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.