POS0525 ARTHRITIC PAIN AS A SURROGATE MARKER FOR ASYMPTOMATIC CARDIOVASCULAR RISK FACTORS: OFFERING PRACTITIONERS A ‘TEACHABLE MOMENT’

Background:

Cardiovascular diseases (CVD) are the number one cause of death worldwide. CVDs are linked to well established risk factors: obesity, hypertension (HTN), dyslipidaemia (DL) and diabetes mellitus (DM)1. While targeting risk factors reduces the burden of CVD, this is often challenging because they are largely asymptomatic and patients are therefore unlikely to seek medical attention. Arthritis, in contrast, causes pain and functional impairment prompting presentation to a healthcare practitioner. Patients with arthritis of varying aetiologies (such as osteoarthritis2, gout3, rheumatoid arthritis4) have been shown to have an increased risk of CVD.

Objectives:

To examine the relationship between arthritis and DM, HTN and DL in adults of all age groups. A secondary objective was to examine whether this relationship existed independent of obesity.

Methods:

Data from the 2017-18 Australian Bureau of Statistics National Health Survey included 13,776 participants, categorised into young (18-39 years), middle aged (40-64 years) and older (≥65 years) adults. Blood pressure, height and weight were measured. BMI was calculated and participants classified as obese (≥30 kg/m2) or non-obese. HTN was defined as > 140/90mmHg. Participants were asked if they had arthritis of any form, DL or DM diagnosed by a doctor. Logistic regression models estimated odds ratios with 95% CI for prevalence of arthritis associated with CVD risk factors.

Results:

Arthritis was reported by 3.9% of young adults, 28.8% of middle-aged adults, and 54.5% ofolderadults. In all three age groups, arthritis was associated with significantly increased odds of obesity, HTN, DL and DM. For example, in middle-aged adults, having arthritis was associated with increased odds of obesity (1.75, 95% CI 1.54-2.01), HTN (1.78, 1.60-2.04), DL (2.14, 1.84-2.49) and DM (1.64, 1.33-2.03). These associations remained statistically significant after adjustment for obesity.

Conclusion:

Compared to those without arthritis, adults with arthritis were at increased risk of obesity, HTN, DM and DL. The increased risk of HTN, DM and DL was independent of obesity and tended to be higher in younger adults. These data suggest that a patient’s presentation with symptomatic arthritis of any aetiology and at any age, may be used opportunistically as a “teachable moment” for screening for asymptomatic CVD risk factors in higher-risk individuals. This provides practitioners an opportunity to manage both arthritis and CVD risk in parallel, rather than in silos.

References:

[1]World Health Organisation. (2017). “Cardiovascular Diseases.” from https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases(cvds).

[2]Wang, H., et al. (2016). “Osteoarthritis and the risk of cardiovascular disease: a meta-analysis of observational studies.” Scientific reports 6: 39672.

[3]Singh, J. (2015). “When gout goes to the heart: does gout equal a cardiovascular disease risk factor?” Annals of the Rheumatic Diseases 74: 631-634.

[4]England, B. R., et al. (2018). “Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications.” British Medical Journal 361: k1036.

Table 1.

Prevalence of CVD risk factors in adults with and without arthritis.

Young18-39 yoMiddle Aged40-64 yoOlder≥65 yoNo arthritisn = 3773Arthritisn = 157OR (95% CI)*adjusted for obesityNo arthritisn = 4055Arthritisn = 1638OR (95% CI)*adjusted for obesityNo arthritisn = 1891Arthritisn = 2262OR (95% CI)*adjusted for obesityObesity473322.07 (1.36-3.16)8685271.75 (1.54-2.01)3266101.89 (1.62-2.21)HTN131142.72 (1.53-4.84)2.35 (1.17-4.70)*7454961.78 (1.60-2.04)1.59 (1.37-1.84)73010911.48 (1.31-1.68)1.35 (1.18-1.55)*DM1945.7 (1.74-15.37)4.87 (1.34-17.69))*2361511.64 (1.33-2.03)1.37 (1.08-1.73)*2563991.37 (1.15-1.62)1.15 (0.95-1.39)*

Disclosure of Interests:

None declared

Saksenaea vasiformis infections: A case of an immunocompetent adult after mild injury and a literature review

Saksenaea vasiformis is an emerging human pathogen, belonging to the order Mucorales of the subphylum Mucormycotina, most often associated with rhino-cerebral, cutaneous and subcutaneous infections following trauma. A review of the published literature was attempted on the occasion of a cutaneous leg infection with favorable outcome in a young immunocompetent man after mild injury. The overall aim was the facilitation of the study and the integrated understanding of this kind of fungal infections.

Clinical Obesity Services in Public Hospitals in Australia: a position statement based on expert consensus

We aimed to describe the current state of specialist obesity services for adults with clinically severe obesity in public hospitals in Australia, and to analyse the gap in resources based on expert consensus. We conducted two surveys to collect information about current and required specialist obesity services and resources using open-ended questionnaires. Organizational level data were sought from clinician expert representatives of specialist obesity services across Australia in 2017. Fifteen of 16 representatives of current services in New South Wales (n = 8), Queensland (n = 1), Victoria (n = 2), South Australia (n = 3), and the Australian Capital Territory (n = 1) provided data. The composition of services varied substantially between hospitals, and patient access to services and effective treatments were limited by strict entry criteria (e.g. body mass index 40 kg/m² or higher with specific complication/s), prolonged wait times, geographical location (major cities only) and out-of-pocket costs. Of these services, 47% had a multidisciplinary team (MDT), 53% had an exercise physiologist/physiotherapist, 53% had a bariatric surgeon and 33% had pharmacotherapy resources. Key gaps included staffing components of the MDT (psychologist, exercise physiologist/physiotherapist) and access to publicly funded weight loss pharmacotherapy and bariatric surgery. There was consensus on the need for significant improvements in staff, physical infrastructure, access to services, education/training in obesity medicine and targeted research funding. Based on the small number of existing, often under-resourced specialist obesity services that are located only in a few major cities, the vast majority of Australians with clinically severe obesity cannot access the specialist evidence based treatments needed.

A review of the nutritional challenges experienced by people living with severe mental illness: a role for dietitians in addressing physical health gaps

People experiencing a severe mental illness (SMI), such as schizophrenia, schizoaffective disorder, bipolar affective disorder or depression with psychotic features, have a 20-year mortality gap compared to the general population. This 'scandal of premature mortality' is primarily driven by preventable cardiometabolic disease, and recent research suggests that the mortality gap is widening. Multidisciplinary mental health teams often include psychiatrists, clinical psychologists, specialist mental health nurses, social workers and occupational therapists, offering a range of pharmacological and nonpharmacological treatments to enhance the recovery of clients who have experienced, or are experiencing a SMI. Until recently, lifestyle and life skills interventions targeting the poor physical health experienced by people living with SMI have not been offered in most routine clinical settings. Furthermore, there are calls to include dietary intervention as mainstream in psychiatry to enhance mental health recovery. With the integration of dietitians being a relatively new approach, it is important to review and assess the literature to inform practice. This review assesses the dietary challenges experienced by people with a SMI and discusses potential strategies for improving mental and physical health.

Preventing weight gain and increased waist circumference during the first two years after antipsychotic initiation in youth with first-episode psychosis

Background

We recently demonstrated that weight gain could be prevented in young people experiencing a first-episode of psychosis commencing treatment with antipsychotics. A 12-week, intensive lifestyle and life skills intervention – the Keeping the Body in Mind program, – was delivered by dedicated nursing, dietetic and exercise physiology clinicians, for new referrals with < one month of antipsychotic exposure. (Curtis et al., Early intervention in psychiatry, in press). At the conclusion of the intervention the 16 young people participating in the program experienced a mean weight gain of 1.8 kilograms, and a mean increase in waist circumference of 0.1 centimeters. The participants were followed up for two years after initial referral.

Methods

During the two-year follow-up, participants had continuing access to an in house gym and weekly cooking groups, but without the same intensity of follow-up. Two year follow-up data were obtained from 11 participants form the original cohort.

Results

Mean weight gain at two-year follow-up was 0.90 (SD 8.7) kilograms, and this difference was not statistically significant [t (10) = 0.3, NS]. Waist circumference decreased by 0.7 (SD 7.7) centimeters, which was not t statistically significant [t (10) = 0.3, NS]. Nine of the participants (82%) did not experience clinically significant weight gain two years after initiation of antipsychotic medication.

Conclusion

This two-year follow-up data demonstrated that it is feasible to prevent weight gain in youth with first-episode psychosis over the first two years of treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Not so sweet: autoimmune diabetes mellitus on triple therapy for chronic hepatitis C infection

BACKGROUND

Triple therapy with pegylated interferon, ribavirin and a protease inhibitor has proven efficacy in hepatitis C infection and is currently the standard of care. Interferon-based therapies have been, rarely, associated with the development of Type 1 diabetes mellitus, but few cases have yet been reported in triple therapy for hepatitis C.

CASE REPORT

We describe a case of autoimmune Type 1 diabetes developing in a 23-year-old woman after initiation of triple therapy for chronic hepatitis C virus infection. The patient had the IL-28B gene polymorphism rs12979860 CT genotype, which is associated not only with antiviral therapy response but also with diabetes risk after liver transplantation for hepatitis C.

CONCLUSION

Further studies are required to determine which individual characteristics may identify patients who are at risk of developing Type 1 diabetes when treated with interferon-based regimens for hepatitis C infection.

Properties of polidocanol foam in view of its use in sclerotherapy

Foam sclerotherapy is a widely used method to treat varicose veins disease. It is easy to use and apply, affordable, and has high efficiency that depends on foam stability upon injection. Since sclerotherapy is usually applied in a medical doctor's office, one of the most employed methods to generate foam is based on the Tessari technique which uses pumping cycles of liquid and air in-and-out of a double syringe system. Finally, the produced foam exits through a small orifice (∼2mm) at the output of a three-way valve. The present work shows results regarding the factors that may influence foam stability (liquid to air ratio, type of connector, syringe diameter, number of pumping cycles, etc.) of a commonly used sclerosing agent (polidocanol). Furthermore, an effort is made to evaluate the effect of adding different substances on the stability of polidocanol foams (0.5% w/w) by altering the surface tension or/and the bulk and interfacial rheological properties of the fluids. It is shown that adding small concentrations of nonionic surfactants can increase foam stability with just a very small variation of the mean bubbles size.

The effects of antipsychotic switching on diabetes in chronic schizophrenia

BACKGROUND

People with severe mental illness have a 20-year life-expectancy shortfall. The majority of antipsychotic medications are associated with obesity and heightened diabetes risk. People with severe mental illness less frequently achieve benchmarked diabetes care, often attributed to poor adherence, lower clinical attendance and documented medical biases in treatment. This case is presented to highlight the profound effect medication change can have on diabetes control.

CASE REPORT

A 56-year-old man with a 42-year history of schizophrenia had required clozapine treatment for the preceding 14 years. Type 2 diabetes and obesity occurred within 4 years of clozapine instigation. Glycaemic control had been continuously poor, despite frequent contact with diabetes services and multiple medications, including insulin at a dose exceeding 200 IU daily. Request for consideration of antipsychotic review and close interaction with the psychiatry team was initiated at the diabetes outpatient clinic. A gradual medication switch from clozapine to aripiprazole was associated with a reduction in HbA(1c) from 80 to 50 mmol/mol (9.5 to 6.7%) over 4 months, associated with a weight loss of 10 kg. Over the ensuing 2 years, the improvement in HbA(1c) has endured, with total weight loss of 13 kg and halving of insulin requirements.

CONCLUSION

This case illustrates the benefits of engagement between endocrinologists and psychiatrists to achieve the shared goal of improved physical health in severe mental illness. Greater interdisciplinary collaboration will help bridge the life-expectancy gap in severe mental illness and may assist in preventing disabling diabetes complications in this vulnerable patient group.

Bariatric surgery for type 2 diabetes: to whom and when?

Achieving clinical and biochemical targets in type 2 diabetes mellitus (diabetes) is fundamental to preventing diabetic microvascular and macrovascular complications. These clinical imperatives are made more challenging in the setting of obesity. This review examines the evidence for bariatric surgery as a means of optimizing diabetes care, addressing diabetes resolution, glucose and lipid metabolism and cardiac effects. Mechanistic evidence of diabetes amelioration is summarized. The question of when bariatric surgery should be offered in the course of obesity-associated diabetes is discussed. Current guidelines and specialist society recommendations for bariatric surgery in diabetes are summarized.

Inflammatory biomarkers predict depressive, but not anxiety symptoms during aging: the prospective Sydney Memory and Aging Study

This study addresses the paucity of research on the prospective relationship between a range of inflammatory markers and symptoms of depression and anxiety during aging. In the Sydney Memory and Aging Study, the relationships between remitted depression, current and first onset of symptoms of depression or anxiety (Geriatric Depression Scale and Goldberg Anxiety Scale (GDS, GAS), and markers of systemic inflammation (C-reactive protein (CRP), interleukins-1β, -6, -8, -10, -12, plasminogen activator inhibitor-1 (PAI-1), serum amyloid A, tumor necrosis factor-α, and vascular adhesion molecule-1) were investigated. The sample consists of N=1037 non-demented community-dwelling elderly participants aged 70-90 years assessed at baseline and after 2-years. All analyses were adjusted for gender, age, years of education, total number of medical disorders diagnosed by a doctor, cardiovascular disorders, endocrine disorders, smoking, body mass index, currently using anti-depressants, NSAIDS or statins and diabetes mellitus. The results show a significant linear relationship between increasing levels of IL-6 and depressive symptoms at baseline only, whereas IL-8 was associated with depressed symptoms at baseline and at 2 years follow-up. In addition, IL-8 was associated with first onset of mild to moderate depressive symptoms over 2 years. Logistic regression analyses showed that PAI-1 (OR=1.37, 95% CI=1.10-1.71, p=0.005) was associated with remitted depression. Results for anxiety symptoms were negative. The findings are suggestive of IL-6 and IL-8 being associated with current symptoms and IL-8 being associated with first onset of depressive symptoms, whereas PAI-1 could be regarded as a marker of remitted depression.

Obesity is associated with activated and insulin resistant immune cells

BACKGROUND

Obesity and type 2 diabetes mellitus are characterized by insulin resistance and 'low-grade inflammation'; however, the pathophysiological link is poorly understood. To determine the relative contribution of obesity and insulin resistance to systemic 'inflammation', this study comprehensively characterized circulating immune cells in different grades of obesity.

METHODS

Immune cell phenotypes and activation status were analysed by flow cytometry cross-sectionally in morbidly obese (n = 16, body mass index (BMI) 42.2 ± 5.4 kg/m2), overweight (n = 13, BMI 27.4 ± 1.6 kg/m2) and normal weight (n = 12, BMI 22.5 ± 1.9 kg/m2) subjects.

RESULTS

Obese, but not overweight subjects, had increased activation marker expression on neutrophils, monocytes, T-lymphocytes and polarization of T helper cells towards a pro-inflammatory type 1-phenotype (Th1). Th1 numbers correlated positively with the degree of insulin resistance (homeostasis model assessment, p < 0.05). Lymphocytes from obese subjects showed reduced insulin-stimulated AKT-phosphorylation in vitro. Supra-physiological insulin concentrations did not affect T-cell differentiation, which under normal circumstances would promote an anti-inflammatory T helper type 2-phenotype.

CONCLUSIONS

These results show that morbid obesity is characterized by circulating immune cells that are activated and insulin resistant, with the T-cell balance polarized towards a pro-inflammatory Th1 phenotype. The loss of insulin-induced suppression of inflammatory phenotypes in circulating immune cells could contribute to the systemic and adipose tissue inflammation found in morbid obesity.

The effects of weight loss and gastric banding on the innate and adaptive immune system in type 2 diabetes and prediabetes

CONTEXT

Obesity-related chronic inflammation is implicated in the pathogenesis of type 2 diabetes (T2D).

OBJECTIVE

The objective of the study was to determine the effects of weight loss on immune cells in T2D and prediabetes.

DESIGN AND SETTING

Thirteen obese subjects with T2D or prediabetes underwent 24 wk dietary energy restriction with gastric banding surgery at 12 wk.

MAIN OUTCOME MEASURES

Measures included weight, waist, and insulin resistance; surface activation marker expression on circulating immune cells; T-helper cell polarization: type 1 (Th1), type 2 (Th2); adipose tissue macrophage number and activation in sc and visceral adipose tissue.

RESULTS

Mean total weight loss was 13.5%. There were significant decreases in expression of proinflammatory activation markers: granulocyte CD11b, monocyte CD66b, and T cell CD69 and CD25. Proinflammatory Th1 cell numbers fell by greater than 80%, as did the Th1 to Th2 ratio. The fall in Th1 to Th2 ratio related to weight (P < 0.05) and waist loss (P < 0.05). Reduction in immune cell activation was more pronounced in subjects with prediabetes. Weight and abdominal fat loss were predicted by lower activation of adipose tissue macrophage in sc and visceral adipose tissue (P < 0.05).

CONCLUSIONS

Energy restriction before and after gastric banding attenuates activation of circulating immune cells of the innate and adaptive immune system in T2D and prediabetes. The role of immune cells in the chronic inflammation of obesity and T2D requires further investigation.

Antiretroviral therapy and the human immunodeficiency virus--improved survival but at what cost?

Patients infected with human immunodeficiency virus are living longer since the introduction of combination antiretroviral therapy more than a decade ago - but at what cost? Highly active antiretroviral therapy has been associated with lipodystrophy and associated metabolic derangements such as dyslipidaemia, insulin resistance and diabetes. These complications are likely to contribute to an increased risk of premature and accelerated atherosclerosis with growing concern about potential cardiovascular consequences.

Do gene-environment interactions influence fasting plasma lipids? A study of twins

BACKGROUND

The aims of this study were to determine the influence of smoking, alcohol consumption, physical activity and hormone replacement therapy (HRT) on lipids, independently of genetic factors, and to detect whether gene-environment interactions influence these associations.

MATERIALS AND METHODS

Fasting plasma total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, apolipoproteins AI and B and lipoprotein(a) were measured in 685 female twins (96 monozygotic, 230 dizygotic pairs and 33 singletons).

RESULTS

Smokers had higher triglyceride and lower HDL cholesterol levels than never-smokers (P < 0.001). After controlling for genetic influences, smoking accounted for 0.35 mmol L(-1) and 0.22 mmol L(-1) differences in triglyceride and HDL cholesterol levels, respectively (P < 0.005), remaining significant after excluding alcohol-discordant twin pairs. In a gene-environment interaction analysis, the association between smoking and triglycerides was exaggerated in subjects at high genetic risk of hypertriglyceridaemia (interaction P=0.04). All levels of alcohol consumption were associated with higher HDL cholesterol levels than abstinence, but only moderate alcohol consumers had lower LDL cholesterol and triglyceride levels. In monozygotic twins concordant for smoking, an alcohol intake > 10 units week(-1) accounted for a 0.32 mmol L(-1) difference in LDL cholesterol, independently of genetic effects (P=0.04). In postmenopausal women, those using HRT had 0.54 mmol L(-1) lower LDL cholesterol and 0.21 micromol L(-1) lower lipoprotein(a) levels than nonusers (P < 0.001 and P=0.04, respectively); these differences were attenuated after accounting for genetic effects in monozygotic twins. Although physically active subjects had higher levels of HDL cholesterol than nonactive subjects, this was nonsignificant after adjusting for genetic factors.

CONCLUSIONS

Smoking-induced aberrations in HDL cholesterol and triglycerides and alcohol-related differences in LDL cholesterol were independent of genetic influences. The association between smoking and hypertriglyceridaemia was accentuated in high genetic risk individuals.

BMI inaccurately reflects total body and abdominal fat in Tongans

It has been noted since the earliest European contact that Polynesian body shape and size differ from those of Europeans. The muscular build of Polynesians, such as Tongans, raises questions as to the accuracy of simple anthropometric indicators, validated for use in European populations, in Polynesians. Body mass index (BMI), total body fat and an abdominal fat window were measured in a sample of Tongan [28 male (M), 28 female (F)] and Australian Caucasian adults (39 M, 46 F), with standard anthropometric and densitometric methods. Tongan males (BMI, 32.8+/-4.6 kg/m(2)) were heavier than Australian males (BMI, 27.1+/-3.7 kg/m(2)); but differences in total body percent fat (28.9+/-8.3 vs. 25.9+/-8.1, p=0.15), abdominal fat (1.84+/-0.69 vs. 1.55+/-0.60 kg, p=0.07) and abdominal percent fat (30.3+/-8.6 vs. 28.5+/-8.3, p=0.40) were non-significant. Tongan females (BMI, 34.3+/-5.5 kg/m(2)) were also heavier than their Australian counterparts (BMI, 26.2+/-6.3 kg/m(2)); with the difference in total body percent fat (41.9+/-5.2 vs. 38.7+/-8.9, p=0.05) and abdominal percent fat (39.3+/-4.8 vs. 33.6+/-8.9, p=0.001) less than expected, given the difference in BMI. This study demonstrates significant body composition variations between Tongans and Caucasians.

Lack of heritability of circulating leptin concentration in humans after adjustment for body size and adiposity using a physiological approach

OBJECTIVE

To construct a simple physiological model of leptin kinetics, based on measures of body size and composition, which is suitable for investigating the influence of genetic and other influences on circulating leptin levels in humans.

METHODS

Consideration of the kinetics of the secretion and clearance of leptin led to a predicted linear relationship between ln(leptin), ln(fat mass), and a function of non-fat body compartments. Results obtained from this model were compared with those from two published empirical models based on adjustment for fat mass alone or for body mass index. Overnight fasted leptin levels, body composition data (dual-energy X-ray absorptiometry) and questionnaire responses were obtained from 527 twin pairs (127 monozygotic, 400 dizygotic; 37 male (age 18-68 y, BMI 18-32 kg/m2), 489 female (age 18-71, BMI 17-44) drawn from the St Thomas' UK Adult Twin Registry.

RESULTS

In a partial correlation analysis ln(fat mass) and ln(height) (r=0.80, P<0.0001) and r=-0.22, P<0.0001 respectively) were independent predictors of ln(leptin) in females but ln(lean mass) was not (r=-0.01). A regression model incorporating ln(fat mass), ln(height) and a second order polynomial in age provided an adequate fit of the ln(leptin) data in females (r2=71%). ln(Leptin) values adjusted for body size and composition using the model were not significantly heritable (P=0.11), were significantly related to gender (r2=2.3%) and to ln(insulin) (r2=5.7%), but not to menopausal status (r2=0.7%), hormone replacement therapy (r2=0.4%), past or current smoking (r2=1.1%), or percentage trunk fat (r2=0.5%). Both empirical models found significant heritability (h2=36-42%), overestimated the effect of gender in the data (r2=14-16%), and produced significant relationships between adjusted ln(leptin) and percentage trunk fat (r2=4-12%).

CONCLUSIONS

We conclude that our physiologically based model provides an adequate description of the relationship between leptin and body composition and provides a more reliable framework than current empirical approaches for the investigation of other influences on circulating leptin levels. Heritable variations in the control of leptin secretion are unlikely to contribute significantly to variations in leptin levels at the population level.

Effect of combination hormone replacement therapy on ambulatory blood pressure and arterial stiffness in diabetic postmenopausal women

BACKGROUND

Diabetes mellitus negates the premenopausal gender benefit with respect to coronary artery disease. Whether hormone replacement therapy (HRT) offers any cardiovascular advantage to diabetic postmenopausal women is not known. Diabetic subjects have increased vascular load and abnormal 24-h blood pressure (BP) profiles. Hormone replacement therapy has been shown to improve indexes of arterial load in nondiabetic postmenopausal women as well as to restore circadian variation in BP. This aim of this study, therefore, was to determine prospectively whether HRT improved arterial stiffness and 24-h ambulatory BP profile in diabetic postmenopausal women.

METHODS

Twelve diabetic postmenopausal women were studied. Six subjects were also hypertensive. Vascular load was characterized by carotid arterial pulse waveform analysis to calculate central augmentation index. All subjects also underwent 24-h BP monitoring. Subjects were studied before commencement of HRT and were then randomized to two groups. The first group was observed for 6 months and then given 2 months of estrogen alone, followed by 4 months of combination estrogen with progestin. The second group received the HRT regimen first, then were restudied after 6 months off HRT.

RESULTS

The HRT did not affect either clinic or ambulatory BP. There were no changes in indexes of vascular load or pulse pressure, an indirect measure of arterial stiffness. There was a low rate of circadian variation in 24-h BP at baseline (55%), which was unaltered by HRT.

CONCLUSIONS

The HRT was well tolerated. Despite evidence for a beneficial effect of HRT on indexes of arterial load and ambulatory BP previously reported in normal subjects, we found no change in this cohort of diabetic postmenopausal women.

What is the evidence, reasons for and impact of weight gain during menopause?

Weight gain in midlife is common among women. Weight gain is associated with age, not menopause. Decreasing physical activity and smoking cessation are major factors in weight gain with age.

Lung function in Gypsies in Greece

The relationship between lung function and smoking and dietary habits was examined in 121 Gypsies (62 males, 59 females) who were 14-70 y of age and who lived in Greece. All were examined clinically, after which they all participated in spirometry tests. Half of the study group had abnormal (< 80% of predicted) forced vital capacity, 36.4% had abnormal (< 80% of predicted) forced expiratory volume in 1 sec, and 5% had serious lung function disturbances (forced vital capacity < 50% of predicted). Approximately 70% of subjects were smokers, and their diets were rich in alcohol and meat; they ate very few salads and oranges. Consequently, decreased lung function might be a major health problem in Gypsies in Greece. Organization of preventive health strategies should improve the overall health of this study group.

Improved indices of insulin resistance and insulin secretion for use in genetic and population studies of type 2 diabetes mellitus

Homeostasis model assessment (HOMA) provides indices of insulin secretion (beta) and insulin resistance (R) derived from fasting plasma glucose (FPG) and fasting plasma insulin (FPI) levels. However, these indices could not account for a significant heritability of fasting plasma glucose (FPG) (h2 = 0.75, P<0.01) in a group of 214 female twins. This result is consistent with a misclassification between effects due to insulin secretion and resistance in the HOMA indices. We report here evidence of such misclassification in the HOMA indices and describe a minor modification to the model which corrects it. Direct measures of insulin resistance (euglycaemic clamp) and secretion (i.v. glucose bolus) were obtained in 43 non-diabetic subjects. Heritability was estimated by statistical modelling of genetic and environmental influences in data from 214 non-diabetic female subjects. Modified HOMA (HOMA') indices were obtained from beta' = (Ln(FPI) - c)/FPG and R' = (Ln(FPI) - c)*FPG where c is a constant derived from regression analysis of Ln(FPI) vs FPG. Indices from both models correlated with the direct measures similarly (r = 0.63 (R), 0.49 (R'), 0.45 (beta), 0.39 (beta'), all P< 0.01). Directly measured insulin resistance and secretion were not significantly correlated (r = 0.13, P = 0.21). However, unmodified HOMA-beta and R were strongly related (r = 0.78, P<0.0001 vs. 0.13) demonstrating substantial misclassification. The relationship between beta' and R' (r = 0.13) was not different from that between the two direct measures and significant heritability of beta' (h2 = 0.68, P<0.01) and R' (h2 = 0.59, P<0.05) was evident in the twin data. The proposed modification to HOMA significantly reduces misclassification and reveals separate components of insulin resistance and insulin secretion in the heritability of FPG.

Clustering of insulin resistance, total and central abdominal fat: same genes or same environment?

Obesity, insulin resistance and disturbed glucose metabolism cluster within the Insulin Resistance Syndrome (IRS). Whether this reflects shared genetic or environmental factors detectable in 'normal' populations (not selected for IRS features) is unknown. This study estimated (i) genetic influences on IRS traits and (ii) shared and specific genetic and environmental factors on the relationships between these traits in healthy female twins. Fasting insulin, glucose, total and central fat were measured in 59 monozygotic (MZ) and 51 dizygotic (DZ) female twin pairs aged (+/- SD) 52 +/- 13 years. Body fat was measured by dual-energy X-ray absorptiometry, insulin resistance and secretion by a modified homeostasis model assessment. Using intraclass correlation coefficients and univariate model-fitting analyses, genetic influences were found in total fat, central fat, insulin resistance, fasting glucose and insulin secretion, with genetic factors explaining 64, 57, 59, 75 and 68% of their variance, respectively, using the latter technique. In matched analysis intra-pair differences in total and central fat related to intra-pair differences in insulin resistance (r2 = 0.19, P < 0.001). Multivariate model-fitting showed a close genetic relationship between total and central fat (r = 0.88). The genetic correlation between IR and central fat (0.41) was significantly greater than that for total fat (0.24), suggesting that central fat is not only a predictor of, but shares considerable genetic influence with, insulin resistance. In Cholesky analysis, these genetic influences were separate from those shared between central and total fat. In conclusion, both shared and specific genetic factors regulate components of the IRS in healthy females. However, there were discrete genetic influences on beta-cell insulin secretion, not shared with other IRS components, suggesting that a separate genetic propensity exists for Type 2 diabetes. These findings suggest we may understand the genetic and environmental influences on IRS from the study of the normal population.

Effects of postmenopausal hormone replacement therapy on central abdominal fat, glycemic control, lipid metabolism, and vascular factors in type 2 diabetes: a prospective study

OBJECTIVE

To examine the effects of hormone replacement therapy (HRT) on lipid metabolism, glycemic control, total body and central abdominal fat, blood pressure (BP), and arterial pulse wave velocity (APWV) in overweight postmenopausal females with type 2 diabetes.

RESEARCH DESIGN AND METHODS

This was a 12-month prospective study of 14 subjects (mean +/- SD age 57.5+/-5.6 years, BMI 29.5+/-4.8 kg/m2) randomized to 6 months of observation or HRT before crossover. HRT consisted of 2 months of conjugated equine estrogen (CEE) 0.625 mg daily, followed by 4 months CEE and medroxyprogesterone 5 mg daily. Measures included anthropometry, fasting glucose, insulin, HbA1c, total and HDL cholesterol, triglycerides, apolipoprotein B, LDL particle size, nonesterified fatty acids (NEFA), sex hormone-binding globulin, resting energy expenditure (REE), total and central abdominal fat (by dual-energy X-ray absorptiometry), resting BP, APWV (by applanation tonometry), physical activity, well-being, and sexual function.

RESULTS

Six months of HRT resulted in significant reductions in waist-to-hip ratio (-0.03+/-0.01 vs. 0.01+/-0.009, P = 0.007), HbA1c (-0.34+/-0.24 vs. 0.6+/-0.4%, P = 0.04), total cholesterol (-0.6+/-0.1 vs. 0.2+/-0.2 mmol/l, P = 0.001), central abdominal fat (-175+/-51 vs. -24+/-56 g, P = 0.05), and improved physical functioning (P = 0.05), compared with observation. There was a minor increase in REE with HRT (33+/-23 vs. -38+/-23 kJ/day, P = 0.04). Total fat mass, fasting glucose, insulin, triglyceride, apolipoprotein B, NEFA, resting BP, APWV, and physical activity were unchanged.

CONCLUSIONS

Postmenopausal HRT in these overweight women with type 2 diabetes was associated with a reduction in central adiposity and improvement in lipid metabolism and glycemic control without deterioration in weight status or cardiovascular parameters measured. Whether HRT-induced improvements in these cardiovascular risk factors result in lower long-term cardiovascular morbidity and mortality, as observed in nondiabetic women, awaits further study.

Dietary underreporting is prevalent in middle-aged British women and is not related to adiposity (percentage body fat)

OBJECTIVE

To determine the phenotypic and dietary characteristics of energy underreporters in a healthy population of middle-aged women using accurate body composition measures.

DESIGN

Cross-sectional study of 436 healthy middle-aged female volunteers, unaware of any hypotheses regarding diet and body fat: mean age 58 y (39-70 y), body mass index (BMI) 24.3 kg/m2 (17.0-41.9 kg/m2). The prevalence of overweight (25.0 > BMI > 29.9 kg/m2) and obesity (BMI > 30 kg/m2) were 30% and 5% respectively.

MEASUREMENTS

Dietary intake by food frequency questionnaire (FFQ) (n = 436), 197 subjects also completed seven-day food records; body composition by dual energy X-ray absorptiometry (DXA); physical activity by standardised questionnaire. Underreporters were subjects whose estimated energy expenditure (EE) exceeded reported energy intake (EI). Three cut-off levels of underreporting were determined from estimates of EE utilising DXA body composition measures: basal, and two including EE from physical activity (using the ratio 1.35 or ratios from reported physical activity level).

RESULTS

Underreporters had significantly greater weight (P < 0.01), BMI (P < 0.01), total fat P < 0.05), fat free mass (P < 0.0001), but not adiposity (% body fat) than adequate-reporters, at each of the three cut-off levels. Underreporters reported significantly lower intakes of energy and all macronutrients (P < 0.0001). Expressed as a percentage of EI, the reported diet of underreporters was significantly lower in fat, similar in carbohydrate and higher in protein. Similar results were found with seven-day food record data, although reported intakes from these were significantly lower than those from FFQ. The prevalence of underreporting was highest in obese subjects (defined by BMI only), with up to 65% of these subjects underreporting EI and in the highest BMI tertile (prevalence of 57%). In those with BMI < 24.9 kg/m2, the maximal prevalence rate of underreporting was 43%. Importantly, however, the rates of underreporting were similar between tertiles of adiposity. Most (68%), but not all, underreporters were found in the lowest tertile for reported EI.

CONCLUSIONS

A low reported EI and greater BMI may help identify energy underreporters. However, whilst underreporters may more frequently be 'bigger' (by BMI), they are not necessarily fatter (using direct measures of body fat). As underreporting was present among all tertiles of BMI and adiposity, these results emphasise the importance of following past recommendations to identify and exclude energy underreporters in nutritional studies. Where underreporters have not been excluded, reported nutrition-disease relationships must remain in doubt.

Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor-associated lipodystrophy, hyperlipidaemia, and diabetes mellitus: a cohort study

BACKGROUND

The prevalence and severity of lipodystrophy syndrome with long-term therapy for HIV-1 infection that includes a protease inhibitor is unknown. We studied the natural course of the syndrome to develop diagnostic criteria and identifying markers that predict its severity.

METHODS

We assessed 113 patients who were receiving HIV-1 protease inhibitors (mean 21 months) and 45 HIV-1-infected patients (28 with follow-up) never treated with a protease inhibitor. Lipodystrophy was assessed by questionnaire (including patients' rating of severity), physical examination, and dual-energy x-ray absorptiometry. Body composition and fasting lipid and glycaemic variables were compared with data obtained 8 months previously. Oral glucose tolerance was investigated.

FINDINGS

There was 98% concordance between patients' reports of the presence or absence of lipodystrophy (reported by 83% of protease-inhibitor recipients and 4% of treatment-naïve patients; p=0.0001) and physical examination. Patients' ratings of lipodystrophy were significantly associated with declining total body fat (p=0.02). Lower body fat was independently associated with longer duration of protease-inhibitor therapy and lower bodyweight before therapy, and more severe lipodystrophy was associated with higher previous (p < 0.03) and current (p < or = 0.01) triglyceride and C-peptide concentrations, and less peripheral and greater central fat (p=0.005 and 0.09, respectively). Body fat declined a mean 1.2 kg over 8 months in protease-inhibitor recipients (p=0.05). The prevalence of hyperlipidaemia remained stable over time (74% of treated patients vs 28% of naïve patients; p=0.0001). Impaired glucose tolerance occurred in 16% of protease-inhibitor recipients and diabetes mellitus in 7%; in all but three patients these abnormalities were detected on 2 h post-glucose load values.

INTERPRETATION

Diagnosis and rating severity of lipodystrophy is aided by the combination of physical examination, patient's rating, and measurement of body fat, fasting triglycerides, and C-peptide. Weight before therapy, fasting triglyceride, and C-peptide concentrations early in therapy, and therapy duration seem to predict lipodystrophy severity. Lipodystrophy was common and progressive after almost 2 years of protease inhibitor therapy, but was not usually severe. Hyperlipidaemia and impaired glucose tolerance were also common.

Genetic and environmental influences on total-body and central abdominal fat: the effect of physical activity in female twins

BACKGROUND

The increasing prevalence of obesity has focused attention on the contribution of physical activity and its interaction with predisposing genetic factors.

OBJECTIVE

To examine 1) the relation between physical activity and total-body and central abdominal fat, independent of genetic and other environmental factors, and 2) the influence of physical activity in persons who are genetically susceptible to generalized or central adiposity.

DESIGN

Cross-sectional study.

SETTING

A London academic teaching hospital.

PATIENTS

970 healthy female twins (mean age, 55.5 years [range, 39 to 70 years]; body mass index, 24.4 kg/m2 [range, 16.4 to 44.0 kg/mg2]). There were 241 monozygotic pairs, 228 dizygotic pairs, and 32 women whose co-twin lacked complete data. Fifty-six percent of participants were of normal weight, 30% were overweight, 7% were obese, and 7% were underweight.

MEASUREMENTS

Total-body and central abdominal fat were measured by dual-energy x-ray absorptiometry. Physical activity was assessed by quantitative and semiquantitative questionnaires. Data on dietary intake, socioeconomic status, smoking status, and use of hormone replacement therapy (HRT) were also gathered.

RESULTS

Total-body and abdominal central adiposity were lower with higher levels of home, sporting, and sweating-associated activity. Total-body and central abdominal fat were 5.6 kg and 0.44 kg lower, respectively, in participants who reported vigorous weight-bearing activity. Physical activity was the strongest independent predictor of total-body fat (beta = -0.6 [CI, -1.06 to -0.15]; P = 0.009) and central abdominal fat (beta = -0.07 [CI, -0.1 to -0.03]; P < 0.001) in a regression model that included age, diet, smoking, HRT use, and socioeconomic status. Monozygotic twin pairs who were concordant for smoking and HRT status but were discordant for moderate-intensity sport showed greater within-pair differences in total-body fat than those who were concordant for activity level. In this model, 1 and 2 hours of moderate-intensity sport accounted for within-pair differences of 1.0 kg (P = 0.050) and 1.4 kg (P = 0.040), respectively, of total-body fat. In participants who had an overweight twin, higher levels of physical activity were still associated with 3.96-kg lower total-body fat and 0.53-kg lower central abdominal fat.

CONCLUSIONS

Current physical activity predicts lower total-body and central abdominal adiposity in healthy middle-aged women. After controlling for genetic and environmental factors, the influence of physical activity was greater than that of other measured environmental factors. Participants with a genetic predisposition to adiposity did not show a lesser effect of physical activity on body fat mass.

Genes versus environment. The relationship between dietary fat and total and central abdominal fat

OBJECTIVE

The influence of diet on body fat has not been quantified independently of genetic influences, although both are held to contribute to regulation of body fat stores. This study examined 1) the relationship between recent diet and total body and central abdominal fat in middle-aged female twins independent of genetic and important environmental factors and 2) evidence of interaction between diet and genetic predisposition.

RESEARCH DESIGN AND METHODS

Measurements in 436 healthy female twins (aged 58 +/- 10 years) included dietary intake by food frequency questionnaire (validated against a 7-day food diary, n = 162), BMI, total body and central abdominal fat by dual-energy X-ray absorptiometry, and environmental covariates (smoking habit, hormone replacement, and physical activity) by standardized questionnaire. Dietary energy underreporters were excluded.

RESULTS

Intake of dietary fat (total and subtype) and carbohydrates was not related to BMI or to total or central fat, confirmed in quintile analysis. With genetic and environmental factors controlled in 90 monozygotic pairs, differences in the intake of energy, fat, or protein were not related to intrapair differences in total and central body fat. However, a minor inverse relationship between carbohydrate intake and total adiposity was confirmed (r = -0.25, P = 0.02). In paired analyses, the twin with the higher intake of total sugars had significantly lower total body and central abdominal adiposity. There was no evidence of a gene-environment interaction between intake of fat or carbohydrates contributing to greater body fat mass in subjects genetically predisposed to obesity.

CONCLUSIONS

Using validated dietary measures and direct measures of body fat and excluding underreporters, no relationship between dietary fat and body fat was found in middle-aged women, particularly after controlling for genetic and some environmental factors. The role of dietary factors in determining total body and central abdominal fat appears to have been overestimated in past cross-sectional studies.

Obesity: genes, glands or gluttony?

Distribution as well as amount of fat has health implications; central abdominal fat seems to be the major contributor to insulin resistance and risk of diabetes, hypertension and cardiovascular disease. Physical activity and diet affect overall adiposity; moreover, exercise specifically reduces visceral fat. The sexes differ in fat distribution; in particular, pre-menopausal women, despite greater overall adiposity, have much less visceral fat than men. There is a strong genetic determination of overall obesity and central abdominal adiposity. Genes regulating obesity (e.g. Ob) could modulate appetite, satiety, metabolic rate or physical activity. Moderate obesity probably results from interaction between genetic predisposition and an environment of abundant calories and reduced physical activity. Single gene mutations are being identified in a few morbidly obese people; however, the common genetic predisposition for obesity may relate to more subtle variations in regulatory controls. Diet and exercise are effective for some, but the response is often disappointing. Definition of pathways controlling appetite, metabolic rate and lipid metabolism may generate improved pharmacological compounds. Education and availability of lower-energy foods may help, but more radical approaches may be needed, such as environmental restructuring to increase physical activity. The problem is great, but failure will mean intolerably increased health costs.

Pathogenesis of HIV-1-protease inhibitor-associated peripheral lipodystrophy, hyperlipidaemia, and insulin resistance

HIV-1 protease-inhibitor treatments are associated with a syndrome of peripheral lipodystrophy, central adiposity, breast hypertrophy in women, hyperlipidaemia, and insulin resistance. The catalytic region of HIV-1 protease, to which protease inhibitors bind, has approximately 60% homology to regions within two proteins that regulate lipid metabolism: cytoplasmic retinoic-acid binding protein type 1 (CRABP-1) and low density lipoprotein-receptor-related protein (LRP). We hypothesise that protease inhibitors inhibit CRABP-1-modified, and cytochrome P450 3A-mediated synthesis of cis-9-retinoic acid, a key activator of the retinoid X receptor; and peroxisome proliferator activated receptor type gamma (PPAR-gamma) heterodimer, an adipocyte receptor that regulates peripheral adipocyte differentiation and apoptosis. Protease-inhibitor binding to LRP would impair hepatic chylomicron uptake and triglyceride clearance by the endothelial LRP-lipoprotein lipase complex. The resulting hyperlipidaemia contributes to central fat deposition (and in the breasts in the presence of oestrogen), insulin resistance, and, in susceptible individuals, type 2 diabetes. Understanding the syndrome's pathogenesis should lead to treatment strategies and to the design of protease inhibitors that do not cause this syndrome.

A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance in patients receiving HIV protease inhibitors

OBJECTIVE

To describe a syndrome of peripheral lipodystrophy (fat wasting of the face, limbs and upper trunk), hyperlipidaemia and insulin resistance in patients receiving potent HIV protease inhibitor therapy.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinic of a university teaching hospital.

PATIENTS

HIV-infected patients either receiving at least one protease inhibitor (n=116) or protease inhibitor-naive (n=32), and healthy men (n=47).

INTERVENTIONS AND MAIN OUTCOME MEASURES

Lipodystrophy was assessed by physical examination and questionnaire and body composition by dual-energy X-ray absorptiometry. Fasting triglyceride, cholesterol, free fatty acid, glucose, insulin, C-peptide and fructosamine levels, other metabolic parameters, CD4 lymphocyte counts, and HIV RNA load were also assessed.

RESULTS

HIV protease inhibitor-naive patients had similar body composition to healthy men. HIV protease inhibitor therapy was associated with substantially lower total body fat (13.2 versus 18.7 kg in protease inhibitor-naive patients; P=0.005), and significantly higher total cholesterol and triglyceride levels. Lipodystrophy was observed clinically in 74 (64%) protease inhibitor recipients after a mean 13.9 months and 1(3%) protease inhibitor-naive patient (P=0.0001). Fat loss occurred in all regions except the abdomen after a median 10 months. Patients with lipodystrophy experienced a relative weight loss of 0.5 kg per month and had significantly higher triglyceride, cholesterol, insulin and C-peptide levels and were more insulin-resistant than protease inhibitor recipients without lipodystrophy. Patients receiving ritonavir and saquinavir in combination had significantly lower body fat, higher lipids and shorter time to lipodystrophy than patients receiving indinavir. Three (2%) patients developed new or worsening diabetes mellitus.

CONCLUSION

A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin resistance is a common complication of HIV protease inhibitors. Diabetes mellitus is relatively uncommon.

Tobacco smoking and oestrogen replacement are associated with lower total and central fat in monozygotic twins

BACKGROUND

The known postmenopausal increase in cardiovascular risk may relate in part to changes in fat distribution. Environmental factors which are known to influence cardiovascular disease risk may do so in part by influencing body fat and its distribution.

OBJECTIVES

To determine the relationships between tobacco smoking, oestrogen replacement (ERT) and body fat and its distribution in postmenopausal women, independent of genetic factors, physical activity, diet composition and socioeconomic factors.

DESIGN

Cross-sectional study in normal post menopausal twins.

SUBJECTS

712 postmenopausal female twins (aged 58.7 +/- 0.2 y, body mass index (BMI) 24.4 +/- 0.1 kg/m2).

MEASUREMENTS

Anthropometry; body composition and fat distribution by dual energy x-ray absorptiometry; physical activity, muscle strength, socioeconomic status, dietary composition and dehydroepiandrosterone sulfate (DHEAS).

RESULTS

In monozygotic pairs discordant for smoking, intrapair differences in total and central fat were greater than that in concordant pairs, with the lower fat mass in the smoking twin. Overall, smokers had a lower weight, BMI, total and central abdominal fat, despite a higher total and saturated dietary fat intake and similar DHEAS levels. The reduction in central fat was not independent of that in total fat. In monozygotic twins discordant for ERT-use the intrapair differences in total and central body fat were significantly greater than in concordant pairs, with the lower fat measure in the ERT-using twin. Overall, current ERT-users had similar body weight, BMI and total fat compared to non-users but had lower central fat. There were no differences in activity levels, diet or socioeconomic factors between ERT-users and non-users.

CONCLUSIONS

Smoking and ERT-use are associated with lower total and central fat in monozygotic postmenopausal twins. In current smokers, the lower central adiposity appears related to its influence on total body fat. In ERT-users, lower central fat may contribute to the reduced cardiovascular risk associated with postmenopausal oestrogen use.

The non-genetic determinants of central adiposity

Central adiposity carries an increased risk of non-insulin dependent diabetes mellitus (NIDDM), cardiac disease, hypertension and death, and is closely related to insulin resistance. Genetic factors explain a large proportion of the population variance in central adiposity, although the genotypic characteristics remain obscure. Hormonal factors such as endogenous sex steroid levels, the menopause, hormone replacement therapy and cortisol may influence body fat partitioning. The link between dietary factors and central adiposity is controversial, with contradictory results in the literature. Smoking is associated with lower total body fat, but investigations of its influence on central adiposity have also yielded contradictory results. Higher levels of physical activity are associated with lesser amounts of central fat, both cross-sectionally and in intervention studies. Some of the contradictory results regarding putative influences on central adiposity may be due to limitations of some of the anthropometric parameters of central adiposity, such as the waist-hip ratio. Further research is required to clarify the relationships between many of these factors and with both compartments of central adiposity: subcutaneous abdominal and intraabdominal adipose tissue.

Relationship of a novel polymorphic marker near the human obese (OB) gene to fat mass in healthy women

The cloning of the murine obese (ob) gene and its human homologue has recently been reported. Mutations in the mouse ob gene result in hereditary obesity; however, the role of variations of OB in the regulation of bodyweight in humans has yet to be determined. The contribution of putative genetic variations in the human OB gene to total and regional fat mass in a normal twin population has been analyzed through linkage and association with a novel polymorphic marker, located in proximity to this gene. The polymorphic dinucleotide repeat, isolated from a P1 clone containing the human OB gene, was physically localized by long-range restriction mapping to within 30 kilobases of the OB locus. The marker was genotyped in a population of 47 healthy female/female dizygotic (DZ) twin pairs for which direct measures of central abdominal and whole body fat had been obtained by dual X-ray absorbtiometry. Possible linkage between the microsatellite marker and whole-body (p = 0.008), but not central abdominal (p = 0.09), fat deposits was indicated. No association between fat depot phenotype and marker genotype was detected. These results suggest that genetic variation in or close to the human OB gene may play a role in the size of body fat stores in healthy women.

Will older sedentary people with non-insulin-dependent diabetes mellitus start exercising? A health promotion model

Exercise and diet are the cornerstones of management of non-insulin-dependent diabetes mellitus (NIDDM). Many older people have difficulty in exercising, missing benefits on glycaemic control, weight, cardiac disease and mood. We report the outcomes of a 6 month structured exercise and support programme based on a health promotion model, on physical activity, glycaemic control and parameters of cardiovascular risk in non-exercisers, compared with standard outpatient clinic education. A total of 26 non-exercising patients were randomised to an intervention or control group (ten men, 16 women; mean age (+/- S.D.) 60 +/- 8 years). Programme participation was not associated with any significant increase in activity. Glycated hemoglobin (HbAtc) levels tended to stabilise in the intervention group during the 6 month programme and to deteriorate in the control group (P = 0.03); by 12 months HbA1C levels deteriorated to a similar level in both. Programme participation did not cause significant change in anthropometric or metabolic parameters. Examining the cohort as a whole, increased activity over 6 months was associated with improvements in weight, body mass index (BMI), body fat and fasting insulin. Activity increases over 12 months were associated with improvements in weight and BMI. These changes could not be attributed to changes in energy intake or dietary composition. We conclude that while exercise can benefit older people with NIDDM, a programme based on a model of health promotion was not effective in increasing physical activity.

Independent genetic factors determine the amount and distribution of fat in women after the menopause

Central adiposity is a strong predictor of cardiovascular disease in women. We studied postmenopausal twins to explore the strength and the relationship between genetic influences on body fat and its distribution in a group where cardiovascular disease is the major cause of mortality. Healthy twin women were recruited from a national media campaign. One hundred nineteen monozygotic (MZ) and 97 dizygotic twin pairs were studied (mean +/- SE age 60 +/- 0.3 yr; 10 +/- 0.4 yr post menopausal). Total and central body fat were measured by dual-energy x-ray absorptiometry. Intrapair resemblance was significantly greater in MZ pairs for total fat (MZ vs. dizygotic, r = 0.70 +/- 0.05 vs. r = 0.46 +/- 0.08, P = 0.005) and central fat (r = 0.62 +/- 0.06 vs. r = 0.35 +/- 0.09, P = 0.005), suggesting a strong genetic influence on these traits. Model-fitting analysis indicated that genetic factors contribute up to 60% of total population variance in both total and central body fat. The heritability of central fat remained, after adjustment for the heritability of total fat, suggesting an independent genetic influence on fat distribution. These results were unchanged after adjusting for the effects of estrogen replacement and smoking. In conclusion, total adiposity and central abdominal fat mass in normal postmenopausal women are under strong genetic influence. The data suggest that some of the genes responsible for central adiposity and its metabolic sequelae will be different from those responsible for total adiposity.