Comparison of insulin degludec/insulin aspart and biphasic insulin aspart 30 in uncontrolled, insulin-treated type 2 diabetes: a phase 3a, randomized, treat-to-target trial

OBJECTIVE

Insulin degludec/insulin aspart (IDegAsp) is the first combination of a basal insulin with an ultralong duration of action, and a rapid-acting insulin in a single injection. This trial compared IDegAsp with biphasic insulin aspart 30 (BIAsp 30) in adults with type 2 diabetes inadequately controlled with once- or twice-daily (OD or BID) pre- or self-mixed insulin with or without oral antidiabetic drugs.

RESEARCH DESIGN AND METHODS

In this 26-week, randomized, open-label, multinational, treat-to-target trial, participants (mean age 58.7 years, duration of diabetes 13 years, BMI 29.3 kg/m(2), and HbA1c 8.4% [68 mmol/mol]) were exposed (1:1) to BID injections of IDegAsp (n = 224) or BIAsp 30 (n = 222), administered with breakfast and the main evening meal and dose titrated to a self-measured premeal plasma glucose (PG) target of 4.0-5.0 mmol/L.

RESULTS

After 26 weeks, mean HbA1c was 7.1% (54 mmol/mol) for both groups, with IDegAsp achieving the prespecified noninferiority margin for mean change in HbA1c (estimated treatment difference [ETD] -0.03% points [95% CI -0.18 to 0.13]). Treatment with IDegAsp was superior in lowering fasting PG (ETD -1.14 mmol/L [95% CI -1.53 to -0.76], P < 0.001) and had a significantly lower final mean daily insulin dose (estimated rate ratio 0.89 [95% CI 0.83-0.96], P = 0.002). Fewer confirmed, nocturnal confirmed, and severe hypoglycemia episodes were reported for IDegAsp compared with BIAsp 30.

CONCLUSIONS

IDegAsp BID effectively improves HbA1c and fasting PG levels with fewer hypoglycemia episodes versus BIAsp 30 in patients with uncontrolled type 2 diabetes previously treated with once- or twice-daily pre- or self-mixed insulin.

Depression and major weight gain: a 6-year prospective follow-up of outpatients

BACKGROUND

Depression and weight change are linked, but there is a paucity of studies on their association during clinical treatment. The present study investigated how risk factors for a weight gain of at least 10% (major weight gain) and mental health modify their mutual association during a 6-year prospective follow-up of depressed outpatients.

METHOD

The study sample consisted of 121 depressed treatment-seeking outpatients with a mean age of 44.9 years. A 6-year follow-up started in January 1996. At baseline and on follow-up after 2 and 6 years, psychiatric diagnoses were obtained using the Structured Clinical Interview for DSM-III-R (SCID-I), while cluster C personality disorders (PD) were assessed on 6-month follow-up (SCID-II). Depression was also assessed with the Hamilton Rating Scale for Depression (HAM-D) and general psychopathology with the Symptom Checklist-90 (SCL-90) at baseline and at the end of the 6-year follow-up. Weight changes were based on measurements at baseline and at the end of the follow-up. Logistic regression was used to study the factors associated with major weight gain (≥ 10%).

RESULTS

Altogether, 16% of the study sample experienced major weight gain during the 6-year follow-up. Adverse childhood/adolescent experiences as a self-perceived cause of depression (OR 3.72, 95% CI 1.06-13.1, p=0.040), higher scores in the HAM-D (OR 1.11, 95% CI 1.02-1.22, p=0.019) and the SCL-90 subscale of anxiety (OR 2.22, 95% CI 1.11-4.42, p=0.023) at baseline, and cluster C PD at 6 months (OR 3.16, 95% CI 1.11-8.97, p=0.031) were separately associated with major weight gain after adjusting for age, gender, and baseline body mass index (BMI).

CONCLUSION

The severity of depressive and anxiety symptoms and linking adverse childhood with depression at the beginning of treatment, as well as cluster C PD at 6 months, were predictors of major weight gain.

Crosslinking with transglutaminase does not change metabolic effects of sodium caseinate in model beverage in healthy young individuals

Background

Postprandial metabolic and appetitive responses of proteins are dependent on protein source and processing technique prior to ingestion. Studies on the postprandial effects of enzymatic crosslinking of milk proteins are sparse. Our aim was to study the effect of transglutaminase (TG)-induced crosslinking of sodium caseinate on postprandial metabolic and appetite responses. Whey protein was included as reference protein.

Methods

Thirteen healthy individuals (23.3 ± 1.1 y, BMI 21.7 ± 0.4 kg/m²) participated in a single-blind crossover design experiment in which the subjects consumed three different isovolumic (500 g) pourable beverages containing either sodium caseinate (Cas, 29 g), TG-treated sodium caseinate (Cas-TG, 29 g) or whey protein (Wh, 30 g) in a randomized order. Blood samples were collected at baseline and for 4 h postprandially for the determination of plasma glucose, insulin and amino acid (AA) concentrations. Gastric emptying (GE) was measured using the ¹³ C-breath test method. Appetite was assessed using visual analogue scales.

Results

All examined postprandial responses were comparable with Cas and Cas-TG. The protein type used in the beverages was reflected as differences in plasma AA concentrations between Wh and Cas, but there were no differences in plasma glucose or insulin responses. A tendency for faster GE rate after Wh was detected. Appetite ratings or subsequent energy intake did not differ among the protein beverages.

Conclusions

Our results indicate that the metabolic responses of enzymatically crosslinked and native sodium caseinate in a liquid matrix are comparable, suggesting similar digestion and absorption rates and first pass metabolism despite the structural modification of Cas-TG.

Feasibility of a lifestyle intervention in early pregnancy to prevent deterioration of glucose tolerance

Background

In conjunction with the growing prevalence of obesity and the older age of pregnant women gestational diabetes (GDM) is a major health problem.

The aim of the study was to evaluate if a lifestyle intervention since early pregnancy is feasible in improving the glucose tolerance of women at a high-risk for GDM in Finland.

Methods

A 75-g oral glucose tolerance test (OGTT) was performed in early pregnancy (n = 102). Women at high risk for GDM (n = 54) were randomized at weeks 8-12 from Apr 2005 to May 2006 to a lifestyle intervention group (n = 27) or to a close follow-up group (n = 27). An OGTT was performed again at weeks 26-28 for the lifestyle intervention and close follow-up groups.

Results

The values of the OGTT during the second trimester did not differ between the lifestyle intervention and close follow-up groups. In the lifestyle intervention group three women had GDM in the second trimester and respectively one woman in the close follow up group. Insulin therapy was not required in both groups. The intervention resulted in somewhat lower weight gain 11.4 ± 6.0 kg vs. 13.9 ± 5.1 kg, p = 0.062, adjusted by the prepregnancy weight.

Conclusions

Early intervention with an OGTT and simple lifestyle advice is feasible. A more intensive lifestyle intervention did not offer additional benefits with respect to glucose tolerance, although it tended to ameliorate the weight gain.

Trial Registration

ClinicalTrials.gov: NCT01130012

Metabolic syndrome is associated with self-perceived depression

OBJECTIVE

To study the association between metabolic syndrome (MetS) and self-perceived depression.

DESIGN

A cross-sectional community-based study.

SETTING

Semi-rural community of Lapinlahti in eastern Finland in 2005.

SUBJECTS

A total of 416 subjects in eight adult birth cohorts (55%) with complete Beck Depression Inventory (BDI-21) questionnaire data.

MAIN OUTCOME MEASURES

The values of the 21 BDI items and the BDI-21 total score with a cut-off point of 14/15 were used to study the association between MetS and depression. National Cholesterol Education Programme (NCEP) 2005 criteria were used for MetS classification.

RESULTS

The total BDI-21 score was significantly higher in the subjects with MetS than in the subjects without MetS (p=0.020). Men with MetS were significantly worse off than men without MetS in the BDI-21 items of irritability (p=0.008), work inhibition (p=0.008), fatigability (p=0.037), weight loss (p=0.045), and loss of libido (p=0.014), while women were only so on the item of loss of libido (p=0.007). In a logistic regression analysis using a BDI-21 cut-off point of 14/15 adjusted for age, marital status, vocational education, and working status, significant association was retained between perceived depression and elevated blood glucose among men (OR=1.697) and large waist circumference among women (OR=1.066).

CONCLUSION

Elevated plasma glucose in men and central obesity in women are associated with self-perceived depression. This co-occurrence deserves attention in clinical practice.

Plasma ghrelin levels after two high-carbohydrate meals producing different insulin responses in patients with metabolic syndrome

Ghrelin is an orexigenic peptide produced in the stomach and its plasma levels are decreased acutely in response to ingested nutrients. To further clarify the role of insulin on ghrelin secretion, the present study was designed to investigate whether circulating ghrelin is affected differently by two mixtures of whole-grain breads known to produce low or high insulin responses in obese non-diabetic subjects with metabolic syndrome. After an overnight fast eight obese subjects with the metabolic syndrome (3 men and 5 women; BMI 33.7+/-0.7 kg/m(2); age 55.6+/-1.8 y) received two different meals consisting of whole-grain rye or wheat breads. The comparison group (3 men and 5 women; BMI 22.5+/-0.5 kg/m(2); age 26.0+/-0.9 y) received a wheat bread meal. Blood samples were collected postprandially at time intervals for 2 h. Feelings of hunger and satiety were analyzed using the visual analogue scales. Ghrelin concentrations decreased after bread meals in lean individuals, but not in obese individuals with the metabolic syndrome. Despite the difference in plasma insulin response, there was no difference in plasma ghrelin or feelings of hunger and satiety in patients with metabolic syndrome. After both rye and wheat bread meals, the decrease in ghrelin concentrations seen in normal-weight individuals after wheat bread meal was absent in subjects with metabolic syndrome. Despite the different plasma insulin response in obese patients, ghrelin levels did not change in response to either type of bread meals. In addition, ghrelin levels did not correlate with insulin, glucose, HOMA1-IR and satiety and hunger ratings in either study groups. This indicates that regulation of ghrelin might be altered in obese patients with metabolic syndrome independently of insulin.

Metabolic syndrome and depression: a cross-sectional analysis

OBJECTIVE

To examine the prevalence of the metabolic syndrome in depressive outpatients and to identify its correlates in depression.

METHOD

This cross-sectional analysis was performed on 121 depressive outpatients from January 2002 through January 2004 who were diagnosed at baseline with the Structured Clinical Interview for DSM-III-R. The metabolic syndrome was diagnosed at 6-year follow-up according to the modified criteria of the National Cholesterol Education Program. The severity of depressive symptoms was assessed at follow-up with the Beck Depression Inventory and the Hamilton Rating Scale for Depression, and general psychopathology was assessed with the Symptom Checklist-90.

RESULTS

At 6-year follow-up, the prevalence of metabolic syndrome in the study group of depressive outpatients was 36% (N = 44). The syndrome was associated with a current diagnosis of major depression and overeating, but not with age or sex.

CONCLUSION

The metabolic syndrome is highly prevalent among patients with a history of depression, especially those with current major depression. This may have implications for treatment. Furthermore, attention should be focused on the physical health of those suffering from depression.

Thyroid storm prior to induction of anaesthesia

A 53- year-old woman without a previous history of thyroid disease was scheduled for mastectomy. On arrival in the operating theatre unpremedicated she appeared restless and tachycardic. Midazolam and fentanyl was administered intravenously. Concomitantly, sinus tachycardia developed and a flush reaction was observed in the skin of the thoracic region and neck. The blood pressure increased to 265/160 mmHg and the patient lost consciousness and became apnoeic. Unconsciousness and apnoea lasted for approximately 25 min and the operation was postponed. Further investigations revealed an elevated serum free thyroxine level and suppressed serum thyrotropin diagnostic of hyperthyroidism. The serum TSH receptor antibody concentration was elevated, indicating that the patient was suffering from Graves' disease. We present a case of a previously unknown hyperthyroid patient, with breast cancer, presenting as a thyroid crisis on induction of anaesthesia. Although being quite a rare occurrence, unsuspected thyroid disease should be borne in mind when an agitated patient enters the operating theatre.

Leucine7 to proline7 polymorphism in prepro-NPY gene and femoral neck bone mineral density in postmenopausal women

Neuropeptide Y (NPY) is a versatile neurotransmitter that has recently been shown to regulate bone metabolism in animal and in vitro studies. We studied the influence of leucine7-to-proline7 (Leu7/Pro7) polymorphism of the NPY signal peptide gene on bone mineral density (BMD) before and after a 5-year hormone replacement therapy (HRT) in 316 early postmenopausal women participating in a randomized controlled trial nested in the population-based Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) study. The participants were randomized into two treatment groups: the HRT group (n = 146) received a sequential combination of 2 mg estradiol valerate and 1 mg cyproterone acetate and calcium lactate, 500 mg/day (equal to 93 mg Ca2+) alone or in combination with vitamin D3, 100-300 IU/day. The non-HRT group (n = 170) received calcium lactate, 500 mg alone or in combination with vitamin D3, 100-300 IU/day. BMDs of the lumbar spine (L2-4) and proximal femur were measured by using dual X-ray absorptiometry (DXA). The frequency of Leu7/Pro7 polymorphism was 15.2%. At baseline, there were no significant differences in the lumbar or femoral neck BMD between the subjects who had Leu7Pro7 polymorphism and the normal subjects. After 5 years, the BMD of the femoral neck remained unaltered and that of the lumbar spine increased by 1.7% in the HRT group, whereas both BMDs were decreased by 4-5% in the non-HRT group. After 5 years, the femoral neck BMD was significantly lower in those with the wild-type NPY polymorphism than in those with Leu7/Pro7 polymorphism (P = 0.040) in the non-HRT group. In the HRT group, the changes in BMD were quite modest and not significantly modified by Leu7/Pro7 genotype. We conclude that the Leu7/Pro7 polymorphism in NPY signal gene may favorably affect femoral neck BMD in postmenopausal women.

Uric acid level as a risk factor for cardiovascular and all-cause mortality in middle-aged men: a prospective cohort study

BACKGROUND

Despite abundant epidemiologic evidence, the role of elevated serum uric acid level as a cardiovascular risk factor is controversial. We assessed the predictive value of serum uric acid levels for cardiovascular and overall mortality.

METHODS

A population-based prospective cohort study was performed of 1423 middle-aged Finnish men initially without cardiovascular disease, cancer, or diabetes. The main outcome measure was death from cardiovascular disease and any cause.

RESULTS

The mean follow-up was 11.9 years. There were 157 deaths during follow-up, of which 55 were cardiovascular. In age-adjusted analyses, serum uric acid levels in the upper third were associated with a greater than 2.5-fold higher risk of death from cardiovascular disease than levels in the lower third. Taking into account cardiovascular risk factors and variables commonly associated with gout increased the relative risk to 3.73. Further adjustment for factors related to the metabolic syndrome strengthened the risk to 4.77. Excluding the 53 men using diuretics did not alter the results. In age-adjusted analyses, men with serum uric acid levels in the upper third were 1.7-fold more likely to die of any cause than men with levels in the lower third. Adjustment for further risk factors strengthened the association somewhat.

CONCLUSIONS

Serum uric acid levels are a strong predictor of cardiovascular disease mortality in healthy middle-aged men, independent of variables commonly associated with gout or the metabolic syndrome. Serum uric acid measurement is an easily available and inexpensive risk marker, but whether its relationship to cardiovascular events is circumstantial or causal remains to be answered.

Mineral water fortified with folic acid, vitamins B6, B12, D and calcium improves folate status and decreases plasma homocysteine concentration in men and women

OBJECTIVE

We investigated the effects of mineral water fortified with folic acid, vitamins B(6), B(12), D and calcium on folate concentrations in serum and erythrocytes, serum vitamin B(12) and plasma homocysteine concentrations in free-living subjects. In addition, we investigated the bioavailability of calcium added to mineral water by measuring urinary calcium excretion and serum alkaline phosphatase activity.

DESIGN

Randomized, controlled, double-blinded, parallel design.

SETTING

Outpatient dietary intervention with free-living subjects in Eastern Finland.

SUBJECTS

Altogether, 66 subjects were recruited for the study. In all, 60 subjects completed the study.

INTERVENTIONS

The study began with a 2-week run-in period followed by an 8-week intervention period. During the intervention study, subjects consumed mineral water fortified with folic acid (563 microg/day), vitamins B(6) (1 mg/day), B(12) (7.5 microg/day), cholecalciferol (0.6 microg/day) and calcium (563 mg/day) or placebo mineral water.

RESULTS

The fortified mineral water increased serum and erythrocyte folate concentrations by 16.1+/-5.6 nmol/l (P<0.001) and 199+/-76 nmol/l (P<0.001), respectively, and decreased plasma homocysteine concentration by 1.6 micromol/l (P<0.001). Urinary calcium excretion and serum alkaline phosphatase activity for 24 h increased significantly (P<0.001 and P=0.01 respectively) in the intervention group.

CONCLUSIONS

Mineral water fortified with folic acid, vitamins B(6), B(12) and D and calcium enhanced folate status and reduced plasma homocysteine concentration in normohomocysteinemic subjects without folate deficiency. Indirect measures of calcium and bone metabolism indicated that the calcium used in the fortification of the mineral water was bioavailable.

Structural differences between rye and wheat breads but not total fiber content may explain the lower postprandial insulin response to rye bread

BACKGROUND

Rye bread has a beneficial effect on the postprandial insulin response in healthy subjects. The role of rye fiber in insulin and glucose metabolism is not known.

OBJECTIVE

The aim of the study was to determine the effect of the content of rye fiber in rye breads on postprandial insulin and glucose responses.

DESIGN

Nineteen healthy postmenopausal women aged 61 +/- 1 y, with a body mass index (in kg/m(2)) of 26.0 +/- 0.6, and with normal glucose tolerance participated in the study. The test products were refined wheat bread (control), endosperm rye bread, traditional rye bread, and high-fiber rye bread; each bread provided 50 g available carbohydrate and was served with breakfast. Plasma glucose, insulin, glucose-dependent insulinotropic polypeptide, glucagon-like peptide 1, and serum C-peptide were measured in fasting and 8 postprandial blood samples. In vitro starch hydrolysis and the microscopic structure of the breads were also determined.

RESULTS

Postprandial insulin, glucose-dependent insulinotropic polypeptide, and C-peptide responses to the rye breads were significantly lower than the response to the control; no significant differences in insulin and C-peptide responses to the rye breads were found. Glucose and glucagon-like peptide 1 responses to the rye breads were not significantly different from those to the control, except at 150 and 180 min. In vitro starch hydrolysis was slower in all rye breads than in the control, and the structure of continuous matrix and starch granules differed between the rye and control breads.

CONCLUSION

Total fiber content does not explain the lower postprandial insulin response to rye bread than to wheat bread, but structural differences between rye and wheat breads might.

Sedentary lifestyle, poor cardiorespiratory fitness, and the metabolic syndrome

PURPOSE

The cross-sectional associations of leisure-time physical activity (LTPA) and cardiorespiratory fitness with the metabolic syndrome (MS) were investigated in a population-based sample of 1069 middle-aged men without diabetes, cardiovascular disease, or cancer.

METHODS

LTPA was assessed using a detailed quantitative questionnaire. Maximal oxygen uptake VO(2max) and core and related features of the MS were determined. A modified World Health Organization definition of the MS and factor analysis were used.

RESULTS

Men who engaged in at least moderate-intensity (>or=4.5 metabolic equivalents) LTPA <1.0 h.wk-1 were 60% more likely to have the MS than those engaging in >or= 3.0 h.wk-1 even after adjustment for confounders. Low-intensity (<4.5 metabolic equivalents) LTPA was not associated with the metabolic syndrome. Men with a VO(2max) <29.1 mL x kg-1 x min-1 were almost seven times more likely to have the MS than those with a VO(2max) >or=35.5 mL.kg-1.min-1 even after adjusting for confounders. In first-order factor analysis using a promax rotation, the principal factor explained 20% of total variance and had heavy loadings for VO(2max) (-0.57) and at least moderate-intensity LTPA (-0.44), and moderate or heavy loadings for the main components of the MS. The second-order factor analysis generated a principal factor that was strongly loaded on by the main components of the MS and VO(2max) (-0.50) but not LTPA.

CONCLUSION

A sedentary lifestyle and especially poor cardiorespiratory fitness are not only associated with the MS but could also be considered features of the MS. Measurement of VO(2max) in sedentary men with risk factors may provide an efficient means for targeting individuals who would benefit from interventions to prevent the MS and its consequences.

Changes in abdominal subcutaneous fat water content with rapid weight loss and long-term weight maintenance in abdominally obese men and women

OBJECTIVE

Insulin resistance decreases blood flow and volume in fat tissue. We hypothesised that fat tissue nutritive blood flow and volume, and thereby water content, would increase during weight loss and weight maintenance in obese persons.

DESIGN

Longitudinal clinical intervention with a 9-week very-low-calorie diet (VLCD) followed by one year of weight maintenance.

SUBJECTS

Obese men (n=13) and women (n=14) with the metabolic syndrome.

MEASUREMENTS

Water content of abdominal subcutaneous fat tissue as estimated by a sensor on the skin surface measuring the dielectric constant at 300 MHz. Anthropometric measures of fatness and fat distribution. Biochemical measures related to insulin resistance.

RESULTS

Subjects lost 14.5+/-3.4% of body weight during the VLCD, and generally sustained this weight loss during weight maintenance. Insulin sensitivity as estimated by an index (qualitative insulin sensitivity check index) increased during the VLCD, and remained increased throughout weight maintenance. The dielectric constant increased from 23.3+/-2.3 to 25.0+/-2.1 (P<0.001) during the VLCD, and further to 27.8+/-1.9 (P<0.001) during weight maintenance, indicating an increase in the water content of subcutaneous fat. The increase in subcutaneous fat water content did not correlate with weight loss and other measures of adiposity during the VLCD, but there was an inverse correlation that strengthened in significance from baseline to 6, 9 and 12 mo (r=-0.32 to -0.64, P=0.079-0.002). Increases in subcutaneous fat water content also correlated with improvements in insulin sensitivity at 6, 9 and 12 months of weight maintenance (r=0.34-0.54, P=0.094-0.006).

CONCLUSIONS

Water content of abdominal subcutaneous adipose tissue increases with weight loss in obese persons with the metabolic syndrome, and may reflect increased subcutaneous fat tissue nutritive blood flow. The increase in water content correlates with the increase in insulin sensitivity, suggesting that weight loss and consequent improved insulin sensitivity could mediate the increase in abdominal subcutaneous fat hydration.

Time course of serum prolactin and sex hormones following successful renal transplantation

BACKGROUND

Chronic renal failure is commonly associated with disturbances in hypothalamic-pituitary-gonadal function.

METHODS

The gonadotrophins, prolactin and estradiol or testosterone levels were measured immediately before renal transplantation, at discharge from the transplantation unit (19 +/- 8 days after Tx) and 6 months after transplantation in 21 patients, 7 females and 14 males, age range 21-60 years.

RESULTS

The mean prolactin level was high during uremia and decreased rapidly after transplantation, from 441 to 167 mU/l in males and from 1,057 to 521 mU/l in females. Hypergonadotrophism was seen in most uremic patients, with the mean LH and FSH levels of 14.2 and 6.0 U/l in males and 14.7 and 4.0 U/l in females, respectively. A temporary change to hypogonadotrophic hypogonadism took place 2-3 weeks after transplantation and was followed by normalization of the hypothalamic-gonadal function. The levels of circulating sex steroids were suppressed when the patients were discharged from the transplantation unit but returned to the normal range at 6 months.

CONCLUSIONS

We conclude that renal transplantation corrects the hyperprolactinemia induced by uremia and is followed by rapid onset of restoration of the hypothalamic-pituitary-gonadal axis.

High-fiber rye bread and insulin secretion and sensitivity in healthy postmenopausal women

BACKGROUND

Fiber and whole-cereal intakes may protect against hyperinsulinemia and the risk of type 2 diabetes.

OBJECTIVE

The aim was to study whether the long-term use of high-fiber rye bread and white-wheat bread modifies glucose and insulin metabolism in healthy postmenopausal women.

DESIGN

The study was a randomized crossover trial consisting of 8-wk test and 8-wk washout periods. The subjects were 20 postmenopausal women [macro x +/- SD age: 59 +/- 6.0 y; body mass index (in kg/m(2)): 27.5 +/- 2.9; baseline fasting serum cholesterol: 6.5 +/- 0.8 mmol/L], of whom 3 had impaired glucose tolerance as determined by a 2-h oral-glucose-tolerance test. The test breads were high-fiber rye and white-wheat breads, planned to make up > or =20% of energy. Fasting blood samples were collected for the measurement of plasma glucose and insulin at the beginning and at the end of both bread periods. The frequently sampled intravenous-glucose-tolerance test was performed at the run-in and at the end of both bread periods. The acute insulin response, insulin sensitivity, and glucose effectiveness were calculated.

RESULTS

The rye bread made up 23.4 +/- 4.3% and wheat bread 26.7 +/- 8.2% of total energy intake. Compared with that during the run-in period, the acute insulin response increased significantly more during the rye bread period (9.9 +/- 24.2%) than during the wheat bread period (2.8 +/- 36.3%; P = 0.047). Other measured variables did not change significantly during the study.

CONCLUSIONS

Modification of carbohydrate intake by high-fiber rye bread did not alter insulin sensitivity in postmenopausal, hypercholesterolemic women. High-fiber rye bread appears to enhance insulin secretion, possibly indicating improvement of b cell function.

Weight loss and weight maintenance, ambulatory blood pressure and cardiac autonomic tone in obese persons with the metabolic syndrome

BACKGROUND

Cardiac autonomic function may play a role in obesity-associated hypertension. Most studies on the effects of weight loss on blood pressure and autonomic function do not distinguish between acute or continuing weight loss and steady-state weight maintenance after weight loss.

OBJECTIVES

We sought to clarify the changes in ambulatory blood pressure, heart rate and heart rate variability as assessed by spectral analysis during rapid weight loss and extended weight maintenance.

PARTICIPANTS

Abdominally obese (body mass index 35.2 +/- 2.1 kg/m2, waist 114.3 +/- 9.0 cm) men and women (n = 41) with the metabolic syndrome.

METHODS AND RESULTS

The 34 men and women completing the 1-year weight maintenance period lost 14.6 +/- 3.5 kg during the 9-week very-low-calorie diet and maintained a 12.5 +/- 7.5 kg weight loss to the end of the trial. Ambulatory 24-h blood pressure decreased dramatically during the diet (-9.0 +/- 8.0/-4.6 +/- 4.9 mmHg), but had risen to near baseline levels by the end of weight maintenance (-2.2 +/- 8.2 /-1.2 +/- 6.1 mmHg). Night-time heart rate decreased (-5.5 +/- 9.6 beats/min, P = 0.012), and heart rate variability total and low-frequency power measured during 5 min of controlled breathing increased by 46-56% (P = 0.003-0.09) during rapid weight loss. These changes gradually attenuated during weight maintenance, and only the change in night-time heart rate was still of borderline significance after 1 year of weight maintenance (-3.6 +/- 8.6 beats/min, P = 0.063). Heart rate variability high-frequency power tended to increase during weight loss and weight maintenance.

CONCLUSION

Despite successful weight maintenance, the decrease in ambulatory blood pressure after rapid weight loss was largely transient. The increase in parasympathetic tone was more sustained, but also gradually attenuated during 1 year of weight maintenance.

The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men

CONTEXT

The metabolic syndrome, a concurrence of disturbed glucose and insulin metabolism, overweight and abdominal fat distribution, mild dyslipidemia, and hypertension, is associated with subsequent development of type 2 diabetes mellitus and cardiovascular disease (CVD). Despite its high prevalence, little is known of the prospective association of the metabolic syndrome with cardiovascular and overall mortality.

OBJECTIVE

To assess the association of the metabolic syndrome with cardiovascular and overall mortality using recently proposed definitions and factor analysis.

DESIGN, SETTING, AND PARTICIPANTS

The Kuopio Ischaemic Heart Disease Risk Factor Study, a population-based, prospective cohort study of 1209 Finnish men aged 42 to 60 years at baseline (1984-1989) who were initially without CVD, cancer, or diabetes. Follow-up continued through December 1998.

MAIN OUTCOME MEASURES

Death due to coronary heart disease (CHD), CVD, and any cause among men with vs without the metabolic syndrome, using 4 definitions based on the National Cholesterol Education Program (NCEP) and the World Health Organization (WHO).

RESULTS

The prevalence of the metabolic syndrome ranged from 8.8% to 14.3%, depending on the definition. There were 109 deaths during the approximately 11.4-year follow-up, of which 46 and 27 were due to CVD and CHD, respectively. Men with the metabolic syndrome as defined by the NCEP were 2.9 (95% confidence interval [CI], 1.2-7.2) to 4.2 (95% CI, 1.6-10.8) times more likely and, as defined by the WHO, 2.9 (95% CI, 1.2-6.8) to 3.3 (95% CI, 1.4-7.7) times more likely to die of CHD after adjustment for conventional cardiovascular risk factors. The metabolic syndrome as defined by the WHO was associated with 2.6 (95% CI, 1.4-5.1) to 3.0 (95% CI, 1.5-5.7) times higher CVD mortality and 1.9 (95% CI, 1.2-3.0) to 2.1 (95% CI, 1.3-3.3) times higher all-cause mortality. The NCEP definition less consistently predicted CVD and all-cause mortality. Factor analysis using 13 variables associated with metabolic or cardiovascular risk yielded a metabolic syndrome factor that explained 18% of total variance. Men with loadings on the metabolic factor in the highest quarter were 3.6 (95% CI, 1.7-7.9), 3.2 (95% CI, 1.7-5.8), and 2.3 (95% CI, 1.5-3.4) times more likely to die of CHD, CVD, and any cause, respectively.

CONCLUSIONS

Cardiovascular disease and all-cause mortality are increased in men with the metabolic syndrome, even in the absence of baseline CVD and diabetes. Early identification, treatment, and prevention of the metabolic syndrome present a major challenge for health care professionals facing an epidemic of overweight and sedentary lifestyle.

Metabolic syndrome and development of diabetes mellitus: application and validation of recently suggested definitions of the metabolic syndrome in a prospective cohort study

The World Health Organization (WHO) and the National Cholesterol Education Program (NCEP) recently proposed definitions for the metabolic syndrome. Little is known of their validity, however. The authors assessed the sensitivity and specificity of the definitions of the metabolic syndrome for prevalent and incident diabetes mellitus in a Finnish population-based cohort of middle-aged men (n = 1,005) followed for 4 years since the late 1980s. Four definitions based on the WHO and NCEP recommendations were compared. All definitions identified persons at high risk for developing diabetes during the 4-year follow-up (odds ratios = 5.0-8.8). The WHO definition including waist-hip ratio > 0.90 or body mass index >or= 30 kg/m(2) was the most sensitive (0.83 and 0.67) and least specific (0.78 and 0.80) in detecting the 47 prevalent and 51 incident cases of diabetes. The NCEP definition in which adiposity was defined as waist girth > 102 cm detected only 61% of prevalent and 41% of incident diabetes, although it was the most specific (0.89 and 0.90). The WHO definition seems valid as judged by its relatively high sensitivity and specificity in predicting diabetes. The NCEP definition including waist > 102 cm also identifies persons at high risk for diabetes, but it is relatively insensitive in predicting diabetes.

Low levels of leisure-time physical activity and cardiorespiratory fitness predict development of the metabolic syndrome

OBJECTIVE

Little is known about the association of leisure-time physical activity (LTPA) and cardiorespiratory fitness with development of the metabolic syndrome, which predisposes diseases such as diabetes and atherosclerosis. We studied the associations of LTPA and cardiorespiratory fitness with development of the metabolic syndrome (World Health Organization [WHO] and the National Cholesterol Education Program [NCEP] definitions).

RESEARCH DESIGN AND METHODS

LTPA over the previous 12 months, VO(2max) (ml. kg(-1). min(-1)), and cardiovascular and metabolic risk factors were assessed in a population-based cohort of 612 middle-aged men without the metabolic syndrome.

RESULTS

At the 4-year follow-up, 107 men had metabolic syndrome (WHO definition). Men engaging in >3 h/week of moderate or vigorous LTPA were half as likely as sedentary men to have the metabolic syndrome after adjustment for major confounders (age, BMI, smoking, alcohol, and socioeconomic status) or potentially mediating factors (insulin, glucose, lipids, and blood pressure), especially in high-risk men. Vigorous LTPA had an even stronger inverse association, particularly in unfit men. Men in the upper third of VO(2max) were 75% less likely than unfit men to develop the metabolic syndrome, even after adjustment for major confounders. Adjustment for possible mediating factors attenuated the association. Associations of LTPA and VO(2max) with development of the metabolic syndrome, as defined by the NCEP, were qualitatively similar.

CONCLUSIONS

In particular, high-risk men engaging in currently recommended levels of physical activity were less likely to develop the metabolic syndrome than sedentary men. Cardiorespiratory fitness was also strongly protective, although possibly not independent of mediating factors.

Serum fatty acid composition predicts development of impaired fasting glycaemia and diabetes in middle-aged men

AIMS

Dietary fatty acid intake is reflected in serum fatty acid composition. Studies prospectively investigating serum fatty acids and development of impaired fasting glycaemia (IFG) or diabetes mellitus (DM) are largely lacking. We assessed the association of serum fatty acid composition with development of IFG or DM.

METHODS

Middle-aged normoglycaemic men (n = 895) participating in a prospective cohort study were followed up after 4 years.

RESULTS

At baseline proportions of serum esterified and non-esterified saturated fatty acids were increased and polyunsaturated fatty acids decreased in men who after 4 years had developed IFG (n = 56) or DM (n = 34). No differences in dietary fatty acid composition as recorded in 4-day dietary records were noted. In logistic regression analyses adjusting for age; obesity; and fasting lipid, glucose and insulin concentrations, men with proportions of non-esterified and esterified linoleate in the upper third had nearly half the risk for IFG or DM compared with the lower third. In covariate analyses, baseline non-esterified linoleate proportions were associated with changes in fasting insulin and glucose concentrations over the 4-year follow-up. Baseline esterified fatty acid composition was also associated with changes in insulin.

CONCLUSIONS

High serum linoleate proportions decreased the risk of developing IFG or DM in middle-aged men over a 4-year follow-up, possibly mediated in part by insulin resistance. These findings support recommendations to substitute vegetable fat for animal and dairy fat in the prevention of disturbances of glucose and lipid metabolism.

Postprandial glucose, insulin, and incretin responses to grain products in healthy subjects

BACKGROUND

Various botanical and structural characteristics of starchy food modify the postprandial glucose and insulin responses in humans.

OBJECTIVE

We investigated what factors in grain products affect human glucose and insulin responses and elucidated the mediating mechanisms.

DESIGN

Ten men and 10 women [mean age: 28 +/- 1 y; mean body mass index (in kg/m(2)): 22.9 +/- 0.7] with normal glucose tolerance were recruited. The test products were whole-kernel rye bread, whole-meal rye bread containing oat beta-glucan concentrate, dark durum wheat pasta, and wheat bread made from white wheat flour. Paracetamol, a marker of the rate of gastric emptying, was added to the breads during baking. Each product provided 50 g available carbohydrate and was served in random order with breakfast (except for the beta-glucan rye bread, which was served at the last visit). Fasting and 8 postprandial blood samples were collected at intervals of 15-30 min for 3 h to determine plasma glucose, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide 1 (GLP-1), serum insulin, and paracetamol concentrations. The in vitro starch hydrolysis, the structural characteristics (by light microscopy), and the molecular weight of beta-glucan in the test products were analyzed.

RESULTS

Glucose responses and the rate of gastric emptying after consumption of the 2 rye breads and pasta did not differ from those after consumption of white wheat bread. However, insulin, GIP, and GLP-1 responses, except for GLP-1 responses to the rye bread containing oat beta-glucan concentrate, were lower after the consumption of rye breads and pasta than after consumption of white wheat bread.

CONCLUSIONS

Postprandial insulin responses to grain products are determined by the form of food and botanical structure rather than by the amount of fiber or the type of cereal in the food. These effects may be mediated through GIP and GLP-1.

Occurrence and predictors of retinopathy and visual acuity in Type 2 diabetic patients and control subjects. 10-year follow-up from the diagnosis

The evolution of visual acuity and retinopathy and their risk factors in patients with newly diagnosed type 2 diabetes and in control subjects. A 10-year prospective study consisting of a representative group of 133 (70 men, 63 women) newly diagnosed type 2 diabetic patients diagnosed at health centers between 1979 and 1981 and 144 (62 men, 82 women) non-diabetic control subjects recruited from the population register. The frequency of retinopathy was determined by grading of 45 degrees fundus photographs at baseline and after 5 and 10 years. By the 10-year follow-up the diabetic patients had lower visual acuity than the control subjects. The impairment of the visual acuity correlated inversely to HbA(1C) value of the 5-year examination. The frequency of retinopathy in type 2 diabetic patients increased sharply after 5 years and at 10-year 55% of diabetic patients had signs of retinopathy. The frequency of retinopathy in the control subjects was low, but detectable. In the diabetic patients poor glycemic control was the most important predictive factor for the development of retinopathy. In the control subjects blood pressure levels were higher and microalbuminuria more common in those with than in those without retinopathy. The visual acuity deteriorated and the frequency of retinopathy increased in newly diagnosed type 2 diabetic patients with duration of disease and poor glycemic control. Interestingly, higher blood pressure levels and microalbuminuria predicted retinopathy in control subjects.

Reduced CD44 standard expression is associated with tumour recurrence and unfavourable outcome in differentiated thyroid carcinoma

CD44 was detected with an antibody recognizing all forms of CD44 (CD44 standard) and others specific for its v3 and v6 variant isoforms; their prognostic value was evaluated in 213 patients with differentiated thyroid carcinoma (DTC). The staining patterns of CD44 standard (s) and CD44v6 in tumour tissue were quite similar, 176 cases (83%) being highly positive for CD44s and 153 cases (72%) for CD44v6. Only 18 (9%) tumours showed high expression of CD44v3. Papillary carcinomas were significantly more often high expressors of CD44s and CD44v6 than follicular carcinomas (p<0.001 for both). Age older than 60 years, distant metastases, and advanced pTNM stage were related to loss of expression of CD44s (p<0.001, p=0.021, and p=0.003, respectively). Tumour recurrence and cancer-related mortality were related to the reduced level of CD44s (p=0.049 and p=0.042). CD44v3 did not associate with any of the clinicopathological factors. In univariate analysis, CD44s was the only significant prognostic factor for disease-free survival (p=0.0488). In multivariate analysis, CD44s and thyroglobulin level were significant prognostic factors for disease-free survival (p=0.040 and p<0.001, respectively). The reduced level of CD44s in DTC patients seems to be an independent prognostic factor for unfavourable disease outcome.

Age-related macular degeneration in newly diagnosed type 2 diabetic patients and control subjects: a 10-year follow-up on evolution, risk factors, and prognostic significance

OBJECTIVE

To investigate the evolution of visual acuity, age-related macular degeneration (AMD), and its relation to 10-year cardiovascular mortality and risk factors in patients with newly diagnosed type 2 diabetes and control subjects.

RESEARCH DESIGN AND METHODS

A 10-year prospective study consisting of a representative group of 133 (70 men, 63 women) newly diagnosed type 2 diabetic patients diagnosed at health centers between 1979 and 1981 and 144 (62 men, 82 women) nondiabetic control subjects recruited from the population register was performed. The frequency of AMD was determined by grading of 45 degrees stereoscopic fundus photographs. The subjects were studied at baseline and after 5 and 10 years.

RESULTS

By the 10-year follow-up, visual acuity had declined more markedly in the diabetic patients than in the control subjects. Although the frequency of AMD was nearly the same in both groups (11-19%), it decreased visual acuity earlier in the diabetic patients than in the control group. AMD at baseline predicted 10-year cardiovascular mortality independently of adjustment for other risk factors in the diabetic patients (odds ratio [95% CI] 4.7 [1.1-19.3], P = 0.033).

CONCLUSIONS

Visual acuity deteriorated earlier in newly diagnosed type 2 diabetic patients than in the control group although the cross-sectional frequency of AMD was nearly the same in both groups. Interestingly, AMD was an independent risk factor for cardiovascular mortality in type 2 diabetic patients, but the background mechanism(s) behind this association is unknown.

Aerobic exercise and the lipid profile in type 1 diabetic men: a randomized controlled trial

PURPOSE

Despite the potential importance of favorable changes in the lipid profile produced by aerobic exercise, training-induced lipid profile changes in atherosclerosis-prone type 1 diabetes mellitus (DM) have not heretofore been adequately addressed.

METHODS

We assessed the effect of a 12- to 16-wk aerobic exercise program on cardiorespiratory fitness and the lipid profile in young men with type 1 DM. Generally active men aged 20-40 yr with type 1 DM (N = 56) were randomized into training (N = 28) and control (untrained, N = 28) groups after baseline measurements. Training consisted of 30-60 min moderate-intensity running 3-5 times a week for 12-16 wk.

RESULTS

For the 42 men finishing the study, peak oxygen consumption (VO2 peak) increased significantly only in the trained group. Total and low-density lipoprotein (LDL) cholesterol and apolipoprotein (apo) B decreased and the high-density lipoprotein (HDL)/apo A-I ratio increased in the trained group. HDL and apo A-I increased in both groups. The exercise program brought about improvements in the HDL/LDL and apo A-I/apo B ratios and apo B and triglyceride levels when comparing the relative (%) changes in the trained versus control group. In the trained group, men with HDL/LDL ratios below the group median at baseline showed even more favorable changes in their lipid profile than those with higher initial HDL/LDL ratios. Body mass index, percent body fat and hemoglobin A1c did not change during the training period in either group.

CONCLUSIONS

Endurance training improved the lipid profile in already physically active type 1 diabetic men, independently of effects on body composition or glycemic control. The most favorable changes were in patients with low baseline HDL/LDL ratios, likely the group with the greatest benefit to be gained by such changes.

Hyperproinsulinemia is not a characteristic feature in the offspring of patients with different phenotypes of type II diabetes

OBJECTIVE

The purpose of this work was to study whether there are differences in plasma proinsulin levels and proinsulin-to-specific insulin ratio in the offspring of patients with different phenotypes of type II diabetes.

DESIGN

Eleven glucose-tolerant offspring of type II diabetic patients with deficient insulin secretion phenotype (IS group), nine glucose-tolerant offspring of patients with insulin-resistant phenotype (IR group), and fourteen healthy control subjects without a family history of diabetes were studied.

METHODS

Plasma specific insulin, plasma proinsulin, and plasma C-peptide levels were measured during a 2-h oral glucose tolerance test and during hyperglycemic clamp.

RESULTS

Plasma proinsulin levels during the oral glucose tolerance test and the hyperglycemic clamp did not differ among the study groups. The IR group had a lower fasting plasma proinsulin-to-specific insulin ratio (10.3+/-1.7%) than the control group (15.4+/-1.4%; P<0.05) and the IS group (18.6+/-2.7%; P<0.05). Furthermore, the IR group had lower plasma proinsulin-to-specific insulin ratio at 30, 60 and 90 min after the oral glucose load than the IS group. However, there were no significant differences in proinsulin-to-C-peptide ratio during the oral glucose tolerance test among the study groups. In stepwise multiple regression analysis, hepatic specific insulin extraction in the fasting state (beta =0.65; P<0.001) and fasting blood glucose (beta =0.32; P<0.05) together explained 52% of the variation in fasting plasma proinsulin-to-specific insulin ratio.

CONCLUSIONS

Hyperproinsulinemia is not a characteristic finding in glucose-tolerant offspring of type II diabetic probands with deficient insulin secretion or insulin-resistant phenotype. The differences in proinsulin-to-specific insulin ratios were most likely explained by different hepatic extraction among the study groups.

Power spectral analysis of heart rate variability during hyperinsulinemia in nondiabetic offspring of type 2 diabetic patients: evidence for possible early autonomic dysfunction in insulin-resistant subjects

Sympathetic activation has been considered as a link between insulin resistance, hyperinsulinemia, and hypertension. However, little is known about the association between insulin sensitivity and autonomic regulation or about the effect of acute hyperinsulinemia on cardiac sympathovagal balance. The aim of this study was to investigate heart rate variability (HRV) during the euglycemic-hyperinsulinemic clamp in nondiabetic offspring of patients with type 2 diabetes. We studied 35 nondiabetic offspring of patients with type 2 diabetes and 19 control subjects. Probands were chosen from a 10-year follow-up study of patients with well-characterized type 2 diabetes according to their fasting C-peptide level (selected from both ends of the distribution) and from control subjects to form three groups: 1) a group including subjects who were offspring of type 2 diabetic patients with low C-peptide levels (deficient insulin secretion group [IS group], n = 17), 2) a group including subjects who were offspring of type 2 diabetic patients with high C-peptide levels (insulin-resistant group [IR group], n = 18), and 3) a control group without a history of type 2 diabetes in first-degree relatives (n = 19). HRV was assessed at baseline and at the steady state during the euglycemic-hyperinsulinemic clamp. Rates of whole-body glucose uptake (M value) were lower in the IR group than in the IS group and the control group (41+/-3 vs. 54+/-2 vs. 60+/-4 micromol x kg(-1) x min(-1), P < 0.01 and P < 0.01, respectively). In all groups, heart rate increased significantly during hyperinsulinemia. In the IR group, insulin infusion increased total power of HRV [from 7.70+/-0.15 to 8.05+/-0.15 ln(ms2), P < 0.01] and the low frequency-to-high frequency ratio (from 0.62+/-0.14 to 1.14+/-0.18, P < 0.01) and decreased power of the high frequency spectral component (from 5.73+/-0.17 to 5.43+/-0.16 ln(ms2), P < 0.05), whereas in other groups, changes in HRV were not significant. We conclude that the HRV response to acute hyperinsulinemia in the offspring of type 2 diabetic probands was likely to be modulated by the type 2 diabetic phenotype of the parent. In insulin-resistant subjects, autonomic dysfunction may be an earlier defect than hitherto acknowledged.

Do high proinsulin and C-peptide levels play a role in autonomic nervous dysfunction?: Power spectral analysis in patients with non-insulin-dependent diabetes and nondiabetic subjects

BACKGROUND

Immunoreactive insulin has been shown to predict the development of parasympathetic autonomic neuropathy. It is possible that constituents of immunoreactive insulin could explain this association. In this cross-sectional study, the relationship of specific insulin, C-peptide, and proinsulin with autonomic nervous dysfunction was evaluated in 57 NIDDM patients and 108 control subjects.

METHODS AND RESULTS

The frequency-domain analysis of heart rate variability was determined by using spectral analysis from stationary regions of registrations while the subjects breathed spontaneously in a supine position. Total power was divided into three frequency bands: low (0 to 0.07 Hz), medium (MFP, 0.07 to 0.15 Hz), and high (HFP, 0.15 Hz to 0.50 multiplied by the frequency equal to the mean RR interval). In NIDDM patients, total power, the three frequency bands (P<.001 for each), and the MFP/HFP ratio (P=.016), which expresses sympathovagal balance, were reduced compared with control subjects. Fasting proinsulin (r(s)=-.324, P=.014 for diabetics and r(s)=-.286, P=.003 for control subjects), C-peptide (r(s)=-.492, P<.001 for diabetics and r(s)=-.304, P=.001 for control subjects), and total immunoreactive insulin (r(s)=-.291, P=.028 for diabetics and r(s)=-.228, P=.017 for control subjects) were inversely related to MFP/HFP. For proinsulin and C-peptide the results did not change after controlling for the effects of age, body mass index, and fasting glucose.

CONCLUSIONS

Both proinsulin and C-peptide levels were significantly associated with the sympathovagal balance of autonomic nervous function in NIDDM patients and control subjects, but this study cannot determine whether these compounds are directly involved in autonomic nervous dysfunction.

Divergent development of autonomic and peripheral somatic neuropathies in NIDDM

There is no information on the mutual occurrence and the development of autonomic and peripheral somatic neuropathies based on long-term follow-up of patients with non-insulin-dependent diabetes mellitus (NIDDM). We investigated the relation between the changes in autonomic function values and electrodiagnostic values, and the relation between the occurrence of autonomic neuropathy and peripheral somatic polyneuropathy in a group of patients with newly diagnosed NIDDM (n = 133, aged 45-65 years) at baseline and 5 and 10 years later. Parasympathetic autonomic neuropathy was diagnosed on the basis of heart rate variability during deep-breathing and sympathetic autonomic neuropathy on the basis of fall in systolic blood pressure while changing from supine to standing. Polyneuropathy was diagnosed on the basis of both clinical criteria and electrodiagnostic studies (nerve conduction velocity and response-amplitude values). In 10 years 36 patients died, mainly from cardiovascular causes. Altogether 78 patients completed the study. At 10 years, parasympathetic autonomic neuropathy was diagnosed in 61.3% of those with polyneuropathy and 66.7% of those without. Likewise, the frequency of sympathetic autonomic neuropathy was similar in those with polyneuropathy (21.9%) and those without (26.5%). The respective figures for combined (both parasympathetic and sympathetic) autonomic neuropathy were 10.0% and 18.8%. The worsening of parasympathetic and sympathetic autonomic function values was not related to the worsening in electrodiagnostic results with time. In conclusion, the development of autonomic and peripheral somatic neuropathies was divergent in patients with NIDDM suggesting different pathophysiological processes for these neuropathies.

Serum leptin in obesity is related to gender and body fat topography but does not predict successful weight loss

OBJECTIVE

Leptin is the product of the ob gene shown to regulate body fat and appetite in mice. It is produced by human adipose tissue also, but its physiological functions in man are poorly known.

STUDY DESIGN AND METHODS

We studied serum leptin concentrations in ten obese men and 35 obese women (age and body mass index 42 +/- 7 years and 35.1 +/- 3.6 kg/m2 respectively) before (baseline) and at 17 and 57 weeks during weight loss of 10.9% of the initial weight.

RESULTS

Serum leptin concentrations at baseline were 55% higher in women than in men (after adjustment for age and body fat mass, P = 0.002) and remained so during the follow-up. At baseline, serum leptin correlated with fat mass (r = 0.60, P < 0.001) estimated by bioelectrical impedance, and the changes in leptin concentrations from baseline to week 17 correlated with the changes in fat mass (r = 0.73, P < 0.001), but baseline leptin levels were not predictive of the successful weight loss. Leptin concentrations correlated with hip circumference (r = 0.49, P < 0.001 at baseline adjusted for age and sex), but the correlation with waist circumference became evident only during the weight loss (at week 57, r = 0.63, P < 0.001).

CONCLUSIONS

Serum leptin concentrations are higher in obese women than in obese men before and during weight loss, but the topography of fat tissue influences serum leptin concentrations. Serum leptin concentrations do not predict the response to weight reduction.

Serum leptin in subjects with impaired glucose tolerance in relation to insulin sensitivity and first-phase insulin response

OBJECTIVE

It has been suggested that insulin could regulate the secretion of leptin, the ob gene product, but the findings have been contradictory. Therefore, we studied the association between leptin and insulin secretion and insulin sensitivity in impaired glucose tolerance (IGT).

SUBJECTS

39 obese subjects (17 men, 22 women, body mass index (BMI) 30.6 +/- 0.6 kg/m2, age 54 +/- 1 y, mean +/- s.e.m.) with IGT.

MEASUREMENTS

Leptin, insulin sensitivity and first-phase insulin response (frequently sampled intravenous glucose tolerance test), anthropometry, infrared densitometric assay.

RESULTS

Leptin correlated with BMI (r = 0.36, P = 0.022), fat percent (r = 0.74, P < 0.001) and fat mass (r = 0.53, P < 0.001). After adjustment for sex and fat mass, leptin showed no significant linear correlation with fasting insulin, insulin sensitivity or first-phase insulin response.

CONCLUSION

In obese IGT subjects fat mass is the main correlate of serum leptin concentration. First-phase insulin response or the degree of insulin resistance are not associated with leptin in IGT.

Autonomic neuropathy predicts the development of stroke in patients with non-insulin-dependent diabetes mellitus

BACKGROUND AND PURPOSE

Our aim was to determine the predictive factors for stroke in patients with non-insulin-dependent diabetes mellitus (NIDDM).

METHODS

We studied 133 patients with NIDDM at the time of diagnosis and 5 and 10 years later.

RESULTS

The number of new fatal or nonfatal strokes was 19 (14.7%; 14 after 5-year examination). High initial fasting blood glucose (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.04 to 1.4) and the use of beta-blocking agents (OR, 6.7; 95% CI, 2.1 to 21.5) at baseline and the presence of parasympathetic neuropathy (OR, 6.7; 95% CI, 1.5 to 29.9), or sympathetic autonomic nervous dysfunction (OR, 1.1; 95% CI, 1.01 to 1.2), hypertriglyceridemia (OR, 5.7; 95% CI, 1.1 to 31.0), or use of beta-blocking agents (OR, 6.4; 95% CI, 1.3 to 31.2), and high fasting plasma glucose (OR, 1.2; 95% CI, 1.0 to 1.5) determined at 5-year examination predicted the development of stroke.

CONCLUSIONS

Autonomic neuropathy is an independent risk factor for stroke in NIDDM.

Evolution, risk factors, and prognostic implications of albuminuria in NIDDM

OBJECTIVE

To study the cumulative incidence of albuminuria and its determinants in NIDDM patients and nondiabetic subjects from the diagnosis and impact of albuminuria on cardiovascular mortality.

RESEARCH DESIGN AND METHODS

We performed a 10-year prospective observational study of 133 well-characterized middle-aged patients with newly diagnosed NIDDM and 144 control subjects. Both groups were examined at baseline and after 5 and 10 years. Urinary albumin excretion was determined from timed 24-h (baseline and 5-year examinations) or overnight samples (10-year examination). Microalbuminuria was defined as urinary albumin excretion of 30-300 mg/24 hr or 20-200 micrograms/min, with the higher values considered as macroalbuminuria.

RESULTS

The cumulative incidence of micro- and macroalbuminuria increased sharply after 5 years in NIDDM patients (baseline: 18.2 and 3.0%; 5 years: 18.9 and 1.8%; and 10 years: 33.0 and 10.2%) but markedly less in control subjects (baseline: 1.4 and 0%, P < 0.001 for diabetic patients vs. control subjects for any albuminuria; 5 years: 6.0 and 0.8%, P < 0.01; 10 years: 11.9 and 0.8%, P < 0.001). The most important determinant of the development of albuminuria was the metabolic control of diabetes in NIDDM patients during the follow-up, whereas in nondiabetic subjects, the development of albuminuria was related to elevated blood pressure and fasting insulin levels. Baseline and 5-year albuminuria predicted subsequent cardiovascular mortality in diabetic patients, even when adjusted for multiple risk factors. The risk of cardiovascular death in NIDDM patients increased by simultaneous occurrence of hyperinsulinemia and albuminuria.

CONCLUSIONS

The frequency of microalbuminuria in patients with NIDDM increases sharply with the duration of diabetes. Chronic hyperglycemia is the main risk factor for microalbuminuria in diabetic patients. Microalbuminuria accompanied by hyperinsulinemia is a powerful predictor of cardiovascular death in NIDDM patients.

Occurrence, predictors, and clinical significance of autonomic neuropathy in NIDDM. Ten-year follow-up from the diagnosis

Little is known about the occurrence and predictive factors of autonomic neuropathy and its relationship to cardiovascular mortality in NIDDM patients, and no long-term follow-up studies including nondiabetic control subjects are available. A total of 133 patients with newly diagnosed NIDDM (70 men) and 144 control subjects (62 men) were examined at baseline and after 5 and 10 years of follow-up. Deep-breathing tests (baseline, 5-year, and 10-year) and active orthostatic tests (5- and 10-year) were performed. Criteria for autonomic neuropathy were parasympathetic (expiration-to-inspiration ratio </- 1.10), sympathetic (systolic blood pressure decrease >/- 30 mmHg in the orthostatic test), and combined autonomic neuropathy (parasympathetic with sympathetic neuropathy). The frequency of parasympathetic neuropathy (NIDDM patients versus control subjects) was 4.9 vs. 2.2% (P = 0.224) at baseline, 19.6 vs. 8.5% (P = 0.017) at 5 years, and 65.0 vs. 28.0% (P < 0.001) at 10 years of follow-up. The frequency of sympathetic neuropathy was 6.8 vs. 5.6% (P = 0.709) at 5 years and 24.4 vs. 9.0% (P = 0.003) at 10 years of follow- up. These figures for combined autonomic neuropathy were 2.1 vs. 1.8% (P = 0.869) at 5 years and 15.2 vs. 4.2% (P = 0.007) at 10 years of follow-up. NIDDM patients with parasympathetic neuropathy at the 10-year examination showed worse glycemic control and higher insulin values than those without parasympathetic neuropathy. Furthermore, in our subjects, women were more prone to have parasympathetic neuropathy than men. Parasympathetic neuropathy at baseline was more frequent in those who died from a cardiovascular cause than those who did not (13 vs. 3%, P = 0.045). Similarly, sympathetic autonomic nervous dysfunction at the 5-year examination predicted the 10-year cardiovascular mortality. In conclusion, the frequency of autonomic neuropathy in NIDDM patients increases sharply with time. The development of autonomic neuropathy is connected with poor glycemic control. Interestingly, a high insulin level seems to have a predictive role in the development of parasympathetic autonomic neuropathy irrespective of obesity and glycemia.

Determinants of the cephalic-phase insulin response in obese nondiabetic subjects

Large interindividual variation is characteristic of the cephalic-phase insulin response (CPIR). Our aim was to examine the largely unknown determinants of CPIR in obese nondiabetic subjects before and after weight reduction. After a 12-hour overnight fast, 20 healthy, obese (body mass index, 31.1 to 41.4 kg/m2) subjects were individually exposed to food without being allowed to eat it. Levels of insulin, glucose, C-peptide, free fatty acids, and salivation, together with assessments of feeling of hunger and desire to eat, were measured during the experiment. Subjects were divided into three groups according to CPIR before the weight reduction: positive (PR), intermediate (IR), and negative (NR) responders. CPIR measurements before and after weight reduction correlated significantly with each other (r = .61, P < . 01,n=18). At the beginning of the study, NR had higher fasting plasma glucose and insulin values, as well as higher postload plasma glucose values, as compared with PR and IR. These differences disappeared after weight reduction. In an intravenous glucose tolerance test (IVGTT) performed 9 to 12 months afterward, first-phase insulin secretion was significantly lower in NR. Thus, the negative CPIR during visual and olfactory exposure to food-related stimuli may be related to the attenuated first-phase insulin secretion and mildly impaired glucose metabolism, possibly related to insulin resistance.

GAD antibodies in NIDDM. Ten-year follow-up from the diagnosis

OBJECTIVE

To study the frequency of antibodies to glutamic acid decarboxylase (GAD) and islet cell antibodies (ICAs) and their predictive value with respect to the development of insulin deficiency in 133 newly diagnosed middle-aged patients with non-insulin-dependent diabetes mellitus (NIDDM) and in 126 control subjects and to study the persistence of GAD antibodies in diabetic patients during the follow-up.

RESEARCH DESIGN AND METHODS

The study participants consisted of a well-characterized group of 133 middle-aged newly diagnosed patients with NIDDM and 126 control subjects. The follow-up examinations were performed 5 and 10 years after the baseline. The development of absolute and relative insulin deficiency was based on a stimulated C-peptide level that was undetectable or < 0.70 nmol/l, respectively. GAD antibodies were measured retrospectively from stored samples.

RESULTS

The overall prevalence of GAD antibody and ICA positivity at the time of diagnosis was 9.0 and 3.8% in diabetic patients and 1.6 and 0% in the control population, respectively. During the 10-year follow-up, 3 (2.3%) and 10 (7.5%) of the diabetic patients developed absolute and relative insulin deficiency, respectively. Of these, two (67%) and six (60%) had been GAD antibody-positive at the time of diagnosis. The sensitivity and specificity of the GAD antibody to predict absolute or relative insulin deficiency were 67 vs. 94% and 60 vs. 95%, while corresponding figures for ICA were 33 vs. 97% and 20 vs. 98%, respectively. The negative predictive value of GAD antibody testing was higher than positive predictive value (97 vs. 50%). During the follow-up, low-grade GAD antibody positivity showed an evanescent nature, whereas the high levels were quite persistent.

CONCLUSIONS

In an unselected population of newly diagnosed NIDDM patients, the prevalence of latent autoimmune diabetes in adults was < 10%. While GAD antibody and ICA measured at the time of diagnosis of NIDDM are equally specific predictors of subsequent insulin dependency, the GAD antibody may have a higher sensitivity. Therefore, measurements of GAD antibody may aid the clinician in the choice of treatment of these patients.

Plasma lipid peroxidation and hyperglycaemia: a connection through hyperinsulinaemia?

Increased lipid peroxidation has been commonly observed in diabetic patients as compared to control subjects. However, studies on the relationship to metabolic control have yielded conflicting results and no data are available on the relationship of hyperinsulinaemia to lipid peroxidation. We investigated, in well-characterized groups of 93 patients with non-insulin-dependent diabetes mellitus, 22 subjects with impaired glucose tolerance (IGT) and 96 subjects with normal glucose tolerance (NGT), the determinants of plasma lipid peroxidation measured by plasma thiobarbituric acid reactive substances (TBARS). These were significantly higher in subjects with IGT (1.04 +/- 0.48 mumol I-1) and in NIDDM patients (1.00 +/- 0.48 mumol I-1) than in those with NGT (0.75 +/- 0.46 mumol I-1; p < 0.05). The glucose tolerance status was the major determinant of increased lipid peroxidation even after controlling for the effects of age, sex, body mass index, physical activity, use of alcohol, smoking, and the use of diuretics. In regression analyses the major determinants of plasma TBARS were fasting plasma glucose, insulin, and apolipoprotein A1 (inversely) levels. To conclude, plasma TBARS were increased in impaired glucose tolerance and in diabetes and they were related to prevailing plasma glucose and insulin levels, suggesting a role for insulin resistance in increased lipid peroxidation process. On the contrary, apolipoprotein A1 may have protective effects in this respect.

Lauric and palmitic acid-enriched diets have minimal impact on serum lipid and lipoprotein concentrations and glucose metabolism in healthy young women

Fifteen healthy young women were fed diets enriched to 4% of energy with either palmitic acid (as palm oil) or lauric acid (as coconut oil). A randomized crossover study design was used so that subjects followed the two experimental diets for 4 wk, both preceded by consumption of a baseline diet for 2 wk. The experimental diets differed only with respect to the fatty acid composition: there was a substitution of 4% of energy intake with palmitic acid or lauric acid in the experimental diets for 4% of energy as monoenes in the baseline diet. There were no differences in the concentration of serum total or lipoprotein lipids, apolipoproteins A-I and B, and lipoprotein (a) or plasma cholesteryl ester transfer protein activity between the experimental diet periods. The VLDL cholesterol concentration (0.38 +/- 0.05 vs. 0.51 +/- 0.05 mmol/L, means +/- SEM, P = 0.01] and plasma cholesteryl ester transfer protein activity [78 +/- 5 vs. 88 +/- 6 mumol/(h.L), P = 0.007) were greater at the end of the lauric acid diet period than at the end of the preceding baseline diet period. No differences were found in glucose effectiveness, insulin sensitivity index or insulin secretion measured by the intravenous glucose tolerance test (Minimal Model method). In conclusion, in terms of serum lipids, lipoproteins, and glucose metabolism, palmitic acid was equal to lauric acid at 4% of total energy intake exchange, and both of these saturated fatty acids were comparable to a 4% of total energy intake exchange with monoenes in healthy young women.

Ten-year cardiovascular mortality in relation to risk factors and abnormalities in lipoprotein composition in type 2 (non-insulin-dependent) diabetic and non-diabetic subjects

The purpose of the present study was to examine 10-year cardiovascular morbidity and mortality in patients with newly-diagnosed Type 2 (non-insulin-dependent) diabetes mellitus and non-diabetic control subjects and to evaluate the effects of general risk factors, plasma insulin, urinary albumin excretion, lipoprotein abnormalities characteristic of Type 2 diabetes and the degree of hyperglycaemia in diabetic patients on cardiovascular mortality. Furthermore, the extent to which the above-mentioned factors could contribute to the excessive cardiovascular mortality observed in diabetic patients was examined. In the years 1979-1981, altogether 133 (70 men, 63 women) newly-diagnosed patients with Type 2 diabetes and 144 (62 men, 82 women) non-diabetic control subjects aged 45-64 years were studied. Both groups were re-examined in the years 1985-1986 and 1991-1992. The impact of different factors on cardiovascular mortality was examined by univariate analyses after adjustment for age and sex and by multiple logistic regression analyses. The age-standardized total and cardiovascular mortality rates were substantially higher in diabetic men (17.8 and 15.0%, total and cardiovascular mortality, respectively p = 0.06 and NS) and women (18.5 and 16.6%, p < 0.01 for both) than in non-diabetic control men (5.2% both total and cardiovascular mortality) and women (4.2 and 2.2%). Cardiovascular mortality was not related to the treatment modality (diet, oral drugs, insulin) at 5 years from diagnosis. Use of diuretics, beta-blocking agents or their combination at baseline did not make a significant contribution to cardiovascular mortality either. In multiple logistic regression analysis on diabetic patients, age, LDL triglycerides, smoking, blood glucose and ischaemic ECG at baseline had independent associations with cardiovascular mortality. Interestingly, urinary albumin excretion rate measured at 5-year examination also predicted 10-year cardiovascular mortality after adjustment for the effects of major risk factors including lipoprotein abnormalities, but its predictive power reduced to a nonsignificant level when the effect of plasma glucose was taken into account. The relative risk of cardiovascular mortality associated with diabetes was 8.2 after allowing for age alone, but it declined to 3.7 when all contributing factors from the baseline examination (except blood glucose) were taken into account. In conclusion, the present results indicate that LDL triglycerides and/or other changes in lipoprotein composition characteristic of Type 2 diabetes and manifesting as elevated serum triglycerides are atherogenic and they strongly predict increased cardiovascular mortality.(ABSTRACT TRUNCATED AT 400 WORDS)

Lower-extremity amputations in diabetic and nondiabetic patients. A population-based study in eastern Finland

OBJECTIVE

To study the incidence of LEAs attributable to PVD in diabetic and nondiabetic patients. The age at first amputation, the level of amputation, the number of reamputations, and survival after amputation also were examined in the study populations.

RESEARCH DESIGN AND METHODS

This retrospective study was based on a population of 253,000 inhabitants in eastern Finland. All patients with their first LEA performed during the period from 1 January 1978 to 31 December 1984 were identified from the registers of operation theaters in the study area. Furthermore, patient records and death certificates were reviewed. Amputations attributable to causes other than evident atherosclerotic vascular disease were excluded.

RESULTS

Altogether, 477 patients (85 diabetic men, 127 nondiabetic men, 169 diabetic women, and 96 nondiabetic women) were identified. The overall LEA rate was 26.9/100,000 per yr, and the incidence increased strongly with age in both diabetic and nondiabetic patients. The age-adjusted amputation incidence per yr was 349.1/100,000 for diabetic men, 33.9/100,000 for nondiabetic men, 239.4/100,000 for diabetic women, and 17.2/100,000 for nondiabetic women. The proportion of peripheral (toe, leg) amputations was markedly higher in diabetic patients who also tended to have more reamputations during the follow-up than did nondiabetic subjects. The diabetic status per se was a statistically significant risk factor for mortality in women, but not in men.

CONCLUSIONS

Diabetic men and women had a 10.3- and 13.8-fold higher risk, respectively, for LEA.

The relationship of hyperinsulinaemia to the development of hypertension in type 2 diabetic patients and in non-diabetic subjects

We have carried out a 5 year follow-up study of a group of 41 originally normotensive (BP less than 160/95 mmHg) newly diagnosed Type 2 (non-insulin-dependent) diabetic patients (26 men, 15 women) and 86 non-diabetic subjects (39 men, 47 women) to assess the predictive value of serum insulin levels with regard to the development of hypertension. Hypertension (BP greater than 160/95 mmHg and/or drug treatment) developed in 14% of diabetic patients and 10% of non-diabetic subjects (NS). The baseline postglucose insulin levels tended to be higher in those diabetic and non-diabetic subjects who developed hypertension during the 5 year follow-up than in those who remained normotensive, and in non-diabetic subjects the differences were statistically significant after adjustment for age, sex and body mass index for the baseline 1 hour serum insulin (104 +/- 18 vs. 68 +/- 5 mU/l; P less than 0.05) and area under the insulin curve (138 +/- 34 vs. 85 +/- 8 mU/l.h, P less than 0.05). Both diabetic and non-diabetic subjects who developed hypertension showed elevated total- and VLDL-triglycerides at baseline compared with those subjects who remained normotensive during the follow-up. In conclusion, the results support the hypothesis that hyperinsulinaemia or insulin resistance may play a role in the pathogenesis of hypertension.

Aortic and lower limb artery calcification in type 2 (non-insulin-dependent) diabetic patients and non-diabetic control subjects. A five year follow-up study

The purpose of the present study was to assess among a representative group of middle-aged newly diagnosed type 2 diabetics and control subjects the baseline prevalence and 5-year incidence of arterial calcifications of aorta and lower limb and their relationship to cardiovascular morbidity. The relationship of baseline risk factors to the development of arterial calcifications was also studied. At the time of diagnosis the age-adjusted prevalence of aortic and lower limb intimal calcifications was higher in diabetics than in control subjects (aortic calcifications: 29 vs. 17% for men, P = 0.05; 26 vs. 19% for women, P = 0.06; lower limb intimal calcifications: 24 vs. 12% for men, P = 0.02; 10 vs. 7% for women; P = NS), whereas no significant difference in baseline prevalence of lower limb medial calcifications was observed (15 vs. 21% for men, 9 vs. 10% for women). The 5-yr incidence of aortic calcifications in both sexes and of lower limb calcifications in men was similar in diabetic and control subjects, but the incidence of lower limb calcifications was higher in diabetic women than in control women (intimal: 33 vs. 11%, P = 0.009: medial: 29 vs. 14%, P = 0.05). The baseline prevalence of abdominal aortic (37 vs. 22%, P = NS for diabetics; 42 vs. 16%, P = 0.02 for control subjects), lower limb intimal (24 vs. 16% for diabetics, P = NS; 15 vs. 7% for control subjects, P = NS) and medial calcifications (23 vs. 7% for diabetics, P = 0.03) were higher in subjects who developed intermittent claudication during the follow-up than in those free of it at the 5-yr examination. Abnormalities in VLDL-metabolism and high systolic blood pressure were associated with the development of aortic calcification in diabetic subjects. In conclusion, already at the time of diagnosis atherosclerotic calcifications are more prevalent in type 2 diabetics than in nondiabetic subjects. During the follow-up diabetic women, but not men, had higher incidence of lower limb intimal and medial calcifications than non-diabetic subjects. Arterial calcifications tended to be associated with the development of intermittent claudication during the follow-up in diabetic and control subjects.

5-year incidence of atherosclerotic vascular disease in relation to general risk factors, insulin level, and abnormalities in lipoprotein composition in non-insulin-dependent diabetic and nondiabetic subjects

The 5-year incidence of myocardial infarction and claudication was examined in a group of middle-aged patients (n = 133, 70 men and 63 women) with newly diagnosed non-insulin-dependent diabetes and nondiabetic control subjects (n = 144, 62 men and 82 women). The effects of general risk factors, plasma insulin level, and lipoprotein abnormalities on the incidence of myocardial infarction and claudication were also evaluated by univariate analyses in both diabetic patients and nondiabetic subjects and by multivariate analyses combining both groups. The age-adjusted incidence of myocardial infarction was higher both in diabetic men (19.4%) and diabetic women (11.0%) than in nondiabetic men (3.2%, p = 0.009) and nondiabetic women (3.0%, p = 0.047). Similarly, the age-adjusted incidence of claudication was higher among the diabetic patients (20.3% vs. 8.0% for men, p = 0.06; 21.8% vs. 4.2% for women, p = 0.003). None of the general risk factors (i.e., low density lipoprotein [LDL] cholesterol, blood pressure, smoking, and high density lipoprotein [HDL] cholesterol) showed an association with the risk of myocardial infarction either in the diabetic or nondiabetic groups of subjects, but an ischemic electrocardiographic abnormality at the baseline examination predicted myocardial infarction in diabetic men. In univariate analyses in diabetic subjects, high serum total cholesterol, low HDL cholesterol, high very low density lipoprotein (VLDL) cholesterol, and high total, LDL and VLDL triglycerides, and in nondiabetic subjects, high VLDL cholesterol and LDL triglycerides were associated with the appearance of claudication. In multivariate analyses including both diabetic and control subjects, only diabetes had an independent association with myocardial infarction, whereas smoking, high LDL triglycerides or VLDL cholesterol, and high fasting plasma insulin showed independent relations to claudication. The present results indicate that changes in lipoprotein composition characteristic of non-insulin-dependent diabetes are atherogenic and increase the risk of atherosclerotic vascular disease. Furthermore, high plasma insulin might also be involved in atherogenesis, independent of lipoprotein abnormalities.

Five-year follow-up study on plasma insulin levels in newly diagnosed NIDDM patients and nondiabetic subjects

A representative group of middle-aged (45- to 64-yr-old) patients with non-insulin-dependent diabetes mellitus (NIDDM) (n = 133; 70 men, 63 women) were examined at the time of diagnosis and 5 yr afterward for metabolic control and insulin response to oral glucose; 144 nondiabetic control subjects (62 men, 82 women) were similarly examined twice between 5-yr intervals. At the 5-yr examination, 56 of the diabetic patients (36 men, 20 women) were on diet therapy only, 60 (27 men, 33 women) received oral antidiabetic drugs, and 5 were treated with insulin. The metabolic control of diabetic patients was poor at the time of diagnosis and 5-yr examination. Fasting plasma insulin levels were higher in diabetic patients than in control subjects both at baseline (23 +/- 2 vs. 14 +/- 1 mU/L, P less than 0.01, for men; 26 +/- 2 vs. 15 +/- 1 mU/L, NS, for women) and 5-yr examination (19 +/- 1 vs. 16 +/- 2 mU/L, NS, for men; 29 +/- 5 vs. 15 +/- 1 mU/L, P less than 0.05, for women). The frequency of insulin deficiency in diabetic patients based on a postglucagon (1 mg i.v.) C-peptide level less than 0.60 nM was 3.3% at the 5-yr examination, indicating that true insulin deficiency was uncommon during the first years after diagnosis of diabetes in middle-aged subjects.