Weight change in the management of youth-onset type 2 diabetes: the TODAY clinical trial experience

BACKGROUND

The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial documented that metformin plus rosiglitazone, but not metformin plus lifestyle intervention, provided superior durability of glycemic control relative to metformin monotherapy.

OBJECTIVES

We examined weight changes among TODAY participants that completed at least 6 months of treatment, evaluated predictors of lifestyle outcome, and examined whether weight changes were related to cardiometabolic outcomes across treatment arms.

METHODS

The 595 youth with type 2 diabetes, (85.1% of randomized participants aged 11-17 years) completed assessments of weight-related and cardiometabolic measures at months 0, 6, 12 and 24. Repeated measures models were used to investigate associations over time.

RESULTS

Lifestyle intervention did not enhance outcome relative to metformin alone and no predictors of response to lifestyle treatment were identified. However, changes in percent overweight across treatment arms were associated with changes in multiple cardiometabolic risk factors, and decreases of ≥ 7% in overweight were associated with significant benefits over 24 months.

CONCLUSIONS

Although adjunctive intensive lifestyle intervention did not improve weight-related outcomes, weight changes in the full TODAY sample were associated with small, but significant improvements in cardiometabolic status, highlighting the importance of optimizing weight management in youth with T2DM.

Preoperative lifestyle intervention in bariatric surgery: initial results from a randomized, controlled trial

OBJECTIVE

To document preoperative outcomes of a behavioral lifestyle intervention delivered to patients prior to bariatric surgery in comparison to treatment as usual (insurance-mandated physician supervised diet).

DESIGN AND METHODS

After completing a baseline assessment, candidates for surgery were randomized to a 6-month, evidence-informed, manualized lifestyle intervention (LIFESTYLE, n = 121) or to preoperative care as usual (USUAL CARE, n = 119). At 6 months, 187 participants remained candidates for bariatric surgery and were included in the analyses.

RESULTS

LIFESTYLE participants lost significantly more weight than those receiving USUAL CARE [8.3 ± 7.8 kg vs. 3.3 ± 5.5 kg, F(1,183) = 23.6, P < 0.0001], with an effect size of 0.72. Additionally, logistic regression modeling indicated that LIFESTYLE patients were significantly more likely to lose at least 5% of initial body weight than those in USUAL CARE [OR (95% CI) = 2.94 (1.253, 6.903)], as were participants who were heavier [OR (95% CI) = 1.07 (1.001-1.14) for each unit increase in BMI] or with larger improvements in eating behaviors [OR (95% CI) = 1.1 (1.049, 1.145) for each unit increase on the Eating Behavior Inventory).

CONCLUSIONS

A behavioral lifestyle intervention for severely overweight individuals leads to clinically significant weight loss prior to bariatric surgery. Post-surgery follow-up will allow us to examine the impact of the preoperative intervention on postoperative outcomes.

Effect of Ethnicity and Geographical Location on Body Weight, Dietary Restraint, and Abnormal Eating Attitudes

Previous studies have examined the effect of ethnicity on obesity, concerns about shape and weight, and attitudes about eating. We hypothesized that geographical location would also influence these variables, and that students growing up in the northern part of the United States and attending northern colleges would differ from students from the South. To examine this, we studied a random sample of 275 African-Americans (AA) and 224 white college students in the entering class of two northern colleges (University of Pittsburgh or University of Massachusetts) or two southern colleges (Augusta or Paine College). All subjects were weighed and completed the Revised Restraint Scale and the EAT-26. AA women were heavier than white women, with no differences due to geographical location. Despite being thinner, white women reported more dietary restraint than AA women. This difference between AA and white women was apparent in both northern and southern college students. In contrast, geographical location was the strongest determinant of bulimic attitudes; both men and women at northern colleges reported higher bulimia scores than those at southern schools. Thus ethnicity appears to be a major determinant of body weight and attitudes about shape and dieting, whereas geographical location appears to exert greater influence on bulimic attitudes.

Rationale, design and methods of the HEALTHY study behavior intervention component

HEALTHY was a multi-center primary prevention trial designed to reduce risk factors for type 2 diabetes in adolescents. Seven centers each recruited six middle schools that were randomized to either intervention or control. The HEALTHY intervention integrated multiple components in nutrition, physical education, behavior change and communications and promotion. The conceptual rationale as well as the design and development of the behavior intervention component are described. Pilot study data informed the development of the behavior intervention component. Principles of social learning and health-related behavior change were incorporated. One element of the behavior intervention component was a sequence of peer-led, teacher-facilitated learning activities known as FLASH (Fun Learning Activities for Student Health). Five FLASH modules were implemented over five semesters of the HEALTHY study, with the first module delivered in the second semester of the sixth grade and the last module in the second semester of the eighth grade. Each module contained sessions that were designed to be delivered on a weekly basis to foster self-awareness, knowledge, decision-making skills and peer involvement for health behavior change. FLASH behavioral practice incorporated individual and group self-monitoring challenges for eating and activity. Another element of the behavior intervention component was the family outreach strategy for extending changes in physical activity and healthy eating beyond the school day and for supporting the student's lifestyle change choices. Family outreach strategies included the delivery of newsletters and supplemental packages with materials to promote healthy behavior in the home environment during school summer and winter holiday breaks. In conclusion, the HEALTHY behavior intervention component, when integrated with total school food and physical education environmental changes enhanced by communications and promotional campaigns, is a feasible and acceptable mechanism for delivering age-appropriate social learning for healthy eating and physical activity among an ethnically diverse group of middle school students across the United States.

Classification of eating disturbance in children and adolescents: proposed changes for the DSM-V

Childhood and adolescence are critical periods of neural development and physical growth. The malnutrition and related medical complications resulting from eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified may have more severe and potentially more protracted consequences during youth than during other age periods. The consensus opinion of an international workgroup of experts on the diagnosis and treatment of child and adolescent eating disorders is that (a) lower and more developmentally sensitive thresholds of symptom severity (e.g. lower frequency of purging behaviours, significant deviations from growth curves as indicators of clinical severity) be used as diagnostic boundaries for children and adolescents, (b) behavioural indicators of psychological features of eating disorders be considered even in the absence of direct self-report of such symptoms and (c) multiple informants (e.g. parents) be used to ascertain symptom profiles. Collectively, these recommendations will permit earlier identification and intervention to prevent the exacerbation of eating disorder symptoms.

Do changes in mood and concerns about weight relate to smoking relapse in the postpartum period?

The majority of women who quit smoking during pregnancy will resume smoking during the postpartum period. Little is known, however, about the predictors of postpartum relapses to smoking. Changes in mood and increases in concerns about weight are common during the postpartum period, and these factors may affect women's postpartum smoking behavior. In this paper, we present a model of the relationship among mood, weight concerns and postpartum smoking. Data from previous postpartum relapse prevention trials are reviewed and evidence of a connection between changes in mood and weight concerns to postpartum relapse is presented. Directions for future research on the prevention of smoking relapses during the postpartum period, and the roles of mood and weight concerns in smoking relapse are presented.

Is family-based behavioral weight control appropriate for severe pediatric obesity?

OBJECTIVE

Although the efficacy of family-based behavioral treatment for moderate pediatric obesity has been well established, few studies have focused on the treatment of severe obesity. We sought to evaluate the acceptability and feasibility of a family-based intervention for severely obese children.

METHOD

Twenty-four families with children aged 8-12 years who were > or =160% of their ideal body weight participated in a 10-12-session behavioral intervention. Participants were weighed and their heights measured at the start of each treatment session and during a follow-up visit 4-13 (M = 7.8) months posttreatment. Children also completed measures of depressive symptoms and anxiety at pretreatment, posttreatment, and follow-up, and eating attitudes were assessed at pretreatment and follow-up.

RESULTS

One third of the families did not complete treatment. However, children who completed the program lost a significant amount of weight and reported significant improvements in depression, anxiety, and eating attitudes that were maintained over time.

DISCUSSION

A short-term, family-based behavioral intervention was successful in moderating weight gain for most children and had positive effects on children's mood and eating disorder symptoms. Future randomized, controlled trials of longer interventions are necessary to determine the success of this approach.

The characteristics of women smokers concerned about postcessation weight gain

Concern about weight gain after quitting smoking is common among women, however, little is known about the characteristics of women concerned about this weight gain. We characterized concerns about smoking and weight, smoking behaviors and eating attitudes among weight-concerned women smokers. Women (N= 219) were participants in a larger trial comparing different approaches to treating postcessation weight gain concerns, and endorsed considerable concern about postcessation weight gain. Women completed assessments of smoking behavior, nicotine dependence and eating attitudes prior to beginning treatment. Although weight-concerned women smokers expected to gain 16.5 lb after quitting, most were willing to tolerate a weight gain of only 5 lb. A substantial number expressed unwillingness to gain any weight at all. However, weight-concerned women did not have elevated nicotine dependency or aberrant eating attitudes. Thus, although weight-concerned women smokers expected to gain large amounts of weight after quitting, they expressed a willingness to tolerate only minimal weight gain. The discrepancy between expected and tolerable weight gain may undermine efforts to quit smoking in this group of women.

Psychological correlates of functional hypothalamic amenorrhea

OBJECTIVE

To determine whether mood, attitudes, or symptoms of disordered eating discriminated women with functional hypothalamic amenorrhea (FHA) from those with organic causes of amenorrhea and eumenorrhea.

DESIGN

Cross-sectional comparison of women with FHA, women with organic amenorrhea, and eumenorrheic control women.

SETTING

Clinical research center in an academic medical institution.

PATIENT(S)

Seventy-seven women > or =18 years old with time since menarche > or =5 and < or =25 years were recruited by advertisement.

INTERVENTION(S)

Ovulation was confirmed in eumenorrheic control women. Causes of anovulation were carefully documented in amenorrheic participants and LH pulse profiles were obtained to document the diagnosis of FHA. All participants were interviewed and completed questionnaires.

MAIN OUTCOME MEASURE(S)

Self-report measures of dysfunctional attitudes, coping styles, and symptoms of depression and eating disorders.

RESULT(S)

Women with FHA reported more depressive symptoms and dysfunctional attitudes than did eumenorrheic women, but not significantly more than women with organic amenorrhea. However, women with FHA reported significantly more symptoms of disordered eating than did either anovulatory or ovulatory women.

CONCLUSION(S)

The findings are consistent with the hypothesis that FHA is precipitated by a combination of psychosocial stressors and metabolic challenge.

Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weight-concerned women

Women smokers concerned about weight gain (N = 219) were randomly assigned to 1 of 3 adjunct treatments accompanying group smoking cessation counseling: (a) behavioral weight control to prevent weight gain (weight control); (b) cognitive-behavioral therapy (CBT) to directly reduce weight concern, in which dieting was discouraged; and (c) standard counseling alone (standard), in which weight gain was not explicitly addressed. Ten sessions were conducted over 7 weeks, and no medication was provided. Continuous abstinence was significantly higher at posttreatment and at 6 and 12 months of follow-up for CBT (56%, 28%, and 21%, respectively), but not for weight control (44%, 18%, and 13%, respectively), relative to standard (31%, 12%, and 9%, respectively). However, weight control, and to a lesser extent CBT, was associated with attenuation of negative mood after quitting. Prequit body mass index, but not change in weight or in weight concerns postquit, predicted cessation outcome at 1 year. In sum, CBT to reduce weight concerns, but not behavioral weight control counseling to prevent weight gain, improves smoking cessation outcome in weight-concerned women.

Sertraline in underweight binge eating/purging-type eating disorders: five case reports

Control trials show that antidepressants are efficacious in eating disorders. Although selective serotonin reuptake inhibitors (SSRIs) are used in clinical practice, there are relatively few controlled or open trials demonstrating that SSRIs are effective. We report five cases of underweight women with binge eating/purging-type eating disorders who gained weight and had reduced core eating disorder behaviors in response to sertraline.

Cerebrospinal fluid levels of corticotropin-releasing hormone in women with functional hypothalamic amenorrhea

OBJECTIVE

Women with functional hypothalamic amenorrhea are anovulatory because of reduced gonadotropin-releasing hormone drive. Several studies have documented hypercortisolemia, which suggests that functional hypothalamic amenorrhea is stress-induced. Further, with recovery (resumption of ovulation), cortisol decreased and gonadotropin-releasing hormone drive increased. Corticotropin-releasing hormone can increase cortisol and decrease gonadotropin-releasing hormone. To determine its role in functional hypothalamic amenorrhea, we measured corticotropin-releasing hormone in cerebrospinal fluid along with arginine vasopressin, another potent adrenocorticotropic hormone secretagog, and beta-endorphin, which is released by corticotropin-releasing hormone and can inhibit gonadotropin-releasing hormone.

STUDY DESIGN

Corticotropin-releasing hormone, vasopressin, and beta-endorphin levels were measured in cerebrospinal fluid from 14 women with eumenorrhea and 15 women with functional hypothalamic amenorrhea.

RESULTS

Levels of corticotropin-releasing hormone in cerebrospinal fluid and of vasopressin were comparable and beta-endorphin levels were lower in women with functional hypothalamic amenorrhea.

CONCLUSIONS

In women with established functional hypothalamic amenorrhea, increased cortisol and reduced gonadotropin-releasing hormone are not sustained by elevated cerebrospinal-fluid corticotropin-releasing hormone, vasopressin, or beta-endorphin. These data do not exclude a role for these factors in the initiation of functional hypothalamic amenorrhea.

How many donuts is a "binge"? Women with BED eat more but do not have more restrictive standards than weight-matched non-BED women

Theories of disordered eating suggest that binge eating may occur as a response to violations of unrealistically restrictive dietary standards, but there are few direct comparisons of the dietary standards of binge eaters and nonbinge eaters. In this study, we asked obese women with Binge Eating Disorder (BED) and weight- and age-matched women without BED to report the minimum amount of each of eight foods they considered a "binge" and "out of control" to determine whether binge eaters had stricter dietary standards than women without BED. Women with BED did not consider smaller amounts of food a "binge" or "out of control" than did women without BED; however, binge eaters did report that their "typical" and "largest-ever" servings of each of the eight foods were larger than those reported by nonbinge eaters. This suggests that for this group of eating- disordered women, eating behaviors may be a more important intervention target than overly restrictive dietary standards.

Prevalence of binge eating disorder, obesity, and depression in a biracial cohort of young adults

This article examined the prevalence of binge eating disorder (BED), obesity, and depressive symptomatology in a biracial, population-based cohort of men and women participating in a longitudinal study of cardiovascular risk factor development. The Revised Questionnaire on Eating and Weight Patterns was used to establish BED status among the 3,948 (55% women, 48% Black) participants (age 28-40 years). Body mass index (BMI: kg/m2) was used to define overweight (BMI > or = 27.3 in women and > or = 27.8 in men). Depressive symptomatology was assessed with the Center for Epidemiologic Study Depression Scale. Prevalence of BED was 1.5% in the cohort overall, with similar rates among Black women, White women, and White men. Black men had substantially lower BED rates. Depressive symptomatology was markedly higher among individuals with BED. Among overweight participants, BED prevalence (2.9%) was almost double that of the overall cohort. There were no differences in BED rates between over-weight Black and White women. Thus, BED was common in the general population, with comparable rates among Black women, White women, and White men, but low rates among Black men. Obesity was associated with substantially higher prevalence of BED. Treatment studies that target obese men and minority women with BED are indicated.

Postdoctoral clinical-research training in psychiatry: a model for teaching grant writing and other research survival skills and for increasing clarity of mentoring expectations

The authors describe a model for teaching grant writing and other research survival skills to postdoctoral clinical-research fellows in psychiatry and for improving research mentoring. Over the past 4 years, the authors have developed a course on writing grant applications for postdoctoral clinical-research fellows, using peer-review processes modeled after a National Institutes of Health study section. At the same time, the authors have clarified expectations of mentors in ways designed to help fellows prepare "K" (Research Career Development) applications and to receive mentored practice in skills being taught in the course. Sixteen of 30 fellows have succeeded in receiving their first extramural support by the end of their two-year fellowship tenure or during the succeeding year. The authors conclude that by teaching grant-writing skills in a supportive peer environment, providing peer review of proposals, and sharpening expectations of mentors, it may be possible to reduce the time between the end of fellowship and the receipt of the first extramural grant.

Eating behavior following stress in women with and without bulimic symptoms

OBJECTIVE

This study examined the effects of an interpersonal stressor on subsequent calorie intake in females with (N = 20) and without (N = 20) significant bulimic symptomatology.

METHOD

Subjects participated in two laboratory sessions that differed according to experimental condition (stress versus no stress), completed self-report measures of mood and anxiety before and after the experimental task, and were provided with an array of snack foods after each session.

RESULTS

Counter to the hypothesis, women with bulimic symptoms did not differentially increase their intake when exposed to stress. However, results for the intake of each macronutrient indicated that both bulimic and control women increased their consumption of carbohydrates following the stressor. Thus, stress was related to increased carbohydrate consumption by all subjects but did not differentially affect the consumption of women with bulimic symptoms.

CONCLUSIONS

It may be that women with bulimic symptoms are not differentially vulnerable to eating in response to stress or that current laboratory paradigms are unable to detect differences in eating following a stressor.

Differences in salivary habituation to palatable foods in bulimia nervosa patients and controls

OBJECTIVE

Bulimia nervosa (BN) patients have been shown to experience anomalous responses to food and food cues. We investigated the response to food over time by presenting repeated food cues and measuring changes in physiological (ie, salivation) and subjective responses.

METHOD

Subjects were 18 BN women and 18 matched control women. Two palatable food stimuli, regular or frozen yogurt, that varied in macronutrient composition but had similar sensory characteristics, were presented to subjects repeatedly during a laboratory session. After two baseline salivation measures, subjects were presented with eight trials of one of the two yogurts. On Trial 9 a lemon juice dishabituator was presented, with the yogurt stimulus presented again at Trial 10.

RESULTS

We found that control subjects had decreased salivation after repeated food presentations. In comparison, BN subjects failed to show a decrease in salivation. The desire to binge increased over trials for the BN subjects, but remained stable for normals.

CONCLUSIONS

These data suggest that salivary habituation may be abnormal in BN patients.

Addressing women's concerns about weight gain due to smoking cessation

Specific concerns about weight gain following smoking cessation inhibit attempts to quit smoking, especially in women. However, adjunct interventions to prevent weight gain after cessation have generally been successful only in attenuating, rather than preventing, weight gain. More aggressive weight control adjuncts may be necessary to prevent cessation-induced weight gain. On the other hand, weight control programs have not been found to improve long-term smoking abstinence and, in fact, may actually impede abstinence, necessitating a search for alternative approaches to addressing weight concerns. Since the typical amount of weight gain is essentially trivial from a health standpoint, particularly when compared with the health benefits of quitting smoking, the most appropriate clinical strategy may be to combat the weight concerns themselves rather than the weight gain. A second alternative approach is to focus all treatment efforts on smoking cessation alone, to avoid placing excessive burdens on participants resulting from attempting simultaneous changes in multiple health behaviors (i.e., smoking and those related to weight). The rationales for these three clinical approaches to addressing concerns about weight gain-more effective weight control, direct reduction in weight concerns by cognitive-behavioral treatment, and smoking cessation only-are presented, followed by descriptions of the adjunct treatments based on these approaches currently being evaluated in a clinical outcome study with women trying to quit smoking.

Weight cycling, psychological health, and binge eating in obese women

This study examined the relationship between weight cycling and psychological health in 120 obese women. Weight cycling was defined in 2 ways by retrospective self-report: total lifetime weight loss and total number of weight cycles > or = 20 lbs (> or = 9.07 kg). Psychological self-report measures assessed psychiatric symptoms, eating behavior, mood, stress, and perceptions of physical health. Of the 52 associations between weight cycling and psychological parameters, 8 were significant, with the most consistent association being between weight cycling and binge eating. Binge eating was also strongly associated with psychological distress, as found in previous studies. After adjusting for binge eating, however, weight cycling was independently related to only one of the psychological measures: perceived physical health.

Weight cycling, psychological health, and binge eating in obese women

This study examined the relationship between weight cycling and psychological health in 120 obese women. Weight cycling was defined in 2 ways by retrospective self-report: total lifetime weight loss and total number of weight cycles > or = 20 lbs (> or = 9.07 kg). Psychological self-report measures assessed psychiatric symptoms, eating behavior, mood, stress, and perceptions of physical health. Of the 52 associations between weight cycling and psychological parameters, 8 were significant, with the most consistent association being between weight cycling and binge eating. Binge eating was also strongly associated with psychological distress, as found in previous studies. After adjusting for binge eating, however, weight cycling was independently related to only one of the psychological measures: perceived physical health.

Exercise in the treatment of binge eating disorder

OBJECTIVE

In this study, we examined the effects of an exercise intervention in the treatment of obese women with binge eating disorder (BED).

METHOD

Subjects were randomized to one of two 6-month treatment programs that included an identical exercise component (n = 44) or to a delayed treatment control condition (n = 33). Exercise level, binge eating frequency, and depressive symptomatology were assessed pre- and posttreatment.

RESULTS

Women who received active treatment reported significantly greater increases in their weekly exercise frequency than did control subjects. At posttreatment, 81.4% of subjects who had received treatment were abstinent from binge eating. Compared to women who were not abstinent at posttreatment, abstinent women evidenced significant changes in exercise frequency and caloric expenditure. However, weight loss and improvements in depressive symptomatology were not related to exercise participation.

DISCUSSION

These results suggest that exercise may be an important aspect of BED treatment and useful in promoting abstinence from binge eating.

Nocturnal eating in binge eating disorder and matched-weight controls

OBJECTIVE

To examine the association of nocturnal eating (getting up out of bed to eat) with overweight, binge eating, and negative mood or anxiety.

METHOD

Forty overweight women diagnosed with binge eating disorder (BED) and 39 overweight controls monitored their nocturnal eating for an average of eight nights.

RESULTS

Seven instances of nocturnal eating were recorded by 6 patients, all of whom were binge eaters. Foods consumed nocturnally tended to be selected from those favored for binge episodes, and reported control over nocturnal eating was low. Patients reported tiredness, but not poor mood or anxiety, at the nocturnal eating episodes.

DISCUSSION

In this sample, nocturnal eating was associated more with eating disorder than overweight. This report should provide the basis of future work to determine whether nocturnal eating should be evaluated and treated among eating disordered or overweight groups of patients.

Binge eating onset in obese patients with binge eating disorder

In this study we examined whether obese women with binge eating disorder (BED) reporting earlier onset binge eating differed from those with later onset binge eating on salient clinical parameters. Subjects were 112 women who sought treatment for BED. Subjects with early (< or = age 18) and later onset (> age 18) did not differ in age, weight, body mass index, or severity of binge eating. Participants were interviewed using the Eating Disorder Examination (EDE) and the Structured Clinical Interview for DSM-III-R, and completed a weight and diet history questionnaire. Early-onset binge eaters were more likely than those with later-onset to binge-eat before dieting, to have early onset of obesity and dieting, to have longer binge-free periods, and more paternal obesity and binge eating. Early-onset binge eaters also reported more eating-disorders psychopathology, and they were more likely to report a lifetime history of bulimia nervosa and DSM-III-R mood disorder. These data suggest that there are marked differences among BED patients presenting for treatment. Further research is needed to determine whether these differences reflect a different etiology or have implications for treatment.

Diagnosis of binge eating disorder: discrepancies between a questionnaire and clinical interview

Binge eating is a common problem among obese individuals, and a simple, accurate way to identify obese binge eaters is needed. This study measured the concordance of the Binge Eating Scale (BES) and the Eating Disorder Examination (EDE). Women seeking obesity treatment (N = 126) were identified as binge eaters or nonbinge eaters using the BES, and then interviewed by clinicians blind to BES score using the EDE, a semistructured interview considered to be the "gold standard" for eating disorder diagnosis. The BES accurately identified nonbinge eaters; 39 of 42 (92.9%) BES-identified nonbinge eaters were confirmed by the EDE. However, the BES did not accurately identify binge eaters; only 43 of the 83 (51.8%) BES-identified binge eaters were confirmed by the EDE. Reasons for the discrepancy between the BES and the EDE in the identification of binge eaters were explored, and modifications to the BES that might improve its accuracy were considered.

Epidermal growth factor precursor is present in a variety of human renal cyst fluids

Progressive human renal cystic diseases are characterized by proliferation of the epithelial cells lining the cyst. The kidney synthesizes epidermal growth factor and its presence in renal cyst fluid might contribute to renal epithelial cell proliferation. We screened autosomal dominant polycystic kidney disease, acquired renal cystic disease, the von Hippel-Lindau syndrome, multilocular cystic nephroma, multicystic dysplastic kidney disease and simple cyst fluids for the presence of epidermal growth factor by radioreceptor assay, specific radioimmunoassay, immunoprecipitation and immunoblotting. Multiple epidermal growth factor immunoreactive species of approximately 180 kD. and lower molecular weights were present in almost all cyst fluids examined, suggesting endogenous synthesis and limited proteolysis of epidermal growth factor precursor protein in cyst fluid. Tamm-Horsfall protein was detected by enzyme-linked immunosorbent assay in most cysts (for example 55 of 59 autosomal dominant polycystic kidney disease samples). The majority of simple and autosomal dominant polycystic kidney disease renal cysts contained high sodium ion concentration, epidermal growth factor precursor protein and Tamm-Horsfall protein, characteristic of the early thick ascending limb. Rather than the mere presence of epidermal growth factor in renal cyst fluids, increased sensitivity to epidermal growth factor or other mitogens present in renal cyst fluid may be pathogenic in progressive renal cystic disease.

Distribution of membrane phospholipids in the rabbit neural retina, optic nerve head and optic nerve

Since diseases of the neural retina and optic nerve can result in alteration of biological membranes, this study determines similarities and differences in the membrane phospholipid content of the neural retina, optic nerve head, and optic nerve to serve as baseline data. Neural retina, optic nerve head, and optic nerve were dissected, isolated as 5 sets from 20 rabbits and frozen in liquid N2. Separate pooled-tissue extracts were prepared for each set of tissues and phosphorus-31 nuclear magnetic resonance (31P NMR) analyses performed. Ten phospholipids were quantified (respective neural retina, optic nerve head, and optic nerve mole % are given for the 5 major phospholipids detected): phosphatidylcholine (PC), 44.61, 27.67, 26.40; PC plasmalogen or alkylacyl PC (CPLIP); phosphatidylinositol (PI); sphingomyelin (SM); phosphatidylserine (PS), 12.63, 14.77, 15.09; phosphatidylethanolamine (PE), 21.21, 9.59, 8.69; PE plasmalogen (EPLAS), 11.07, 30.96, 33.93; an unidentified (unknown) phospholipid (U) at the chemical-shift value of 0.13 ppm; diphosphatidylglycerol (DPG); and phosphatidic acid (PA), 0.46, 2.92, 1.57. Significant differences between the various tissues were determined by the one-way analysis of variance, using a Scheffé range value of P < 0.05. The neural retina in all phospholipids detected except for the uncharacterized (unknown) phospholipid was significantly different from the optic nerve head tissue. The optic nerve head was significantly different from the optic nerve in PC, CPLIP, PE, EPLAS, U, DPG, and PA. The data provide a baseline for studies on pathologically changed neural retina, optic nerve head, and optic nerve.

A draining sinus tract of obscure etiology: a case report

A patient presented with a draining sinus tract on the lingual alveolus of the posterior mandibular ridge. The source of the sinus tract was not readily apparent. Radiographs created the impression that a lesion of unusual and possibly metastatic origin might be involved. Comprehensive diagnostic tests were ordered, but the source of the lesion remained obscure until a surgical exploration was performed.

Caloric restriction per se is a significant factor in improvements in glycemic control and insulin sensitivity during weight loss in obese NIDDM patients

OBJECTIVE

To examine the effects of caloric restriction, independent of differences in weight loss, on improvements in glycemic control, fasting insulin, and insulin sensitivity.

RESEARCH DESIGN AND METHODS

We randomized 93 obese type II diabetic patients to two different degrees of calorie restriction (1,674 or 4,185 kJ/day; 400 or 1,000 kcal/day) and compared the changes in fasting glucose, fasting insulin, and insulin sensitivity that resulted from a comparable reduction in body weight (11% of initial body weight). Insulin sensitivity was assessed using the minimal model analysis of frequently sampled intravenous glucose tolerance tests.

RESULTS

Despite equal weight losses, subjects in the 1,674 kJ/day (400 kcal) condition had lower fasting glucose levels (7.61 vs. 10.13 mM, P = 0.03) and greater insulin sensitivity (1.79 vs. 1.13, P = 0.04) after weight loss than did subjects in the 4,185 kJ/day (1,000 calorie) condition. Subjects were restudied 15 weeks later when both groups were consuming a 4,185 kJ/day (1,000 kcal/day) diet. Subjects who increased from 1,674 to 4,185 kJ (400 to 1,000 calories) had worse fasting glycemic control in spite of continued weight loss, whereas subjects who remained on 4,185 kJ (1,000 calories) throughout had further improvements in both blood glucose and insulin sensitivity with increased weight loss.

CONCLUSIONS

Both degree of calorie restriction and magnitude of weight loss have independent effects on improvements in glycemic control and insulin sensitivity.

Binge eating disorder should be included in DSM-IV: a reply to Fairburn et al.'s "the classification of recurrent overeating: the binge eating disorder proposal"

Extensive recent research supports a proposal that a new eating disorder, binge eating disorder (BED), be included in DSM-IV. BED criteria define a relatively pure group of individuals who are distressed by recurrent binge eating who do not exhibit the compensatory features of bulimia nervosa. This large number of patients currently can only be diagnosed as eating disorder not otherwise specified (EDNOS). Recognizing this new disorder will help stimulate research and clinical programs for these patients. Fairburn et al.'s critique of BED fails to acknowledge the large body of knowledge that indicates that BED represents a distinct and definable subgroup of eating disordered patients and that the diagnosis provides useful information about psychopathology, prognosis, and outcome (Fairburn, Welch, & Hay [in press]. The classification of recurrent overeating: The "binge eating disorder" proposal. International Journal of Eating Disorders.) Against any reasonable standard for adding a new diagnosis to DSM-IV, BED meets the test.

Lifetime prevalence of major depression and its effect on treatment outcome in obese type II diabetic patients

OBJECTIVE

To assess the lifetime prevalence of major depression (MD) and its relation to glycemic control among a group of non-insulin-dependent (type II) diabetic subjects seeking obesity treatment and to determine whether a history of MD affected response to treatment.

RESEARCH DESIGN AND METHODS

Sixty-six obese subjects with type II diabetes (22 men, 44 women) completed the Inventory to Diagnose Depression-Lifetime Version before a 52-wk behavioral weight-control program. Weight, glycosylated hemoglobin, fasting blood glucose, and mood were assessed at pre- and posttreatment.

RESULTS

Thirty-two percent of the subjects reported a history of MD. Neither a history of MD nor current depressive symptoms were associated with pretreatment glycemic control. However, a history of MD was related to treatment attrition (52.4 vs. 22.2%, P = 0.03). Subjects with and without a history of MD showed comparable improvements in weight, glycemic control, and mood.

CONCLUSIONS

A history of MD among type II diabetic patients seeking obesity treatment was not related to pretreatment glycemic control but was associated with higher rates of attrition from treatment. Individuals with a history of MD who completed the program did not differ from those with no history of MD in response to treatment.

Psychological responses of obese type II diabetic subjects to very-low-calorie diet

OBJECTIVE

Very-low-calorie diets have been shown to produce dramatic improvements in glycemic control in obese subjects with non-insulin-dependent (type II) diabetes. There have been no studies of the psychological responses of diabetic subjects to these diets.

RESEARCH DESIGN AND METHODS

This study examined changes in hunger, depression, and anxiety in 33 obese type II diabetic subjects who were randomly assigned to behavior modification programs that used either a balanced diet of 4185-6277 J/day (1000-1500 cal/day) throughout or included an 8-wk period of a very-low-calorie diet (1674 J/day or 400 cal/day of lean meat, fish, or fowl). Subjects completed the Beck Depression Inventory, the Spielberger State Anxiety Questionnaire, and self-report measures of hunger frequently throughout the 20-wk program.

RESULTS

Both groups experienced significant improvements in depressive symptomatology, anxiety, and lessening of hunger during the course of the program, with no significant differences observed between the balanced diet and the very-low-calorie diet groups.

CONCLUSIONS

Very-low-calorie diets, used in the context of a behavioral weight-control program, result in reductions in hunger and improvements in mood state comparable to those observed on more moderate weight-loss regimens.

Effects of a very-low-calorie diet on long-term glycemic control in obese type 2 diabetic subjects

We tested the hypothesis that the use of a very-low-calorie diet (VLCD) in combination with behavior modification would promote long-term glycemic control in obese type 2 diabetic subjects. Thirty-six diabetic subjects were randomly assigned to a standard behavior therapy program or to a behavior therapy program that included an 8-week period of VLCD. The behavior therapy group consumed a balanced diet of 4200 to 6300 J/d throughout the 20-week program. The VLCD group consumed a balanced diet of 4200 to 6300 J for weeks 1 to 4, followed by a VLCD (1680 J/d of lean meat, fish, and fowl) for weeks 5 to 12. The VLCD group then gradually reintroduced other foods during weeks 13 to 16 and consumed a balanced diet of 4200 to 6300 J/d for weeks 17 to 20. Thirty-three of the 36 subjects completed the 20-week program and the 1-year follow-up. Use of the VLCD produced greater decreases in fasting glucose at the end of the 20-week program and at 1-year follow-up and greater long-term reductions in HbA1. The VLCD group also had greater weight losses at week 20, but weight losses from pretreatment to 1-year follow-up were similar in the two treatment groups. The improved glycemic control with the VLCD appeared to be due to increased insulin secretion, but further research is needed to confirm this.

A "family-based" approach to the treatment of obese type II diabetic patients

Forty-nine obese diabetic patients with obese spouses (diabetic or nondiabetic) were randomly assigned to an alone or together condition. Patients in the alone group participated by themselves in a 20-week behavioral weight control program; their spouses attended assessment sessions only. Patients in the together group attended the program with their spouses; both were targeted for weight loss and taught social support strategies. Weight losses of patients treated alone and together did not differ significantly at posttreatment (19.9 vs. 19.1 lb) or 1-year follow-up (11.6 vs. 7.0 lb). However, there was a significant interaction of treatment and gender; women did better when treated with their spouses, whereas men did better when treated alone. A "family-based" approach was not effective for these obese Type II diabetic patients as a whole but may be helpful for women.

Immediate replacement of two radicularly fractured and avulsed anterior teeth with cylindrical endosseous implants: a case report

Occasionally, absolutely healthy teeth are traumatized to the extent that they must be extracted. The use of cylindrical endosseous implants as single-tooth replacements is gaining acceptance. The case of a healthy young adult who suffered a traumatic injury that rendered his maxillary left central and lateral incisors nonrestorable is reviewed.

Long-term followup of patients treated with 1 or 2, 6-week courses of intravesical bacillus Calmette-Guerin: analysis of possible predictors of response free of tumor

We report our long-term experience with 104 patients treated for recurrent superficial bladder tumors followed for a mean of 48 +/- 2 months (range 6 to 83 months). Patients received 6 weekly intravesical bacillus Calmette-Guerin instillations, and were followed for response with urinary cytology, cystoscopy and bladder biopsy. Patients were considered treatment failures if either urinary cytology or biopsy results were positive for tumor. Of 69 patients who failed the initial treatment course 60 were given an additional 6-week course of therapy. A 6-week course of bacillus Calmette-Guerin was successful in 19 of 55 patients (35%) treated for prophylaxis, 10 of 32 (31%) treated for carcinoma in situ and 6 of 17 (35%) treated for residual tumor. The response rate for the total patient population treated with 1, 6-week course was 34% (35 of 104). Another 6-week course was successful in 32 of 60 patients (53%). The over-all response rate free of tumor for patients treated with either 6 or 12 weeks of therapy was 64%. The mean interval free of tumor was 48 months. We evaluated tumor type, stage and grade in conjunction with muscle invasion to assess potential indicators of response to a second course of bacillus Calmette-Guerin. Of 13 patients with carcinoma in situ and 45 with papillary disease 5 (38%) and 26 (58%), respectively, responded to a second course of bacillus Calmette-Guerin (not significantly different). In contrast, 5 of 8 carcinoma in situ failures (63%) had muscle invasive disease, compared to only 3 of 19 papillary nonresponders (16%) (p less than 0.02). These results suggest that intravesical bacillus Calmette-Guerin for the treatment of superficial bladder tumors is an effective long-term therapy. One 6-week course may be ineffective for some patients and another 6-week course provides long-term survival free of tumor for many course 1 failures. Patients who present with carcinoma in situ after a single 6-week course of intravesical bacillus Calmette-Guerin have a significantly higher risk for muscle invasive disease than those with recurrent papillary tumors.

A double-blind, placebo-controlled trial of fluoxetine plus behavior modification in the treatment of obese binge-eaters and non-binge-eaters

To determine whether fluoxetine is effective in the long-term treatment of obesity and whether it is particularly useful in the treatment of obese binge-eaters, the authors randomly assigned 45 obese subjects (22 with binge-eating problems and 23 without binge-eating) to fluoxetine (60 mg/day) or placebo in a 52-week double-blind trial. The 21 subjects who completed the trial made 13 clinic visits and were taught basic behavior modification strategies. Patients treated with fluoxetine plus behavior modification lost significantly more weight than those treated with placebo plus behavior modification. However, the drug did not appear to have a differential benefit for binge-eaters.

Variables associated with weight loss and improvements in glycemic control in type II diabetic patients in behavioral weight control programs

Because weight loss is difficult to achieve, it would be helpful to determine whether there are subgroups of obese type II diabetic patients who benefit most from participation in a behavioral weight loss program. We studied 178 obese patients with type II diabetes, who participated in a 12-20 week behavioral weight loss program and were followed for 1 year after the program to determine whether age, gender, percent overweight, medication, duration of diabetes or fasting glucose were related to weight loss and/or to the magnitude of improvement in glycemic control experienced with weight loss. Gender was the only variable related to weight loss; males lost more weight and had greater decreases in percent overweight than females. The variable most strongly related to improvement in glycemic control was pretreatment fasting glucose level; patients with higher initial glucose levels experienced the greatest improvements in control. There was no evidence to support the belief that patients on insulin have poorer weight losses or that patients with long-duration diabetes benefit less from weight reduction than those with recent-onset diabetes.

Depressive symptomatology in obese adults with type II diabetes

This study compared depressive symptomatology in 32 obese subjects with type II (non-insulin-dependent) diabetes (16 men, 16 women) and their obese nondiabetic spouses. All subjects completed the Beck Depression Inventory (BDI) before participation in a behavioral weight-loss program. Diabetic subjects reported significantly more depressive symptomatology than their overweight nondiabetic spouses (10.6 +/- 6.4 vs. 7.5 +/- 6.2, P less than 0.04). Diabetic subjects scored higher than their spouses on 15 of 20 BDI items, with significant differences in feelings of being punished, perceived appearance, and interest in sex. Mean BDI score in the diabetic spouses was similar to that observed in the first 123 diabetic subjects to enter the weight-loss program (BDI 11.2 +/- 6.9). Further studies are needed to determine whether diabetic subjects differ from age-, sex-, and weight-matched nondiabetic individuals in clinical depression and depressive symptomatology.

Analysis of changes in eating behavior and weight loss in type II diabetic patients. Which behaviors to change

To identify the behavior-change strategies that are most clearly related to weight loss, 106 patients with type II (non-insulin-dependent) diabetes completed the Eating Behavior Inventory (EBI) before and after participating in a behavioral weight-loss program and at 1-yr follow-up. The EBI is a standardized questionnaire that assesses behavioral strategies typically taught in a behavioral weight-loss program. Pretreatment scores on the EBI were not related to weight-loss outcome, but changes on the EBI in the direction of more frequent use of appropriate strategies were related to weight loss at both posttreatment and 1-yr follow-up. Specific strategies related to weight loss at both times were 1) eating foods that help in losing weight, 2) recording foods eaten, 3) refusing food offered by others, and 4) being able to stop eating when appropriate. However, few patients maintained frequent use of these strategies at follow-up. It is concluded that weight-loss programs should focus on the strategies most strongly related to weight loss and try to improve long-term use of these techniques.

Type II diabetic subjects lose less weight than their overweight nondiabetic spouses

To determine whether diabetic individuals have more difficulty losing weight than nondiabetic individuals, 12 overweight diabetic subjects (6 men, 6 women) and their overweight nondiabetic spouses were treated together in a behavioral weight-control program. Diabetic and nondiabetic subjects did not differ in age, weight, or percent overweight. Weight losses of nondiabetic spouses were significantly greater than those of diabetic patients (13.4 +/- 1.7 vs. 7.5 +/- 1.4 kg; P less than .01). Differences emerged by wk 5 and became greater over the 20-wk program. Nondiabetic subjects reduced their intake significantly more than diabetics, suggesting that differences in dietary adherence were responsible for the differences in weight loss.

Giant cell lichenoid dermatitis

A case of drug-induced lichenoid dermatitis with an unusual epidermotropic multinucleated giant cell inflammatory response is reported. The patient is a 52-year-old white woman who is steroid-dependent because of long-standing systemic lupus erythematosus. At the time of presentation of her generalized papulosquamous pruritic eruption, she was taking oral antihypertensive medications (methyldopa and chlorothiazide). After discontinuation of these medications and local treatment with topical corticosteroids, the skin eruption dramatically improved. Microscopically, the skin lesions had a lichenoid inflammatory pattern, with multiple cytoid bodies, multinucleated giant cells, and a mixed chronic inflammatory infiltrate that included lymphocytes, histiocytes, and eosinophils.

Subclinical eating disorders and glycemic control in adolescents with type I diabetes

Several recent case reports have shown that anorexia nervosa and bulimia negatively affect glycemic control in diabetic patients. However, there have been no systematic studies to assess the prevalence of clinical or subclinical eating disorders among diabetic patients or to determine the impact of such disturbances on glycemic control. This study reports a survey of 202 adolescents, aged 12-18 yr, seen in the Diabetes Clinic, Children's Hospital of Pittsburgh, who were asked to complete the Binge Eating Scale (BES) and the EAT-26 questionnaire. Responses of diabetic patients to the EAT-26 questionnaire were compared with those of a nondiabetic control group and were related to measures of glycemic control. Diabetic subjects scored higher on the total EAT-26 than nondiabetic control subjects, ordinarily indicative of more eating pathology. However, diabetic subjects scored higher only on the dieting subscale of this questionnaire, probably reflecting adherence to the diabetes dietary regimen. Subjects with diabetes scored lower, or did not differ significantly, from nondiabetic control subjects on measures of oral control and bulimia. Among diabetic subjects, self-reported bulimic behaviors were related to poorer glycemic control. Patients with the highest scores on the BES had an average HbA1 of 13.1% compared with 11.8% for age- and sex-matched patients at the 50th percentile, and 10.8% for patients in the lowest 10th percentile. Further studies are needed to determine whether modification of these eating behaviors would improve glycemic control.

Binge eating and dietary restraint in obese patients

The present study was conducted to determine the prevalence and severity of binge eating among 432 women seeking behavioral treatment for obesity and to assess the relationship between binge eating and dietary restraint. Subjects completed standardized self-report questionnaires which assessed the severity of binge eating and habitual dietary restraint. Binge eating was extremely prevalent, with 46% of subjects reporting serious problems. Serious binge eating was more common in younger and heavier subjects. Further, binge eating severity was significantly related to overall dietary restraint. The current findings indicate that the treatments of binge eating may need to be considered in planning behavioral programs for the obese.

Mood changes in behavioral weight loss programs

Ten studies investigating the relationship between mood change and weight loss in behavioral weight loss programs were reviewed. Significant positive changes in mood were observed in 6 of the 10 studies. There was no evidence to indicate that untoward reactions to dieting were frequent, that patients with juvenile-onset obesity experienced more negative mood changes than those with adult-onset obesity, or that dropping out of treatment was a response to increasing depression. The positive changes in mood were related to active participation in a treatment program, and occurred in behavioral and nonbehavioral treatment programs. Differences between the studies reviewed and the earlier research on mood and weight loss are discussed and suggestions made for subsequent studies of mood changes during weight reduction.