Treatment of osteoporosis with denosumab in patients with decreased kidney function

INTRODUCTION

Little is known about treatment of osteoporosis with denosumab (Prolia®) in patients with decreased kidney function. The aim of this retrospective case report study was to investigate effects and side-effects of such treatment.

METHODS

Since 2012, 75 patients with osteoporosis and decreased kidney function had been treated with denosumab (Prolia®) in the osteoporosis outpatient clinic of the department of endocrinology, Bispebjerg Hospital, University of Copenhagen, Denmark, and data were retrospectively collected from the patient records of these patients in 2021.

RESULTS

At baseline, the mean estimated glomerular filtration rate (eGFR) was 34 mL/min (range 9-50) and the median age was 85 years (range 45-103). 95% of the patients had had low-energy fractures, and the bone mineral density T score of the hips was on average - 2.7. All, but one, patients had normal/high parathyroid hormone (PTH) levels. The mean duration of the treatment with denosumab at the follow-up was 5.3 years (range 1.5-10). There was an annual increase of 12% and of 7% in the T score of in the lumbar spine and hip, respectively, compared to the T-scores prior to the denosumab treatment. 20% had a new fracture during the follow-up. 21% had biochemical hypocalcemia following denosumab injection, 7% developed symptoms of hypocalcemia, whereas 4% needed to be hospitalized acutely.

CONCLUSION

Treatment with denosumab of osteoporosis in patients with decreased kidney function (eGFR 9-50 mL/min), with normal/high PTH, seems in general to be well tolerated, with improvement of bone and decreased risk of new fractures.

Long-Term Changes in Sarcopenia and Body Composition in Diabetes Patients with and without Charcot Osteoarthropathy

BACKGROUND

Charcot osteoarthropathy of the foot (COA) can currently only be treated using prolonged periods of immobilization of the affected extremity. Therefore, the hypothesis is that COA leads to altered body composition and increased sarcopenia.

OBJECTIVE

To investigate the changes over several years in sarcopenia, body composition, and fat distribution in diabetes patients with previous COA compared to diabetes patients without previous COA.

METHODS

Prospective observational clinical study. Twenty-one subjects were included and had two DXA scans done with mean 8.6-year intervals to compare changes in lean mass and fat distribution. The lean mass of limbs was used as an estimate of appendicular lean mass (aLM). Fat mass and aLM were then used to detect sarcopenic individuals using different methods. Results and Conclusions. As compared to baseline, both groups had significant loss of lean mass, and diabetics without COA had significant gain of total fat percentage. No statistically different prevalence of sarcopenia between the groups could be established. Likewise, no difference was found in total lean and fat mass changes. None of the groups had statistically significant changes of android fat distribution. As compared with published data on sarcopenia, people with diabetes might be more prone to sarcopenia than healthy individuals.

Quality of diabetes treatment in four orthopaedic departments in the Capital Region of Denmark

INTRODUCTION

Hyperglycaemia during hospitalisation is associated with a longer and more complicated admission and with increased mortality. Therefore, guidelines suggest that blood glucose should be less than 10 mmol/l. In this audit, we aimed to describe the prevalence of diabetes patients at four orthopaedic departments in the Capital Region of Denmark and to measure the quality of in-hospital diabetes management.

METHODS

We conducted audits of medical records in the electronic health record system for two months in 2019. All patients admitted were included in the audit. We gathered information on diabetes status, orthopaedic diagnosis, glycosylated haemoglobin and diabetes management.

RESULTS

Among 2,463 included patients, 10% had diabetes. The three most frequent diagnosis groups were infection, fracture of lower extremity and hospitalised for alloplastic surgery. The number of blood glucose measurements during 24-hour perioperative care was 6.5. Among patients analysed, 10-20% did not have their blood glucose measured in the days following surgery. Among patients, 64% received insulin 1-50% of the required times.

CONCLUSION

We demonstrated that 10% of hospitalised patients suffer from diabetes. The audit also showed that blood glucose is generally measured according to guidelines, whereas the treatment of an elevated blood glucose is far from being given according to guidelines. This may potentially delay recovery and prolong hospitalisation.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Risk factors for development of nephropathy in patients with a diabetic Charcot foot

Objective

Charcot foot is a rare complication to neuropathy and can cause severe foot deformities and ulcerations, which often require prolonged antibiotical treatment. The objective of this retrospective study was to investigate whether this treatment is associated to impaired renal function.

Results

In total, 163 patients were included, of whom 105 (64%) had received β-lactam antibiotics for a mean total duration of 13.0 months. There was a significant increase in the urine albumin/creatinine ratio in the group that received antibiotics (p = 0.017), and the use of antibiotics was associated to a subsequent diagnosis of nephropathy (p = 0.01). Patients treated with antibiotics had a 21.9% risk of developing subsequent nephropathy versus 5.2% for patients not treated with antibiotics. We suggest increased awareness on signs of nephropathy in patients with severe Charcot foot.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05811-5.

Fractures and Osteoporosis in Patients With Diabetes With Charcot Foot

OBJECTIVE

Charcot foot is a serious complication of diabetes, with degeneration of the bones and joints in the foot and ankle. It is unknown whether patients with diabetes with a Charcot foot have an increased risk of osteoporosis and fractures. The aim of this study was to investigate whether patients with diabetes with a Charcot foot have an increased risk of fracture and/or osteoporosis compared with patients with diabetes without Charcot foot.

RESEARCH DESIGN AND METHODS

A Danish register-based, nationwide population-based matched cohort study was conducted. During 1995-2018, we identified 1,602 patients with diabetes with Charcot foot and matched them on sex and date of diagnosis of diabetes with 16,296 patients with diabetes without Charcot foot. We used logistic regression to estimate odds ratios (ORs) with 95% CIs for fracture and osteoporosis. Information about exposure, outcome, and comorbidities was retrieved from the Danish National Patient Register.

RESULTS

Diabetes patients with Charcot foot had higher risk of fractures compared with those without Charcot foot (i.e., ORs for any fracture, lower-leg fracture, foot fracture, and osteoporotic fracture were 1.8 [95% CI 1.6-2.0], 2.4 [2.0-2.8], 2.9 [2.6-3.3], and 1.3 [1.1-1.4], respectively). Furthermore, patients with diabetes with Charcot foot had higher risk of osteoporosis compared with the patients without Charcot foot, with an OR of 1.3 (95% CI 1.1-1.5).

CONCLUSIONS

Patients with diabetes with a Charcot foot have an increased risk of fractures and osteoporosis compared with patients with diabetes without a Charcot foot.

Study protocol for optimising glycaemic control in type 1 diabetes treated with multiple daily insulin injections: intermittently scanned continuous glucose monitoring, carbohydrate counting with automated bolus calculation, or both? A randomised controlled trial

INTRODUCTION

There are beneficial effects of advanced carbohydrate counting with an automatic bolus calculator (ABC) and intermittently scanned continuous glucose monitoring (isCGM) in persons with type 1 diabetes. We aim to compare the effects of isCGM, training in carbohydrate counting with ABC and the combination of the two concepts with standard care.

METHODS AND ANALYSIS

A multi-centre randomised controlled trial with inclusion criteria: ≥18 years, type 1 diabetes ≥1 year, injection therapy, HbA1c >53 mmol/mol, whereas daily use of carbohydrate counting and/or CGM/isCGM wear are exclusion criteria. Inclusion was initiated in October 2018 and is ongoing. Eligible persons are randomised into four groups: standard care, ABC, isCGM or ABC+isCGM. Devices used are FreeStyle Libre Flash and smart phone diabetes application mySugr. Participants attend group courses according to treatment allocation with different educational contents. Participants are followed for 26 weeks with clinical visits and telephone consultations. At baseline and at study end, participants wear blinded CGM, have blood samples performed and fill in questionnaires on person-related outcomes, and at baseline also on personality traits and hypoglycaemia awareness. The primary outcome is the difference in time spent in normoglycaemia (4-10 mmol/L) at study end versus baseline between the isCGM group and the standard care group. Secondary outcomes will also be analysed. Results are expected in 2020.

ETHICS AND DISSEMINATION

Regional Scientific Ethics Committee approval (H-17040573). Results will be sought disseminated at conferences and in high impact journals.Trial registration numberClinicalTrial.gov registry (NCT03682237).

Healing of Diabetic Foot Ulcers in Patients Treated at the Copenhagen Wound Healing Center in 1999/2000 and in 2011/2012

AIM

To describe differences in healing time of diabetic foot ulcers for patients treated at the Copenhagen Wound Healing Center, Bispebjerg Hospital, between the years 1999/2000 and 2011/2012. The Center is highly specialized and receives diabetes patients with hard-to-heal foot ulcers. A further aim is to attempt to find predictors of healing time of diabetic foot ulcers.

METHODS

A retrospective descriptive study of records from patients with diabetic foot ulcer treated at the Copenhagen Wound Healing Center in 1999, 2000, 2011, or 2012. Follow-up data was collected until the 3^rd of August 2018.

RESULTS

Median time (range) to healing was 6 (61.3) months in 1999/2000 and 6.6 (67.8) in 2011/2012 (p = 0.2). About 33% of ulcers were healed, 17% were minor or major amputated, and 1.5% were dead within one year in 1999/2000, whereas 30% of ulcers were healed (p = 0.6), 14% were amputated (p = 0.2), and 12.8% were dead within one year in 2011/2012 (p < 0.001). The single factor found significantly associated with longer ulcer duration was infection. Related to shorter ulcer duration were toe localization of the ulcer and good glycemic control.

CONCLUSION

The median time to healing of a diabetic foot ulcer was long, around 6 months and with a high recurrence rate in 1999/2000 as well as in 2011/2012. Some factors were found to be significantly related to healing time, and intervention addressing these may improve the time to heal, although such interpretations must be taken with precaution from the present study and should be proven in randomized prospective intervention trials.

Long-term effects on the progress of neuropathy after diabetic Charcot foot: an 8.5-year prospective case–control study

Objective

Charcot foot is a severe complication to diabetes mellitus, associated with diabetic neuropathy. Any long-term effects of a Charcot foot on the progress of neuropathy are still largely unexplored. The objective was to investigate whether a previous Charcot foot had any long-term effects on the progress of neuropathy.

Results

An 8.5-year follow-up case–control study of 49 individuals with diabetes mellitus, 24 of whom also had Charcot foot at baseline visit in 2005–2007. Neuropathy was assessed with a questionnaire, biothesiometry, heart rate variability and venous occlusion plethysmography. Of the 49 baseline participants, 22 were able to participate in the follow-up. Twelve had passed away in the meantime. Heart rate variability was unchanged in both groups; from 9.7 to 7.2 beats/min (p = 0.053) in the Charcot group, and 14.3 to 12.6 beats/min (p = 0.762) in the control group. Somato-sensoric neuropathy showed no difference between baseline and follow-up in the Charcot group (from 39.1 to 38.5 V) (p = 0.946), but a significantly worsened sensitivity in the control group (from 25.1 to 38.9 V) (p = 0.002). In conclusion, we found that any differences in somatic or cardial autonomic neuropathy present at baseline had disappeared at follow-up after 8.5 years.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3253-5) contains supplementary material, which is available to authorized users.

Mortality and complications after treatment of acute diabetic Charcot foot

AIMS

Charcot foot is a rare but disabling complication to diabetic neuropathy, and can cause permanent, limb-threatening deformities. The aim of this study was to investigate a population of patients a Charcot foot on a case-by-case basis, in order to assess the consequences of an acute Charcot foot and its complications.

METHODS

The study was conducted a retrospective study of patients admitted to the Copenhagen Wound Healing Center between 1996 and 2015 with the diagnosis of Charcot foot (DM14.6) and diabetes mellitus type 1 or 2 (DE10.X and DE11.X). Physical and electronic records were used, and compared to data from the Danish Diabetes Registry.

RESULTS

In total 392 patients were identified of which 173 were included. There were 26% with type 1 diabetes (initial HbA1c 81.7 ± 21.4 mmol/mol) and 74% with type 2 diabetes (initial HbA1c 66.5 ± 20.3 mmol/mol). Primary off-loading was with a removable walker in 95% of the cases (average off-loading time 8.3 months). The 5-year mortality was 14% with a mean survival time of 12.7 years. There was an association between lack of compliance and occurrence of foot complications, as well as between having a Charcot foot and leaving the workforce.

CONCLUSION

More patients had type 1 diabetes compared to the background population, and they had a higher HbA1c than the general population of diabetes patients. A total of 67% developed complications such as ulcers, while patients non-compliant to treatment did significantly worse than those being compliant. The 5-year mortality was low, 14%, and comparable to diabetes patients without Charcot foot.

A review of bone metabolism and developments in medical treatment of the diabetic Charcot foot

Charcot foot is a rare but severe, and possibly limb-threatening, complication to neuropathy and diabetes mellitus. The current treatment consists of long-term off-loading, and has a large negative impact on the patient's life. Much research has gone into understanding the condition and its biochemical mechanisms, however, the underlying pathogenesis of a Charcot foot is not yet fully understood. In the recent decades several key advances in our understanding of the Charcot foot have been made, both in regards to the changes in bone metabolism and structure an acute Charcot foot can cause, and to the molecular pathways involved in this. This review summerizes the available research into the bone metabolism around a Charcot foot, with an emphasis on the biochemical profile. The existing data regarding attempts at medical treatment is also reviewed, including novel trials targetting specific inflammatory pathways upregulated in the acute diabetic Charcot foot.

Bone mineral density and markers of bone turnover and inflammation in diabetes patients with or without a Charcot foot: An 8.5-year prospective case-control study

BACKGROUND AND AIMS

Charcot foot is a rare but severe complication to diabetes and peripheral neuropathy. It is still unclear if an acute Charcot foot has long-term effects on the bone metabolism. To investigate this, we conducted a follow-up study to examine if a previously acute Charcot foot has any long-term effects on bone mineral density (BMD) or local or systemic bone metabolism.

METHODS

An 8.5-year follow-up case-control study of 44 individuals with diabetes mellitus, 24 of whom also had acute or chronic Charcot foot at the baseline visit in 2005-2007, who were followed up in 2015 with DXA scans and blood samples.

RESULTS

21 of the 44 baseline participants participated in the follow-up. There were no difference in the change in total hip BMD from baseline to follow-up in either the Charcot or the control group (p = 0.402 and 0.517), and no increased risk of osteoporosis in the previous Charcot feet either. From baseline to follow-up, there was a significant difference in the change in levels of fsRANK-L in the Charcot group, but not in the control group (p = 0.002 and 0.232, respectively). At follow-up, there were no differences in fsRANK-L between the groups. The fsRANK-L/OPG ratio also significantly decreased from baseline to follow-up in the Charcot group (3.4 versus 0.5) (p = 0.009), but not in the control group (1.3 versus 1.1) (p = 0.302).

CONCLUSION

We found that diabetes patients with an acute Charcot foot have an elevated fsRANK-L/OPG ratio, and that the level decreased from baseline to follow-up to be comparable to the level in diabetes patients without previous or current Charcot foot. We found no permanent effect of an acute Charcot foot on hip or foot BMD.

Markers of Local Inflammation and Bone Resorption in the Acute Diabetic Charcot Foot

OBJECTIVE

Due to the localized nature of Charcot foot, systemically altered levels of inflammation markers can be difficult to measure. The aim of this study was to investigate whether it is possible to detect an arteriovenous (A-V) flux in any locally produced inflammatory biomarkers from an acute Charcot foot by comparing local and systemic measurements.

METHODS

We included patients with acute diabetic Charcot foot. Blood was sampled from the vena saphena magna on the distal part of the crus bilaterally as well as from the arteria radialis. To minimize the A-V shunting effect, the feet were externally cooled with ice water prior to resampling.

RESULTS

Both before and after cooling, the A-V flux of interleukin-6 (IL-6) between the Charcot feet and the arterial level was significantly higher than the flux between the healthy feet and the arterial level (Δvalue_before: 7.25 versus 0.41 pg/mL, resp., p = 0.008; Δvalue_after: 10.04 versus 1.68 pg/mL, resp., p = 0.032). There were no differences in the fluxes for other markers of inflammation.

CONCLUSION

We have found an increased A-V flux of IL-6 in the acute diabetic Charcot foot compared to the healthy foot in the same patients.

Clinical management of acute diabetic Charcot foot in Denmark

INTRODUCTION

Charcot foot is a severe complication to diabetes mellitus and treatment involves several different clinical specialities. Our objective was to describe the current awareness, knowledge and treatment practices of Charcot foot among doctors who handle diabetic foot disorders.

METHODS

This study is based on a questionnaire survey sent out to healthcare professionals, primarily doctors, working with diabetic foot ulcers and Charcot feet in the public sector of the Danish healthcare system.

RESULTS

The survey obtained a 52% response rate. A temperature difference of > 2 °C between the two feet was the most used method of diagnosing Charcot foot. Along with clinical inspection, temperature difference was also the measurement used for monitoring of healing. None of the suggested formalised classification systems were used to any extent. Most responders use detachable bandages for offloading (83%). All centres use some form of a multidisciplinary team, with the most common permanent members being orthopaedic surgeons (71%), wound specialist nurses (76%), podiatrists (65%), endocrinologists (47%) and diabetes specialist nurses (41%).

CONCLUSION

We conducted a survey of the diagnosis and treatment practices of acute diabetic Charcot foot at diabetes foot clinics in Denmark. The responders seem to follow the international recommendations and guidelines on management of the acute diabetic Charcot foot, despite a lack of Danish guidelines.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Sarcopenia and body composition in diabetic Charcot osteoarthropathy

BACKGROUND

Treatment of Charcot osteoarthropathy (COA) requires restricted walking and offloading for several months, which lead to fat re-distribution and increased sarcopenia.

OBJECTIVES/AIM

To investigate whether subjects with COA have an altered body composition compared to controls.

METHODS

Cross-sectional case-control study of people with diabetes with acute or chronic Charcot osteoarthropathy, matched with otherwise healthy people with diabetes. A total of 49 subjects (distribution ~1:1) had a total body DXA-scanning, measuring appendicular lean mass, android/gynoid and truncal/total body fat distribution ratios.

RESULTS

Sarcopenia frequency was higher in the total population with diabetes overall (9-40%), compared to normal materials. Using two different models for correlating appendicular lean mass to sarcopenia, there were no differences in sarcopenia-rates between the groups (P=0.413 and 0.948 respectively). There was no significant difference in lean tissue mass between the affected and the unaffected leg in the immobilised subject group (P=0.830). The average fat percentage was (29.4-37.7%) in the population with diabetes, compared to a matching background population (24.5-31.9%), whereas there were no significant differences found between the groups (P=0.065). Neither truncal/total fat percent nor android/gynoid fat percent ratios showed differences between the groups.

CONCLUSION

To our knowledge, this is the first published dataset investigating body composition in subjects with Charcot osteoarthropathy. The study population of diabetics were more fat and sarcopenic than normal subjects, whereas no statistically significant impact of Charcot osteoarthropathy was found.

The management of diabetic foot ulcers in Danish hospitals is not optimal

INTRODUCTION

The diabetic foot is a complicated health issue which ideally involves several different specialists to ensure the most effective treatment. The Danish Health and Medicines Authority recently published a national guideline to address the implementation of multidisciplinary teams in the treatment. The objective of this study was to describe the treatment practices at the time the guidelines were launched.

METHODS

A questionnaire-based survey was conducted among Danish hospital departments working with diabetic feet. All public departments were invited by e-mail to participate and the participant answering the questionnaire was identified as knowledgeable about the department's procedures on treatment of diabetic feet. Only one questionnaire per department was allowed.

RESULTS

A total of 62 questionnaires were sent out. We achieved a response rate of ~37% (n = 23). Respondents (n = 13) were mostly orthopaedic surgeons. A classification system of the diabetic foot was rarely or never used, and eight respondents (42%) reported having a multidisciplinary team in accordance with the national guidelines. 73% of the respondents performed some form of surgical intervention on diabetic feet, mainly minor procedures.

CONCLUSION

The study demonstrated that several areas of treatment practices relating to the diabetic foot had potential for improvement as they did not adhere to national Danish guidelines. A follow-up survey, allowing time for local implementation, seems warranted.

The Effect of Oral Loading Doses of Cholecalciferol on the Serum Concentration of 25-OH-Vitamin-D

Background/Objectives: Severe vitamin D deficiency can be treated with oral loading doses of cholecalciferol. Our objective was to develop an algorithm to accurately calculate the amount of cholecalciferol needed for a loading dose, and what factors should be taken into account.Methods: Two studies were conducted on subjects with Vitamin D deficiency. Study 1 was observational, retrospective and included 88 subjects treated with a daily supplementation of cholecalciferol. 60 of these furthermore received a loading dose, calculated by an algorithm.Study 2 was prospective and included 29 subjects treated with a cholecalciferol loading dose, calculated by an algorithm developed based on data from study 1, which included BMI.Results: Baseline 25OH-vit.D was below 25 nmol/L (study 1) and 23 nmol/L (study 2). Subjects were given a single loading dose of cholecalciferol, averaging 172,000 IU (study 1) and 212,000 IU (study 2), based on their baseline 25OH-vit.D level.25OH-vit.D increased by 35 nmol/L (study 1) and 56 nmol/L (study 2)(range 113.0, SD 29.79) respectively. In study 2 the increase lead to an end 25OH-vit.D of 79 nmol/L - not significantly different from the target value of 80 nmol/L (P = 0.46). The increase in 25OH-vit.D in study 1 was significantly lower than in study 2 (P<0.001).Conclusion: When calculating loading doses of cholecalciferol, taking subject BMI into account gives a better estimate of the loading dose of vitamin D3 needed to treat vitamin D deficiency. It does not, however, remove the large interindividual variation in dose-response.

Efficacy and safety of the PPARγ partial agonist balaglitazone compared with pioglitazone and placebo: a phase III, randomized, parallel-group study in patients with type 2 diabetes on stable insulin therapy

BACKGROUND

Treatment of patients with perioxisome proliferator-activated receptor-γ full agonists are associated with weight gain, heart failure, peripheral oedema, and bone loss. However, the safety of partial perioxisome proliferator-activated receptor-γ agonists has not been established in a clinical trial. The BALaglitazone glucose Lowering Efficacy Trial aimed to establish the glucose-lowering effects and safety parameters of the perioxisome proliferator-activated receptor-γ partial agonist balaglitazone in diabetic patients on stable insulin therapy.

METHODS

Four hundred and nine subjects from three countries with type 2 diabetes on stable insulin therapy were randomized to 26 weeks of double-blind treatment with once daily doses of 10 or 20 mg balaglitazone, 45 mg pioglitazone, or matching placebo (n ≥ 99 in each group). The primary endpoint was the efficacy of balaglitazone 10 and 20 mg versus placebo on the absolute change in haemoglobin A(1c) . Secondary endpoints included levels of fasting serum glucose, and changes in body composition and bone mineral density as measured by dual energy X-ray absorptiometry, in comparison to pioglitazone 45 mg. This study is registered with Clinicaltrials.gov identifier: NCT00515632.

RESULTS

In the 10- and 20-mg balaglitazone groups, and in the 45-mg pioglitazone group, significant reductions in haemoglobin A(1c) levels were observed (−0.99, −1.11, and −1.22%, respectively; p < 0.0001) versus placebo. Fasting serum glucose was similarly reduced in all treatment arms. Dual energy X-ray absorptiometry analyses showed that, while balaglitazone at 10 mg caused weight gain and fluid retention compared to placebo, the magnitude of these effects was significantly smaller than that of pioglitazone 45 mg and balaglitazone 20mg. Balaglitazone at either dose did not appear to reduce bone mineral density, while Pioglitazone showed a trend towards a reduction.

CONCLUSION

Patients treated with balaglitazone at 10 mg and 20 mg and pioglitazone at 45 mg showed clinically meaningful improvements in glucose levels and HbA(1c) . With the 10 mg dose, the benefits (glucose & HgA(1c) lowering) and untoward effects (fluid and fat accumulation) were less, results that encourage further studies of this drug candidate.

Effects of acute and chronic attenuation of postprandial hyperglycemia on postglucose-load endothelial function in insulin resistant individuals: is stimulation of first phase insulin secretion beneficial for the endothelial function?

The aim of the study is to determine if attenuation of postprandial hyperglycemia, by acutely and chronically enhancing postprandial insulin secretion in insulin-resistant individuals, improves the endothelial dysfunction. We assessed postoral glucose-load endothelial function in 56 insulin-resistant subjects with the Flow-Mediated-Dilation (FMD) technique. We randomized subjects to intervention/control group, and examined the acute and chronic effect of nateglinide, an oral antidiabetic drug of rapid action. In the intervention group, postoral glucose-load (post-OGL) FMD delta values deteriorated when compared to pre-OGL values, most significantly at 3 h post-OGL, on the following days: on the first study day termed "Baseline day" (p=0.04); on both days after 3 months of nateglinide treatment [with nateglinide administered on study-day "acute+chronic" (p=0.01); and without nateglinide on study-day "Closing day", p=0.001]. Post-OGL changes in the control group were nonsignificant both at Baseline and on Closing day. After a single dose of nateglinide "Acute day", post-OGL FMD deterioration was abolished. There was an increment in post-OGL FMD delta values most significant at 2 h post-OGL (p=0.02). Insulin concentrations increased while glucose concentrations decreased on study-days with nateglinide when compared to study-days without (p=<0.001 for both insulin and glucose). Comparisons for insulin and glucose concentrations between days with nateglinide, and likewise between days without, showed no significant difference. Postglucose load endothelial dysfunction can be prevented by administration of nateglinide, however, after 3 months of nateglinide treatment, this effect is abolished. Chronically increased insulin secretion could counteract the initial beneficial effect of reduced glucose excursions. We found no relationship between postprandial hyperglycemia and post-OGL FMD.

[Charcot's arthropathy]

Charcot's arthropathy is a rare complication to diabetes with peripheral neuropathy. The diagnosis is based on a red, oedematous foot with 2 degrees C difference in skin temperature between the affected foot compared to the unaffected foot. The condition is characterised by fractures, dislocation of joints and deformity. The treatment is off-loading. When the off-loading treatment is completed, the patient should gradually adjust to wearing bespoken shoes. Lifelong control of the feet and shoes is necessary.

Treatment of diabetic ketoacidosis in adults in Denmark: a national survey

The aims of this study were to investigate management routines of diabetic ketoacidosis (DKA) in adult patients in departments of internal medicine in Denmark and to relate current routines of treatment to available evidence. A questionnaire requesting information on management routines of DKA was sent to all departments of internal medicine in Denmark responsible of managing DKA. Fifty-nine departments (88%) returned the questionnaire and/or a copy of their management protocol. At 19 departments (32%), all patients with DKA were managed in an intensive care unit (ICU). Twenty-four different insulin regimens and 21 fluid protocols were identified. Routines of insulin therapy varied in terms of doses and routes of administration. Fifty-eight departments (97%) used isotonic saline for hydration. Potassium supplements were administered as a separate infusion of either isotonic potassium-sodium-chloride (83%) or isotonic potassium-chloride (10%). Recommended volumes to be administered during the first 8h of treatment varied significantly (median 4800ml, range 3750-7700ml). Use of bicarbonate was endorsed by 80%. This study shows significant variations in management routines of DKA in Denmark. In many cases, the treatment routines employed are not supported by evidence from clinical trials. We recommend implementation of national and/or European guidelines for management of DKA in adult patients.

[Diabetic ketoacidosis in Denmark--registry-based estimation of incidence and mortality. Secondary publication]

The aim of this study was to estimate the incidence of diabetic ketoacidosis (DKA) and mortality from DKA using data from public health registries. We extracted information on 4807 admissions during the period 1996-2002 and 137 deaths during the period 1996-2000 with a diagnosis of DKA from the Danish National Patient Registry (NPR) and the Danish Cause of Death Registry (CDR) respectively. The annual incidence of DKA in the general population was estimated to 12.9 per 100,000. Overall mortality was 4%. Death from DKA was associated with increasing age and with somatic comorbidity.

[Treatment of diabetic ketoacidosis in adults in Denmark--need for national guidelines. Secondary publication]

This study examines variations in treatment routines for diabetic ketoacidosis (DKA) in Denmark. All departments of internal medicine in Denmark managing DKA were invited to complete a questionnaire. 88% replied. The study shows significant variations in management routines of DKA in Denmark. In many cases, the routines are not supported by evidence from clinical trials. National guidelines for the management of DKA in adult patients are needed.

Diabetic ketoacidosis in Denmark Incidence and mortality estimated from public health registries

The aims of this study were to estimate incidence of diabetic ketoacidosis and mortality from diabetic ketoacidosis using data from public health registries. Four thousand eight hundred and seven admissions in the period 1996-2002 and 137 deaths in the period 1996-2000 with a diagnosis of diabetic ketoacidosis were identified from the Danish National Patient Registry and Danish Cause of Death Registry, respectively. Annual incidence of diabetic ketoacidosis in the general population was estimated to 12.9 per 100,000, being higher in males than in females (14.4 versus 11.4 per 100,000, p<0.0001). Twelve percent of all patients were classified as Type 2 diabetes, predominantly in patients >50 years. Overall mortality was 4%, being higher in patients >70 years than in patients < or =70 years (15% versus 2%, p<0.0001). One or more additional somatic diagnoses were stated on 77% of the death certificates, most often a diagnosis of cardiovascular (47%) or infectious (30%) diseases. Compared to previous studies, the incidence in the general population seems to have remained unaltered the past 25 years, but may have decreased in younger patients. Older patients with diabetic ketoacidosis differed from younger patients in having a higher mortality and a larger proportion of patients classified as Type 2 diabetes.

[Drug treatment of obesity]

Acceptable adverse effects and a clinical relevant weight loss of 3 to 5 kilograms have been found in long-term randomized clinical trials for sibutramine (Reductil) and orlistat (Xenical); these drugs may be prescribed for treatment of obesity for a duration of one and four years, respectively. This also seems to be the case for rimonabant (Acomplia), which is expected to receive approval in 2005 or 2006. However, until data on morbidity and mortality are available from RCTs, there is no absolute indication for prescribing drugs for treatment of obesity.

[Guidelines for treatment of overweight/obesity, 2006]

Guidelines for evaluation and treatment of overweight and obesity in adults in Denmark are given. These guidelines are evidence-based and are similar to international guidelines.

The impact of idiopathic childhood-onset growth hormone deficiency (GHD) on bone mass in subjects without adult GHD

OBJECTIVE

Despite seemingly adequate growth hormone (GH) treatment during childhood, children with GH deficiency (GHD) have reduced bone mineral density (BMD) at final height. The aim was to evaluate BMD and bone mineral content (BMC) in adults treated for idiopathic childhood-onset (CO) GHD, 18 years after stopping GH treatment.

SUBJECTS AND METHODS

Twenty-six (11 females) patients with idiopathic CO GHD participated. All patients but two had been treated for isolated GHD in childhood. The childhood diagnosis was established by an insulin tolerance test (ITT) and reassessed in adulthood by an ITT (N = 21) or arginine test (n = 5), revealing that 10 patients had GHD according to adult criteria. Accordingly, the patient group was divided into (1) patients who did not have persistent GHD in adulthood and (2) patients who did have persistent adult GHD. Twenty-six healthy subjects acted as age-, gender- and body mass index (BMI)-matched controls.

RESULTS

The patients who did not have persistent GHD had significantly lower IGF-I values and whole-body, femoral neck and lumbar spine BMD compared to controls [0.994 +/- 0.10 vs. 1.114 +/- 0.11 g/cm2 (P = 0.003), 0.842 +/- 0.12 vs. 0.962 +/- 0.11 g/cm2 (P = 0.006) and 1.026 +/- 0.14 vs. 1.127 +/- 0.13 g/cm2 (P = 0.004), respectively]. Femoral neck BMD was significantly reduced in the patients who had persistent GHD, compared to controls (0.842 +/- 0.09 vs. 0.938 +/- 0.11, P = 0.04). Significant correlations were observed between all bone variables and IGF-I in all subjects, whereas no correlations were observed between bone variables and GH peak levels in the 26 patients.

CONCLUSION

In conclusion, we found that (1) patients with idiopathic CO GHD, who at retest in adulthood did not have GHD according to adult criteria, had reduced serum IGF-I and BMD/BMC compared to controls. (2) This observation was also made in the patients who did have persistent GHD in adulthood. The findings may reflect the fact that the present diagnostic criteria for adult GHD (i.e. response to the ITT) do not reflect the clinical consequences of disordered GH-IGF axis in CO GHD young adults who were treated with GH in childhood. Alternatively, despite seemingly adequate GH treatment in childhood an optimal peak bone mass in adolescence may never have been reached in either of the groups. (3) IGF-I levels correlated with clinical signs of the adult GHD syndrome. We believe that further studies on the indications and diagnostic procedures for GH treatment after cessation of linear growth are necessary.

Abnormal bone collagen morphology and decreased bone strength in growth hormone-deficient rats

Patients with growth hormone deficiency (GHD) have an increased risk of bone fractures. In these patients, the well-described decrease in bone mineral density (BMD) and content (BMC) may, however, not alone explain the increase in fracture rate. Accordingly, the aim of this study was to evaluate collagen morphology and bone mineralisation in cortical bone as well as bone strength in GHD rats to try to clarify the explanation for the increased fracture rate. The Dw-4 rat was used as a model for GHD. This strain of rats has an autosomal recessive disorder, reducing GH synthesis to approximately 10% and growth rate to approximately 40-50% when compared to normal control rats. Five male Dw-4 rats were examined at age 12 weeks and five healthy Lewis rats served as age-matched controls. The animals were examined for (1) bone mineral status by dual energy X-ray absorptometry (DXA) and ash weight/bone volume, (2) biomechanical properties, (3) serum insulin-like growth factor I (IGF-I) and IGF binding protein 3 (IGFBP-3), and (4) collagen morphology of cortical bone from the right femurs was examined by scanning and transmission electron microscopy. A significant decrease was found in serum IGF-I, IGFBP-3 and biomechanical properties in GHD rats compared to controls (P < 0.009). While DXA-derived BMD was decreased, no significant difference was found in ash weight/bone volume. Electron microscopy showed a significant decrease in the number and a significant increase in the diameter of collagen microfibrils in GHD rats as compared to their controls (P < 0.009). In conclusion, we report for the first time that collagen morphology in bone is markedly altered in rats with isolated GHD. Whether similar conditions are present in GHD patients need further investigations. The changes described, however, may provide a co-explanation for the increased fracture rate in GHD.

Abnormal sympathoadrenal activity, but normal energy expenditure in hypopituitarism

In this study of 23 hypopituitary patients and 26 healthy controls, we have addressed whether the obese state of substituted hypopituitary patients is facilitated by abnormal sympathoadrenal activity or energy expenditure (EE). All patients received adequate substitution therapy including GH therapy. The investigation program included assessment of sympathoadrenal activity (urinary catecholamines), body composition (dual-energy x-ray absorptiometry), appetite sensations (visual analog scale), and EE (indirect calorimetry in respiration chamber). Twenty-four-hour urinary epinephrine adjusted for lean body mass and fat mass was significantly lower in patients compared with controls. GH and hydrocortisone were single negative predictors of urinary epinephrine. The major determinants of EE in patients were lean body mass and fat mass, explaining 96, 95, and 80% of the variance in 24-h EE, sleeping EE, and basal metabolic rate, respectively. Addition of urinary catecholamines explained another 1-4% of the variance in 24-h EE and basal metabolic rate, respectively. Lean patients exhibited significantly more hunger than obese patients and lean controls. In conclusion, hypopituitary patients have lower sympathoadrenal activity but normal EE, compared with healthy controls. This may reflect a central defect in hypopituitarism, however the possible impact of long-term GH and hydrocortisone treatment requires further attention.

High risk of adrenal insufficiency in adults previously treated for idiopathic childhood onset growth hormone deficiency

The aim was to reevaluate a group of adults treated for idiopathic childhood onset GH deficiency (GHD) after 18 yr without GH treatment. Twenty-six (11 females) patients participated. All but two had isolated GHD. Childhood diagnosis was established by insulin tolerance test (ITT). The patients were retested with an ITT to evaluate adult GH status. In five patients, an arginine and a synacthen test were performed instead of an ITT. Eleven of 25 patients had a subnormal cortisol response to ITT or synacthen. Ten patients had a GH peak less than 3.0 microg/liter (0.5. +/- 0.5 microg/liter), whereas 16 patients displayed a normal GH response (12.3 +/- 10.6 microg/liter) after ITT. IGF-I values were decreased in the patients with a pathological retest as well as in patients with a normal GH response compared with controls (P < 0.005). In 26 idiopathic childhood onset GHD patients, 44% of the patients had developed adrenal insufficiency; 38.5% had persistent GHD in adulthood, using the same test in both childhood and adulthood. Patients having a normal GH test had decreased IGF-I levels, compared with controls, indicating impaired function of a seemingly normal GH axis. It is imperative that pituitary axes other than the GH axis are tested at regular intervals, even in the absence of GHD in adulthood.

Should measurement of body composition influence therapy for obesity?

This paper presents a review on assessment of obesity by measurement of body composition. It is recommended that cross-calibrations between methods are made and that cut-off levels for defining obesity are based on the association between body fat% and morbidity and mortality. The recommendation is made for assessment of obesity to measure body mass index (BMI) and waist circumference in combination with clinical judgment and a disease risk assessment. Assessment of body composition for evaluation of obesity is a valuable tool in research, but currently it does not influence the choice of therapy in an obese individual. An individual who is misclassified by BMI may benefit from measurement of body composition, but not until further evidence and development of current body composition methods are available.

Comparisons of leptin, incretins and body composition in obese and lean patients with hypopituitarism and healthy individuals

OBJECTIVE

To identify possible abnormalities specific for obesity in hypopituitary patients.

STUDY DESIGN

Cross-sectional case-control study. MEASUREMENTS AND STUDY SUBJECTS: Body composition (DEXA) and measurements of fasting plasma levels of glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptides (GLPs), insulin, C-peptide, glucose, leptin and lipids were performed in 25 hypopituitary patients (15 obese, 10 normal weight) and 26 BMI and age-matched healthy controls (16 obese, 10 normal weight). All hypopituitary patients had GH deficiency and received adequate substitution therapy on this and other deficient axes (3 +/- 1).

RESULTS

Fasting GIP-levels were significantly higher in obese hypopituitary patients compared to lean hypopituitary patients (P < 0.01), while the fasting concentrations of GLP-1 and GLP-2 were comparable between obese and lean hypopituitary patients. The same trend was seen in obese healthy controls vs. lean controls. No differences were observed in glucose, insulin or C-peptide between the hypopituitary patients and the controls. Leptin levels were increased in obese hypopituitary patients compared to lean hypopituitary patients when adjusted for gender. At least a 2-fold higher level of leptin was observed in women compared to men in both patient groups and healthy controls. Lean female hypopituitary patients had higher leptin levels than matched controls.

CONCLUSIONS

Fasting levels of GIP were elevated in obese substituted hypopituitary patients, while fasting concentrations of GLPs were similar. Obese hypopituitary patients had the same degree of hyperinsulinaemia, affected glucose tolerance, dyslipoproteinaemia and central obesity as obese healthy controls. Further studies are required to identify the possible biochemical reasons for obesity in patients with apparently well-substituted hypopituitarism.

[Sporadic registration of obesity as secondary diagnosis]

INTRODUCTION

The aim was to examine the extent to which obese patients, who are followed up for an obesity-related disease in an outpatient clinic, are correctly registered with the secondary diagnosis of obesity.

MATERIAL AND METHODS

We investigated the number of patients at the Endocrine Outpatient Clinic, Rigshospitalet, Copenhagen, who were registered in the patient administrative system with the primary diagnosis of type 2 diabetes, and how many of these were registered with the secondary diagnosis of obesity.

RESULTS

Of 233 patients with type 2 diabetes, 79 had a BMI between 25.0 and 29.9 kg/m2 (overweight) and 108 a BMI > 30 kg/m2 (obesity). Thus, 80% of these patients were overweight or obese. Of the 108 patients with a BMI > 30 kg/m2. only 13 (12%) were registered with the secondary diagnosis of obesity, and of 17 severely obese patients with a BMI > 40 kg/m2 only four (24%) were registered with the secondary diagnosis of obesity.

DISCUSSION

Obese patients with type 2 diabetes are seldom correctly registered with the secondary diagnosis of obesity. The actual practice of registration probably causes a large underestimation of the impact, and thereby of the magnitude of the economic cost of and the contribution of obesity to total health care costs. Improved registration of obesity as secondary diagnosis in obesity-related diseases is needed.

[Obesity in Danish hospitals--treatment in the year 2000]

INTRODUCTION

Obesity is of increasing public health concern. The aim of the study was to investigate the treatment of obesity at Danish hospitals in the year 2000, and to compare the results with a similar study from 1987.

MATERIALS AND METHODS

A questionnaire was sent to the heads of departments of internal medicine at all Danish hospitals where such departments exist (64).

RESULTS

Ninety-one percent of the questionnaires were answered. Fewer hospitals (76%) in Denmark treated obesity in 2000 compared to 1987. About 1400 patients were referred, and the treatment of 500-900 patients was concluded yearly. Many departments reject patients when the primary diagnosis for referral is obesity, often because they lack resources or do not have the capacity. Except for university hospitals, obesity was more often treated on an outpatient basis in 2000 than in 1987. Apart from surgery, the same methods were used to treat obesity at the different types of hospitals. Instructions for treatment, long-term outpatient follow-up, quality assurance, evaluation of the treatment, and research in obesity are carried out to some degree at the university hospitals, and only to a small extent at other types of hospitals.

DISCUSSION

Although obesity is becoming an increasing threat to public health, treatment at Danish hospitals has decreased over the last ten years, and in the year 2000 only a few per thousand obese patient were offered treatment by a hospital. Increased focus and resources, as well as development and research targeted specifically on the treatment of obesity are needed.

[Obesity in Danish hospitals--attitudes in the year 2000]

INTRODUCTION

The aim was to investigate the attitudes towards obesity of those responsible for the treatment at Danish hospitals.

MATERIALS AND METHODS

A questionnaire was sent to the heads of departments of internal medicine at all Danish hospitals where such exist (n = 64).

RESULTS

Eighty-nine per cent of the questionnaires were answered. Sixteen per cent believed that obesity is a self-imposed, life-style disease, and 56% answered "perhaps". 66% believed that obesity is a chronic condition or disease, and 32% thought that obese patients should be followed up life-long. Most believed that diseases would be prevented or improved, if obesity were treated, and 72% believed that it was possible to treat obesity. Thirty-five percent answered "perhaps" to whether it is worth the effort to treat obesity, as weight loss seldom lasts in the long term, and 25% answered "perhaps" to whether loss of weight in the obese incurs health risk. Fifty per cent believed that more resources were needed for the treatment of obesity, and that research in obesity should be given more attention, whereas only a few answered in the negative (6-9%). Thirty-three per cent believed that there was a need for public obesity clinics. Only 15% thought that Danish doctors are sufficiently trained to treat obesity, and only 9% answered "no" to whether better treatment of obesity required altered attitudes to obesity among Danish health care personnel.

DISCUSSION

The heads of departments of internal medicine at Danish hospitals had different attitudes to obesity, but most believed that there is a need for altered attitudes, information, and training of Danish doctors and other health care personnel in the treatment of obesity.

Are soft tissue composition of bone and non-bone pixels in spinal bone mineral measurements by DXA similar? Impact of weight loss

Weight loss seems associated with a decrease in bone mineral density (BMD) as measured by absorptiometry, which may be the result of accuracy errors caused by differences in soft tissue between non-bone and bone pixels. The aim was to study the abdominal fat% and thickness in regions corresponding to non-bone, soft tissue-only and bone pixels for spinal BMD measurements by dual energy X-ray absorptiometry (DXA), and to calculate the theoretical errors in measurement of changes in BMD by DXA as a result of changes in soft tissue heterogeneity with weight loss. Abdominal computed tomography (CT) and DXA scans were performed in 34 obese subjects (42.1+/-10.1 years (mean +/- SD), wt: 102.1+/-12.8 kg and BMI: 36.6+/-3.8 kg m(-2)) before and after weight loss (11.3+/-6.9 kg after 1 year). There were some significant differences in fat% and thickness of soft tissue between abdominal regions corresponding to non-bone and bone pixels, respectively, for spinal BMD measurements by DXA, both before and after weight loss. With weight loss there were some changes in the soft tissue heterogeneity, which caused a minor theoretical error (apparent, but false decrease of 1-2%) of borderline significance for the anterior-posterior (AP) spinal BMD by DXA.

Body composition in italian and Danish women

The objective of this cross-sectional study was to compare the body composition and fat distribution measured by dual energy X-ray absorptiometry (DPX, Lunar) in different age decades of age-matched Danish and Italian women. The subjects comprised 133 healthy Italian women (age 20-60 years) age-matched to a representative sub-sample of healthy Danish women (n=375). Total and abdominal body fat tissue mass were measured by dual-energy X-ray absorptiometry. Italian women were shorter and fatter compared with age-matched Danish women, but in middle-age, had a less abdominal fat distribution. There was no difference in total body bone mineral density.

Measurements of body composition by dual-energy X-ray absorptiometry improve prediction of energy expenditure

The prediction of energy expenditure by dual-energy X-ray absorptiometry (DXA) and bioimpedance analysis (BIA) was assessed in 35 healthy individuals of both sexes, with a mean body mass index (BMI) of 23.8 kg/m2 (range 18-33.8), and mean age of 30 years (22-40). Energy expenditure (EE) was measured under standard conditions in a respiration chamber, the total and regional body composition by DXA, and total body composition by BIA. When body composition was measured by BIA, 88.5% of the variation in 24-h EE was explained by lean body mass (LBM); this figure was increased by DXA, where total lean tissue mass (LTM) and total fat tissue mass (FTM) could account for 91.5% of the variation. Also, the prediction of resting energy expenditure (REE) was improved by DXA, from 88.1% to 89.8% (LBM vs. LTM, FTM). Measurements of regional body composition showed that trunk LTM was significantly superior as a predictor, especially of REE and sleeping EE (EE sleep), compared to the peripheral LTM; thus, the predictions of REE were 83% vs. 87% (peripheral vs. trunk), respectively; and the predictions of EE sleep were 83% vs. 89% (peripheral vs. trunk), respectively. Therefore, body composition measurements by DXA improved the prediction of EE. Trunk LTM was a superior predictor, especially of REE and EE sleep, compared to peripheral LTM. In conclusion, the present results suggest that measuring total and regional body composition by DXA can somewhat improve the prediction of EE.

The influence of long-term supplementation with biotin on the prevention of lameness in pasture fed dairy cows

In a double-blind study, the influence of biotin supplementation on lameness in dairy cows was investigated over a 13-mo period. The experimental site was a tropical upland environment and involved over 2705 Holstein and Friesian cows on 20 participating farms. Cows on 10 farms received biotin at a rate of 20 mg/head per day in the concentrate, and cows on 10 other farms received feed without the biotin supplement. Premixes with or without biotin were incorporated into a grain concentrate that was fed at a constant rate to cows at milking. Farmers maintained accurate records of the nature of hoof problems and any treatment applied. Each herd was evaluated for locomotion scores at 8-wk intervals. Locomotion scores were significantly correlated with the number of days with measurable rainfall per month (r = 0.88). The biotin-supplemented herds exhibited better locomotion scores than the unsupplemented herds. In the wet summer period the number of lame cows, as observed by the farmer, were significantly fewer during the rainy period for the biotin-supplemented herds and required fewer antibiotic treatments than unsupplemented herds. Most hoof lesions were most commonly observed in the outer claws of the hind limb. Daily milk production (17.3 vs. 18.5 L) was not affected by biotin supplementation. Reduced milk fat percentage and somatic cell counts of bulk milk were recorded in the biotin supplemented herds during the wet, summer period.

Comparison of resting energy expenditure measurements by ventilated canopy and by respiration chamber

The study compared measurements of resting energy expenditure (REE) by two methods, namely the commercially available ventilated canopy (Medgraphics CCM system) and the respiration chamber. Thirty-five healthy subjects of both sexes with a wide weight range (BMI 18-33.8 kg m-2) were measured on both systems. The linear regression equation was REEcanopy = 0.66 x REEresp.cham. + 61.1 (kJ h-1), and the corresponding SEE% was 8.6%. The correlation was high (r = 0.89). However, the mean REE measured using the ventilated canopy was 41 kJ h-1 (13%) lower than that using the respiration chamber (P < 0.01). The Medgraphics CCM canopy system seems valid for measurements of REE. However, the REE results measured by the canopy were systematically lower than when measured by the respiration chamber, but can be converted by the equation given with an accuracy error of 9%.

Does paracentesis of ascites influence measurements of bone mineral or body composition by dual-energy x-ray absorptiometry?

Measurements of bone mineral content (BMO) and density (BMD) by dual-energy x-ray absorptiometry (DXA) may be affected by changes in soft tissue overlying bone. Furthermore, the accuracy error for body composition determined by DXA may be high in the trunk region due to the complex bone geometry. Our objective was to evaluate the impact of paracentesis on measurements of bone mineral and body composition by DXA. DXA (Norland XR-36; Norland, Fort Atkinson, WI) scans were performed in six patients with cirrhosis of the liver before and after treatment of ascites by paracentesis. There were no significant differences in the spinal BMC (change [delta] = 0.04%) and BMD (delta = -0.9%) (P > .05), nor in total body BMC ([TBBMC] delta = 1.9%) and BMD ([TBBMD] delta = 0.4%) (P > .05). The median volume of ascites drained (6.8 L; range, 1.6 to 14.7) was not significantly different from the median change in total (5.8 kg; range, 2.0 to 16.1) or trunk lean tissue mass ([LTM] 5.8 kg; range, 1.9 to 11.9) (P > .05). The changes in body weight correlated with the changes in trunk LTM (r = .93, standard error of the estimate [SEE] = 1.8 kg, P = .007). Total and regional fat mass were not changed significantly by the paracentesis. We conclude that measurements of total body and spinal bone mineral by DXA are unaffected by large changes in the soft tissue composition and height of the trunk. Furthermore, the change in body composition induced by ascites drainage was accurately determined as a change in total body and trunk LTM on a group level.

Bone mineral in pre- and postmenopausal women with insulin-dependent and non-insulin-dependent diabetes mellitus

The aim of the study was to compare bone mineral density (BMD) and bone turnover in pre- and postmenopausal women with insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM) and normal reference women. In a cross-sectional study 31 and 11 premenopausal and 22 and 21 postmenopausal IDDM and NIDDM patients, respectively, were recruited from an outpatient clinic. BMD in the forearm, spine, femur and total body and biochemical markers of bone turnover were measured and compared with reference values obtained from measurements of normal healthy pre- and postmenopausal women. Postmenopausally, but not premenopausally, IDDM patients had lower BMD values than NIDDM patients. Postmenopausal NIDDM patients had higher BMD value than normal women. The differences in BMD between IDDM and NIDDM patients could be explained statistically by differences in body weight between the NIDMM (obese) and IDDM (lean) women. Markers of bone turnover were significantly higher postmenopausally than premenopausally in both IDDM and NIDDM patients. Osteocalcin was significantly lower in postmenopausal NIDDM compared with postmenopausal IDDM patients and reference values. Otherwise there were no differences in the markers of bone turnover between NIDDM and IDDM patients. In conclusion, postmenopausal IDDM patients have a relatively decreased BMD, whereas NIDDM patients seem to be relatively protected from postmenopausal bone loss.

Leptin in overweight postmenopausal women: no relationship with metabolic syndrome X or effect of exercise in addition to diet

OBJECTIVE

To examine the effect of diet with exercise on serum leptin and whether leptin is associated with the metabolic syndrome X in a high risk population such as overweight postmenopausal women.

STUDY DESIGN AND SUBJECTS

121 healthy overweight, postmenopausal women (aged 49-58y, body mass index (BMI) 25-42 kg/m2) were randomized to: A low-energy-diet, 4.2 MJ/d (n = 51), low-energy-diet + standardized physical exercise (n=49) or no intervention (control: n=21) for 12 weeks, followed by 6 months follow-up without intervention.

MEASUREMENTS

S-leptin was measured by Radio Immuno Assay (RIA), body composition and fat distribution by dual energy X-ray absorptiometry (DEXA) and anthropometry. Factors associated with the metabolic syndrome X and sex hormones were measured.

RESULTS

S-leptin was two-fold higher than in normal-weight postmenopausal women and S-leptin was normalized after weight loss induced by the 12-week low-energy-diet, without any additive effect of the exercise. Of the factors associated with the metabolic syndrome X, serum-leptin correlated significantly only with sex-hormone-binding-globulin and plasminogen-activator-inhibitor-1, whereas factors associated with obesity per se correlated significantly with leptin. Changes in S-leptin correlated with changes in fat tissue mass during the follow-up, but not during the intervention. S-leptin at baseline did not correlate with either short term or long term weight loss.

CONCLUSION

There is no effect of exercise added to diet on S-leptin in overweight postmenopausal women. Leptin does not seem to be associated with the metabolic syndrome X, but rather with fatness. S-leptin is probably associated with both dynamic and static effects of adipose tissue. S-leptin did not predict weight loss.