid, vitamins B6, B12, D and calcium on serum and erythrocyte folate concentrations, serum vitamin B12 and plasma homocysteine concentrations in pregnancy.

DESIGN

A randomized, controlled, double-blind, parallel-group intervention study.

METHODS

Seventy-four pregnant women were recruited from two health care units. The study began at the eleventh week with a two-week run-in period, followed by an eight-week intervention period. The diet was monitored by food records. During the intervention, subjects consumed 1000 mL/day fortified or normal mineral water. The pregnancies were monitored carefully.

RESULTS

The folate intake was 255 microg/day in the study group and 274 microg/day in the controls. Serum folate concentrations increased in the study group by 10.3 nmol/L and decreased in the controls by 2.7 nmol/L (P<0.05) during the study. The erythrocyte folate concentrations increased in the study group by 360.9 nmol/L and in the controls by 195.6 nmol/L (P=0.004) and serum homocysteine concentrations fell by 1.1 micromol/L and by 0.3 micromol/L, respectively (P<0.05).

CONCLUSIONS

Finnish pregnant women have low dietary folate intake. Fortified mineral water improved folate status and reduced plasma homocysteine concentrations in the pregnant subjects.

Serum adipokines are associated with cholesterol metabolism in the metabolic syndrome

BACKGROUND

The purpose of this study was to investigate whether cholesterol metabolism is associated with serum adipokines and inflammatory markers.

METHODS

In fifty-eight subjects with impaired fasting glucose or impaired glucose tolerance and features of the metabolic syndrome cholesterol metabolism was assayed with serum non-cholesterol sterol ratios to cholesterol, surrogate markers of synthesis (cholesterol precursors) and dietary absorption % of cholesterol (cholestanol and plant sterols) and related them to serum adiponectin, leptin, high-sensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha).

RESULTS

Adiponectin was negatively related to synthesis markers (e.g. desmosterol r=-0.371, P<0.01), and positively to absorption markers (e.g. cholestanol r=0.269, P<0.05). Leptin was associated with synthesis markers (e.g. desmosterol r=0.271, P<0.05) and negatively with absorption markers (e.g. sitosterol r=-0.278, P<0.05). Hs-CRP was negatively associated with absorption markers (e.g. sitosterol r=-0.407, P<0.001). IL-6 and TNF-alpha were not related to cholesterol metabolism. When dividing the subjects into tertiles by the serum desmosterol/cholestanol ratio, the I tertile (high synthesis/low absorption) was associated with low adiponectin concentrations, high BMI and serum leptin concentrations (P<0.05 for all).

CONCLUSIONS

Adiponectin, leptin and hs-CRP were associated with variables of cholesterol metabolism. A high ratio of cholesterol synthesis to absorption is characterized by high serum leptin and low adiponectin concentrations.

Dietary carbohydrate modification induces alterations in gene expression in abdominal subcutaneous adipose tissue in persons with the metabolic syndrome: the FUNGENUT Study

BACKGROUND

Diets rich in whole-grain cereals and foods with a low glycemic index may protect against type 2 diabetes, but the underlying molecular mechanisms are unknown.

OBJECTIVE

The main objective was to test whether 2 different carbohydrate modifications--a rye-pasta diet characterized by a low postprandial insulin response and an oat-wheat-potato diet characterized by a high postprandial insulin response--affect gene expression in subcutaneous adipose tissue (SAT) in persons with the metabolic syndrome.

DESIGN

We assessed the effect of carbohydrate modification on SAT gene expression in 47 subjects [24 men and 23 women with a mean (+/-SD) age of 55 +/- 6 y] with the features of the metabolic syndrome in a parallel study design. The subjects had a mean (+/-SD) body mass index (kg/m(2)) of 32.1 +/- 3.8 and a 2-h plasma glucose concentration of 8.0 +/- 2.3 mmol/L. Adipose tissue biopsies were performed, and oral-glucose-tolerance tests and other biochemical measurements were conducted before and after the intervention.

RESULTS

We detected 71 down-regulated genes in the rye-pasta group, including genes linked to insulin signaling and apoptosis. In contrast, the 12-wk oat-wheat-potato diet up-regulated 62 genes related to stress, cytokine-chemokine-mediated immunity, and the interleukin pathway. The insulinogenic index improved after the rye-pasta diet (P=0.004) but not after the oat-wheat-potato diet. Body weight was unchanged in both groups.

CONCLUSIONS

Dietary carbohydrate modification with rye and pasta or oat, wheat, and potato differentially modulates the gene expression profile in abdominal subcutaneous adipose tissue, even in the absence of weight loss.

Effect of orlistat on weight regain and cardiovascular risk factors following a very-low-energy diet in abdominally obese patients: a 3-year randomized, placebo-controlled study

OBJECTIVE

To investigate the efficacy of orlistat on the maintenance of weight loss over 3 years following a major weight loss induced by very-low-energy diet (VLED) in obese patients with metabolic risk factors such as dyslipidemia, impaired fasting glucose, and diet-treated type 2 diabetes.

RESEARCH DESIGN AND METHODS

Initially, weight loss was induced by an 8-week VLED (600-800 kcal/day) in 383 patients with a mean BMI of 37.5 kg/m(2) (range 30.0-45.2). Those who lost > or = 5% of their body weight (309 of 383 patients) were then randomized to receive lifestyle counseling for 3 years together with either orlistat 120 mg t.i.d. or matching placebo capsules. Primary end points were the maintenance of > or = 5% weight loss after 3 years. Additionally, differences in the development of type 2 diabetes between orlistat and placebo were analyzed.

RESULTS

The VLED induced a mean weight loss of 14.4 +/- 2.0 kg among the subsequently randomized patients. The mean weight gain after 3 years was lower with orlistat than with placebo (4.6 +/- 8.6 vs. 7.0 +/- 7.1 kg; P < 0.02). The number of participants who achieved > or =5% weight loss also favored orlistat (67 vs. 56%; P = 0.037). Waist circumference was significantly more reduced in the orlistat group (P < 0.05), but no other differences in the risk factors were observed between the two groups. The incidences of new cases of type 2 diabetes were significantly reduced in the orlistat group (8 cases out of 153 subjects) versus placebo (17 cases out of 156 subjects) (P = 0.041).

CONCLUSIONS

The addition of orlistat to lifestyle intervention was associated with maintenance of an extra 2.4 kg weight loss after VLED for up to 3 years in obese subjects. The combination of orlistat and lifestyle intervention was associated with a reduced occurrence of type 2 diabetes.

Interaction between cholesterol and glucose metabolism during dietary carbohydrate modification in subjects with the metabolic syndrome

BACKGROUND

Carbohydrate modification based on rye bread and pasta enhances early insulin secretion in subjects with the metabolic syndrome.

OBJECTIVE

Because the actions of insulin and cholesterol metabolism are interrelated, the question is raised of whether it is possible to alter cholesterol metabolism by means of dietary carbohydrate modification.

DESIGN

We investigated the 12-wk effects of dietary carbohydrate modification on cholesterol synthesis and absorption by measuring the ratios of surrogate markers of precursor (cholestenol, desmosterol, and lathosterol) and absorption (cholestanol and plant sterols) sterols to cholesterol and their association to glucose metabolism in 74 subjects with the metabolic syndrome. The subjects were randomly assigned to diets with rye bread and pasta (RPa) or oat, wheat bread, and potato (OWPo) as the main carbohydrate source (34% and 37% of energy intake, respectively).

RESULTS

During the study, serum cholesterol concentrations remained unchanged. Cholesterol synthesis was lower (6-10% for cholestenol and lathosterol; P < 0.05) and absorption higher (9%; P < 0.05 for sitosterol) with the OWPo diet than at baseline. With the RPa diet, cholesterol absorption was lower and synthesis higher than with the OWPo diet. The increment in the glucose area under the curve with the RPa diet was positively related to baseline cholesterol synthesis (eg, lathosterol; r = 0.480, P < 0.05) and negatively to absorption (for cholestanol; r = -0.520, P < 0.05). In the combined group, the changes in the cholestanol ratio and the insulinogenic index were interrelated (r = -0.464, P < 0.001).

CONCLUSIONS

Carbohydrate modifications had dissimilar effects on cholesterol metabolism. Consumption of RPa, as compared with OWPo, may be clinically more favorable because it seems to inhibit the absorption of cholesterol, a factor crucial in the development of arterial atherosclerosis.

Quality of life in treated patients with acromegaly

CONTEXT

It is not known to what extent quality of life of patients treated for acromegaly is dependent on levels of GH and IGF-I attained.

OBJECTIVE

The objective of this study is to examine the health-related quality of life (HRQoL) and its dependence on treatment outcome and modality in a nationwide survey of acromegalic patients.

DESIGN, SETTING, AND PATIENTS

All eligible patients with acromegaly, diagnosed from January 1980 through December 1999 in Finland, were invited to a follow-up study, carried out 11.4 +/- 5.7 (mean +/- sd) yr after initial treatment. HRQoL of the patients, measured by the generic 15D instrument, was compared with that of the general population. Factors related to HRQoL were analyzed by logistic regression.

MAIN OUTCOME MEASURE

HRQoL was the main outcome measure.

RESULTS

Of 277 eligible patients, 231 (83.4%) participated in the follow-up study. Of them, 51.1% were in remission according to consensus criteria. The patients reported reduced HRQoL in comparison to the age- and gender-standardized general population (P < 0.001). HRQoL was related to nadir GH in oral glucose tolerance test (GHOGTT) in an inverted U-shaped fashion (overall P = 0.021). Patients with GHOGTT nadir values between 0.3-1.0 microg/liter had a better HRQoL than those with lower or higher values. A normal IGF-I (P = 0.038) and not having had radiotherapy (P = 0.004) were also associated with a better HRQoL.

CONCLUSIONS

HRQoL is reduced in treated patients with acromegaly. The best HRQoL may be achieved by normalization of IGF-I and by targeting the GHOGTT nadir to levels between 0.3 and 1.0 microg/liter. Radiotherapy is associated with adverse HRQoL.

Metabolic Syndrome and the Risk of Stroke in Middle-Aged Men

BACKGROUND AND PURPOSE

The metabolic syndrome, a clustering of disturbed glucose and insulin metabolism, obesity and abdominal fat distribution, dyslipidemia, and hypertension is associated with cardiovascular diseases. The aim of this study was to examine the relationship of metabolic syndrome, as defined by National Cholesterol Education Program (NCEP) and World Health Organization (WHO) criteria, with the risk for stroke.

METHODS

Population-based cohort study with an average follow-up of 14.3 years from eastern Finland. A total of 1131 men with no history of cardiovascular disease and diabetes at baseline participated. Sixty-five strokes occurred, of which 47 were ischemic strokes.

RESULTS

Men with the metabolic syndrome as defined by the NCEP criteria had a 2.05-fold (95% CI, 1.03 to 4.11; P=0.042) risk for all strokes and 2.41-fold (95% CI, 1.12 to 5.32; P=0.025) risk for ischemic stroke, after adjusting for socioeconomic status, smoking, alcohol, and family history of coronary heart disease. Additional adjustment for ischemic changes during exercise test, serum low-density lipoprotein cholesterol, plasma fibrinogen, energy intake for saturated fats, energy expenditure of leisure time physical activity, and white blood cell count, the results remained significant. The risk ratios among men with metabolic syndrome as defined by the WHO criteria were 1.82 (95% CI, 1.01 to 3.26; P=0.046) for all strokes and 2.16 (95% CI, 1.11 to 4.19; P=0.022) for ischemic stroke. After further adjustment, the respective risks were 2.08 (95% CI, 1.12 to 3.87; P=0.020) and 2.47 (95% CI, 1.21 to 5.07; P=0.013).

CONCLUSIONS

The risk of any stroke is increased in men with metabolic syndrome, in the absence of stroke, diabetes and cardiovascular disease at baseline. Prevention of the metabolic syndrome presents a great challenge for clinicians with respect to stroke.

Dietary carbohydrate modification enhances insulin secretion in persons with the metabolic syndrome

BACKGROUND

The metabolic syndrome markedly increases the risk of type 2 diabetes and cardiovascular disease, but the influence of dietary modification on insulin and glucose metabolism independent of weight loss is still poorly understood.

OBJECTIVE

Our aim was to test whether carbohydrate dietary modifications improve insulin sensitivity and secretion and glucose tolerance in overweight or obese persons with the metabolic syndrome, even in the absence of weight loss.

DESIGN

We assessed the effect of carbohydrate modification on insulin and glucose metabolism in 72 overweight or obese men and women with the metabolic syndrome, as determined according to the National Cholesterol Education Program criteria. The subjects were randomly assigned to 12-wk diets in which either rye bread and pasta or oat and wheat bread and potato were the main carbohydrate sources (34% and 37% of energy intake, respectively).

RESULTS

Body weight did not significantly change in either group during the trial. No significant difference was observed in the changes in fasting glucose and insulin concentrations or in glucose and insulin areas under the curve between the groups during a 2-h oral-glucose-tolerance test. The insulinogenic index (an index of early insulin secretion) increased more in the rye bread and pasta group than in the oat and wheat bread and potato group (33.2% compared with 5.5%; P = 0.026). In the combined groups, an enhanced insulinogenic index was associated with improved glucose tolerance, whereas weight gain worsened glucose tolerance. Moreover, even modest weight gains abolished the relative improvement in the insulinogenic index in the rye bread and pasta group compared with the oat and wheat bread and potato group (P for the interaction between weight change and group = 0.019).

CONCLUSIONS

Rye bread and pasta-based carbohydrate modification enhances early insulin secretion in persons with the metabolic syndrome, which may lower the risk of deteriorating glucose tolerance and development of type 2 diabetes.

Subtle hyperproinsulinaemia characterises the defective insulin secretory capacity in offspring of glutamic acid decarboxylase antibody-positive patients with latent autoimmune diabetes mellitus in adults

OBJECTIVE

We set out to assess whether hyperproinsulinaemia is an early finding in latent autoimmune diabetes in adults (LADA).

RESEARCH DESIGN AND METHODS

We measured plasma proinsulin and C-peptide responses during a 2-h oral glucose tolerance test (OGTT) and in the hyperglycaemic clamp in 21 normoglycaemic offspring of LADA patients testing positive for glutamic acid decarboxylase antibodies (GADA) or islet cell antibodies (ICA), and in 17 healthy control subjects without a family history of diabetes.

RESULTS

The study groups had comparable areas under the curves of blood glucose, plasma proinsulin, C-peptide and proinsulin/C-peptide in the OGTT. However, the offspring of LADA patients had higher proinsulin/C-peptide in the hyperglycaemic clamp (P < 0.01 versus the control group). The offspring of GADA-positive LADA patients (n = 9) had higher proinsulin and proinsulin/C-peptide than did the control group in the OGTT (P < 0.05 for both comparisons) and in the hyperglycaemic clamp (P < 0.001 and P < 0.05 respectively). They also had higher proinsulin than the offspring of ICA-positive LADA patients (n = 12) (P < 0.001) in the hyperglycaemic clamp. The offspring of ICA-positive LADA patients did not clearly show hyperproinsulinaemia during the tests, but they had lower maximal glucose-stimulated insulin secretory capacity than the control group (P < 0.05) and the offspring of GADA-positive LADA patients (P < 0.05) in the hyperglycaemic clamp.

CONCLUSIONS

These results suggested that insulin secretion in the offspring of GADA-positive LADA patients is characterised by subtle defects in the processing of insulin precursors. Furthermore, various proinsulin responses among the offspring of LADA patients with different autoimmune markers provided further evidence that LADA is a heterogeneous disorder.

Glycemic responses of oat bran products in type 2 diabetic patients

BACKGROUND AND AIM

Cereal products with low postprandial glycemic response are encouraged in the management of hyperglycemia. In this study, we determined the postprandial glycemic response of two different oat bran products in patients with type 2 diabetes. In addition, we investigated the effects of oat bran flour on postprandial glucose response following an oral glucose load.

METHODS AND RESULTS

A randomized, controlled, repeated measures design with two test series was used. Twelve type 2 diabetic patients participated in five 2-h meal glucose tolerance tests on separate occasions. Volunteers were given in random order oat bran flour, oat bran crisp and glucose load providing 12.5 g glycemic carbohydrate (series 1), 25 g glucose load alone and 25 g glucose load with 30 g oat bran flour (series 2). Finger-prick capillary blood analysis was carried out fasting and then 15, 30, 45, 60, 90 and 120 min after the start of the meal. The oat bran flour had a lower 0-120 min area under the glucose response curve (AUC) (47+/-45 mmol min/L) than the glucose load (118+/-40 mmol min/L) (p<0.002), but there was no difference between the oat bran crisp (93+/-41 mmol min/L) and the glucose load in this respect. The oat bran flour decreased the glucose excursion from baseline by 1.6 mmol/l (2.4, 0.8) (mean (95% CI)) and 1.5 mmol/l (2.0, 1.1) at 30 and 45 min after the glucose load, respectively.

CONCLUSIONS

Oat bran flour high in beta-glucan had a low glycemic response and acted as an active ingredient decreasing postprandial glycemic response of an oral glucose load in subjects with type 2 diabetes.

A nationwide survey of mortality in acromegaly

CONTEXT

Increased mortality in acromegaly has been confined to those with posttreatment basal GH of 2.5 microg/liter or greater, but the impact of IGF-I and pituitary radiotherapy on mortality has remained controversial.

OBJECTIVE

The purpose of this nationwide survey was to examine the all-cause mortality of patients with acromegaly and evaluate the impact of treatment outcome and mode of treatment on survival.

DESIGN, SETTING, AND PATIENTS

All-cause mortality of all patients with acromegaly diagnosed during January 1980 and December 1999 in the five university hospitals of Finland was followed up by the end of 2002 (12.5 +/- 5.6 yr) and compared with that of the general population by using age- and gender-adjusted standardized mortality ratios (SMRs). Logistic regression analysis was used to investigate factors related to mortality within the survey population.

MAIN OUTCOME MEASURE

Mortality was the main outcome measure.

RESULTS

Of the 334 patients, 56 (16.8%) had died during follow-up. SMR of the patients was 1.16 [confidence interval (CI) 0.85-1.54, not significant (NS)]. However, patients with basal serum GH concentration 2.5 microg/liter or greater (SMR 1.63, CI 1.10-2.35, P < 0.001) measured 5.2 +/- 4.4 yr after the initial treatment, and those irradiated (SMR 1.69, CI 1.05-2.58, P < 0.001) showed excess mortality. In a multivariate model, the effect of radiotherapy was of borderline significance only (P = 0.083). Posttreatment IGF-I levels, available for 72.2% of the patients, did not have impact on mortality.

CONCLUSIONS

The posttreatment basal GH concentration less than 2.5 microg/liter in acromegalic patients is associated with a normal lifespan. Excess mortality is confined to poorly controlled patients and possibly those who have received conventional radiotherapy.

C-reactive protein in the prediction of cardiovascular and overall mortality in middle-aged men: a population-based cohort study

AIMS

Cut-offs for C-reactive protein concentrations have been recommended for risk stratification, but little is known about how these cut-offs predict cardiovascular risk in population-based cohorts. We therefore assessed the association of C-reactive protein levels with cardiovascular mortality in a population-based cohort of 2321 middle-aged men stratified by the presence of cardiovascular disease (CVD) at baseline.

METHODS AND RESULTS

C-reactive protein concentrations were categorized according to current recommendations (1 and 3 mg/L). During the 15 year follow-up, 77 men without CVD and 121 men with CVD at baseline died of CVD. In men without CVD at baseline (n=1476), age-adjusted cardiovascular mortality was 4.1-fold higher (95% CI 2.1-8.2) for C-reactive protein levels between 3.0 and 9.9 mg/L at baseline than for C-reactive protein levels <1.0 mg/L. In men with CVD at baseline (n=845), the corresponding age-adjusted cardiovascular mortality was 3.3-fold higher (95% CI 2.0-5.3). Adjustment for conventional CVD risk factors attenuated the risk somewhat. Further adjustment for dietary and lifestyle factors and factors related to insulin resistance did not affect the association. Classification of C-reactive protein by tertiles gave qualitatively similar results, but identified twice as many men at high risk. C-reactive protein levels also predicted overall mortality.

CONCLUSION

Currently, recommended cut-offs for C-reactive protein levels identify men at risk for cardiovascular and overall death independently of conventional and other risk factors in a population-based sample of middle-aged men with and without CVD at baseline. Lower cut-offs may better identify men at high risk for cardiovascular death, but improvement of current recommendations will require standardization of C-reactive protein assays.

Cardiac Power During Exercise and the Risk of Stroke in Men

Background and Purpose— Low maximal oxygen uptake (VO 2max ) has been shown to predict the risk of stroke. However, VO 2max does not take into account the differences in cardiac afterload between subjects. The aim of this study was to examine the relationship of exercise cardiac power (ECP), defined as a ratio of VO 2max with peak systolic blood pressure (SBP) during exercise, with the risk for stroke.

Methods— Population-based cohort study with an average follow-up of 12 years from eastern Finland. A total of 1761 men with no history of stroke or coronary heart disease at baseline participated. Among these men, 91 strokes occurred, of which 69 were attributable to ischemic causes.

Results— The relative risk of any stroke in men with low ECP (<10.3 mL/mm Hg) was 2.7 (95% CI, 1.2 to 6.0; P =0.01; P =0.02 for the trend across the quartiles), and the relative risk for ischemic stroke was 2.7 (95% CI, 1.1 to 7.0; P =0.03; P =0.04 for trend across the quartiles) compared with men having high ECP (>14.3 mL/mm Hg) during exercise after adjusting for age, examination year, cigarette smoking, alcohol consumption, body mass index, diabetes, serum total cholesterol level, energy expenditure of physical activity, exercise-induced myocardial ischemia, and the use of antihypertensive medication. After further adjustment for resting SBP, results were statistically nonsignificant.

Conclusions— Low ECP provides noninvasive and easily available measure for stroke risk. One of the most potential explanations for the association between ECP and the increased risk of stroke is an elevated afterload and peripheral resistance indicated by elevated SBP.

Prediction of cardiovascular mortality in middle-aged men by dietary and serum linoleic and polyunsaturated fatty acids

BACKGROUND

Substitution of dietary polyunsaturated for saturated fat has long been recommended for the primary prevention of cardiovascular disease (CVD), but only a few prospective cohort studies have provided support for this advice.

METHODS

We assessed the association of dietary linoleic and total polyunsaturated fatty acid (PUFA) intake with cardiovascular and overall mortality in a population-based cohort of 1551 middle-aged men. Dietary fat composition was estimated with a 4-day food record and serum fatty acid composition.

RESULTS

During the 15-year follow-up, 78 men died of CVD and 225 of any cause. Total fat intake was not related to CVD or overall mortality. Men with an energy-adjusted dietary intake of linoleic acid (relative risk [RR] 0.39; 95% confidence interval [CI], 0.21-0.71) and PUFA (RR, 0.38; 95% CI, 0.20-0.70) in the upper third were less likely to die of CVD than men with intake in the lower third after adjustment for age. Multivariate adjustment weakened the association somewhat. Mortality from CVD was also lower for men with proportions of serum esterified linoleic acid (RR, 0.42; 95% CI, 0.21-0.80) and PUFA (RR, 0.25; 95% CI, 0.12-0.50) in the upper vs lower third, with some attenuation in multivariate analyses. Serum and to a lesser extent dietary linoleic acid and PUFA were also inversely associated with overall mortality.

CONCLUSIONS

Dietary polyunsaturated and more specifically linoleic fatty acid intake may have a substantial cardioprotective benefit that is also reflected in overall mortality. Dietary fat quality seems more important than fat quantity in the reduction of cardiovascular mortality in men.

The metabolic syndrome and smoking in relation to hypogonadism in middle-aged men: a prospective cohort study

In men, hypoandrogenism is associated with features of the metabolic syndrome. It is not known whether men with the metabolic syndrome are at a higher risk of developing hypogonadism. We therefore assessed whether the metabolic syndrome predicts development of hypogonadism 11 yr later in 651 middle-aged Finnish men participating in a population-based cohort study. Men with the metabolic syndrome at baseline as defined by the World Health Organization (n = 114, 20%) had a 2.6-fold increased risk of developing hypogonadism as defined by total testosterone levels less than 11 nmol/liter at the 11-yr follow-up independent of age, smoking, and other potential confounders. Further adjustment for body mass index (OR, 2.0; 95% CI, 1.1-3.8) or baseline total testosterone levels (OR, 1.9; 95% CI, 1.0-3.4) attenuated the association. The association of the metabolic syndrome with hypogonadism as defined by calculated free testosterone levels less than 225 pmol/liter was similar, but weaker. The adjusted decrease in testosterone concentrations during the 11-yr follow-up was also greater in men with than without the metabolic syndrome. Smokers had a nonsignificantly lower risk of developing hypogonadism during follow-up, whereas a decrease in smoking increased the risk of hypogonadism. The metabolic syndrome predisposes to development of hypogonadism in middle-aged men. Prevention of abdominal obesity and the accompanying metabolic syndrome in middle age may decrease the risk of hypogonadism in men, especially in those who quit smoking.

Physical activity in the prevention of type 2 diabetes: the Finnish diabetes prevention study

Clinical trials have demonstrated that lifestyle changes can prevent type 2 diabetes, but the importance of leisure-time physical activity (LTPA) is still unclear. We carried out post hoc analyses on the role of LTPA in preventing type 2 diabetes in 487 men and women with impaired glucose tolerance who had completed 12-month LTPA questionnaires. The subjects were participants in the Finnish Diabetes Prevention Study, a randomized controlled trial of lifestyle changes including diet, weight loss, and LTPA. There were 107 new cases of diabetes during the 4.1-year follow-up period. Individuals who increased moderate-to-vigorous LTPA or strenuous, structured LTPA the most were 63-65% less likely to develop diabetes. Adjustment for changes in diet and body weight during the study attenuated the association somewhat (upper versus lower third: moderate-to-vigorous LTPA, relative risk 0.51, 95% CI 0.26-0.97; strenuous, structured LTPA, 0.63, 0.35-1.13). Low-intensity and lifestyle LTPA and walking also conferred benefits, consistent with the finding that the change in total LTPA (upper versus lower third: 0.34, 0.19-0.62) was the most strongly associated with incident diabetes. Thus increasing physical activity may substantially reduce the incidence of type 2 diabetes in high-risk individuals.

Cross-calibration of Lunar DPX-IQ and DPX dual-energy x-ray densitometers for bone mineral measurements in women: effect of body anthropometry

When dual-energy X-ray absorptiometry (DXA) instruments are replaced, it is essential to determine if systematic differences in measurements occur. As a part of the Kuopio Osteoporosis Risk Factor and Prevention study (N=14,220), a group of women, aged 36 to 69 yr underwent anteroposterior lumbar spine L2 to L4 (n=89) and proximal femur scans (n=88) by the Lunar DPX and DPX-IQ, respectively, during the same visit. A high linear association (r from 0.944 to 0.989, p<0.001) between the two scanners was established for lumbar spine and proximal femur bone mineral density (BMD). The average DPX values for BMD were 1.1% and 2.0% higher than those of DPX-IQ for the lumbar spine (p<0.001) and Ward's triangle (p=0.001), respectively. Femoral neck BMD values by the DPX were 1.4% lower (p<0.001) compared to DPX-IQ. The difference between trochanter BMD results (0.1%) was not significant (p=0.809). In the femoral neck and trochanter, but not in the lumbar spine or Ward's triangle, the differences in BMD values of the two machines were found to depend on body mass index. After linear formulas based on simple and multivariate linear regression analyses were calculated, the differences were negligible, enabling objective comparison of longitudinal measurements.