The Social Costs of Gambling: An Economic Perspective

Much of the opposition to legalized gambling is based on analyses of the social costs that occur as a result of pathological gambling. It is our contention that many, if not most, authors who have contributed to this literature are either unclear or misguided in what they define as social costs. Instead of starting with a clear definition of what constitutes a social cost, these authors have adopted an ad hoc approach-using "common sense" to determine what constitutes losses to society and then attempting to quantify the impact of those activities. We believe this is not, as some suggest, simply a matter of semantics. Rather, it is a serious problem in the gambling literature. How do we differentiate between a consequence of pathological gambling that is a "social cost" and one that is not? Which of the consequences of addictive behaviors that are associated with gambling arise when gambling is legal, and which will be manifest in some form whether or not gambling is legal? In this article we explain the economic perspective on social costs. An understanding of this paradigm removes the subjectivity in the classification of pathological gambling's social costs. The paper has three major components. First, we introduce the economic notion of social costs. Using this paradigm, we differentiate between the "true" social costs related to pathological gambling, and other negative consequences that cannot legitimately be classified as social costs. Second, we evaluate a recent social cost study using the economics social cost paradigm. Third, we discuss two types of social costs that have been largely overlooked in the gambling literature. One is caused by gambling prohibition. The other occurs as a result of "rent seeking" that is related to the political process surrounding the legalization of gambling.

Rosiglitazone in Type 2 diabetes mellitus: an evaluation in British Indo-Asian patients

AIMS

To evaluate the effectiveness of rosiglitazone in reducing hyperglycaemia in patients with Type 2 diabetes mellitus (DM) of Indo-Asian origin taking concurrent sulphonylurea therapy.

METHODS

A randomized, double-blind, placebo-controlled study of 26 weeks' duration at 31 primary and secondary care centres in areas of the UK with a high Indo-Asian population, including 177 patients aged 28-78 years. Rosiglitazone 8 mg/day or matching placebo was added to existing sulphonylurea therapy. The primary endpoint was change from baseline in glycosylated haemoglobin A1c (HbA1c) at week 26.

RESULTS

The mean changes in HbA1c were -1.16% with rosiglitazone (baseline 9.21%) and +0.26% with placebo (baseline 9.06%) (treatment difference P < 0.001; 95% confidence interval (CI) -1.81, -1.08). HbA1c fell below 8% in 55% and 19% of patients, respectively (treatment difference P < 0.001; 95% CI 0.22, 0.51). The greatest improvements occurred in patients whose glycaemic control was initially poor. Improvements in homeostasis model assessment of insulin sensitivity and pancreatic beta-cell function with rosiglitazone were not accompanied by a change in plasma insulin or C-peptide after 26 weeks. Free fatty acids fell by 0.09 mmol/l with rosiglitazone and increased by 0.03 mmol/l with placebo (treatment difference P < 0.001; 95% CI -0.19, -0.07).

CONCLUSION

Rosiglitazone improved insulin sensitivity, pancreatic beta-cell function, and glycaemic control in Indo-Asian patients with Type 2 DM who are at greater risk of the complications of Type 2 DM than other ethnic groups.

17Beta-estradiol and anti-estrogen ICI:compound 182,780 regulate expression of lipoprotein lipase and hormone-sensitive lipase in isolated subcutaneous abdominal adipocytes

We sought to investigate the influence of 17beta-estradiol (E(2)) on key enzymes of lipogenesis and lipolysis in subcutaneous (SC) abdominal adipocytes isolated from women. In addition, we wished to determine the influence of an anti-estrogen, ICI:compound 182,780 (anti-E), known to act via the estrogen receptor (ER), alone and in combination with E(2). Adipose tissue was obtained from 17 women undergoing elective surgery, with a mean age of 47 years (range, 34 to 62), mean weight of 65.4 kg (range, 58.1 to 75.0), and mean body mass index (BMI) of 25 kg/m(2) (range, 22 to 27). Isolated adipocytes were treated with varying doses of E(2), anti-E, or E(2) in combination with anti-E 10(-8) mol/L for 48 hours. Following treatment, proteins were extracted and the effects on lipogenesis and lipolysis were assessed, using Western blotting to determine the relative expression of the key enzymes of these processes, lipoprotein lipase (LPL; 56 kd), and hormone-sensitive lipase (HSL; 84 kd), respectively. Glycerol release into the medium was also measured as an index of lipolytic activity. The protein expression studies demonstrated that E(2) altered expression of LPL relative to control, with the highest dose significantly reducing LPL expression and the lower doses significantly increasing LPL expression (mean protein expression relative to control +/- SE): E(2) 10(-12) mol/L, 1.79 +/- 0.16 (P <.001); E(2) 10(-7) mol/L, 0.56 +/- 0.08 (P <.05). In contrast, HSL expression was increased relative to control at the higher doses of E(2) but was not significantly altered relative to control at the lower doses: E(2) 10(-12) mol/L, 1.02 +/- 0.14 (P >.05); E(2) 10(-7) mol/L, 1.55 +/- 0.17 (P <.01). Anti-E 10(-8) mol/L alone reduced LPL protein expression relative to control (P <.05) and increased HSL protein expression relative to control (P >.05). In combination with E(2) 10(-7) mol/L, anti-E 10(-8) mol/L did not abrogate the inhibitory effect on LPL expression relative to control (P <.05). Furthermore, E(2) 10(-7) mol/Lin combination with anti-E 10(-8) mol/L, displayed a stimulatory effect on HSL expression relative to control (P <.01). Glycerol release studies following the higher doses of E(2), and also following E(2) 10(-7) mol/L in combination with anti-E 10(-8) mol/L, provided support for the HSL protein expression studies. We conclude that the highest concentration of E(2) (10(-7) mol/L) significantly reduced LPL expression relative to control, while the lower concentrations significantly increased LPL expression relative to control. The highest concentration of E(2) also significantly increased both HSL expression and glycerol release relative to control. The effects of anti-E suggest that the in vitro effects of E(2) on lipogenesis and lipolysis occur, at least in part, through a receptor-mediated pathway. In addition, as recently observed in other tissues, ICI:compound 182,780 does not appear to behave as a pure anti-estrogen in isolated human adipocytes.

Nitric oxide synthase gene polymorphisms and diabetic nephropathy

AIMS/HYPOTHESIS

Susceptibility to diabetic nephropathy in subjects with Type 1 diabetes is mainly genetically determined. Excess cardiovascular risk associated with diabetes is overwhelmingly concentrated in patients with nephropathy. Endothelial dysfunction is a feature of cardiovascular disease, hypertension, dyslipidaemia and smoking, all of which are associated with diabetic nephropathy. Nitric oxide regulates endothelial function and so genes encoding nitric oxide synthases could confer susceptibility to nephropathy. Recently positive associations have been reported. We examined polymorphisms within NOS3 and NOS2A, the genes encoding endothelial- and inducible nitric oxide synthase, for association with nephropathy.

METHODS

Large case-control studies of patients with Type 1 diabetes and overt nephropathy who had hypertension and diabetic retinopathy. The control group comprised Type 1 diabetic subjects who have been on insulin for 50 or more years and have an extremely low risk of nephropathy. Genotyping was by PCR and agarose- or automated polyacrylamide gel electrophoresis using fluorescence-labelled primers.

RESULTS

NOS3 intron 4 genotype frequencies (n=860: 464 cases, 396 control subjects) were 2.6%, 23.3%, 74.1% and 2.3%, 22.7%, 75.0% for aa, ab and bb genotypes; p=0.935. NOS2A promoter genotype frequencies (n=715: 358 cases, 357 control subjects) were 0.3%, 16.8%, 83.0% and 0.3% 17.6% and 82.1% for +/+, +/- and -/- genotypes (p=0.952).

CONCLUSION/INTERPRETATION

In our cohort of Caucasian subjects with Type 1 diabetes there is no association between either of the polymorphisms studied and diabetic nephropathy. The previous suggestion from smaller studies that the intron 4 polymorphism in NOS3 could play a role in susceptibility to the disease is not confirmed.

Fasting serum adiponectin concentration is reduced in Indo-Asian subjects and is related to HDL cholesterol

AIMS

Adiponectin is a 30-kDa protein secreted by adipose tissue. The aim of the present study was to compare serum adiponectin in male Indo-Asian and Caucasian subjects and examine its association with fat topography and metabolic parameters.

METHODS

Diabetic and non-diabetic male subjects (n = 48) were studied. A single observer carried out blood pressure and anthropometric measurements. Serum glucose, insulin, lipid profile and adiponectin (measured by RIA) were measured on a fasting sample.

RESULTS

There was no statistically significant difference in serum adiponectin between diabetic and BMI-matched non-diabetic subjects. However, serum adiponectin was lower in Indo-Asians compared with BMI-matched Caucasians, [median adiponectin (interquartile range) 3.3 (2.1-3.9) vs. 4.9 (3.5-6.6) microg/ml respectively (p = 0.016)]. Univariate analysis showed serum adiponectin to be positively associated with HDL in diabetic (p = 0.039) and non-diabetic subjects (p = 0.0098). Waist circumference (p = 0.02), saggital diameter (p = 0.04) were negatively correlated with serum adiponectin in diabetic subjects. Multiple regression analysis including waist, HDL, fasting insulin, age, diabetes and ethnicity in all subjects showed HDL to be the best predictor of serum adiponectin.

CONCLUSIONS

Serum adiponectin is associated with HDL cholesterol and central obesity. Caucasians have higher serum adiponectin levels compared with Indo-Asians. Further studies are needed to explore basis for the association of adiponectin with HDL cholesterol and the reason for lower levels in Indo-Asians.

Molecular aspects of type 1 diabetes

Type 1 diabetes is a T cell mediated autoimmune disease, characterised by the selective destruction of pancreatic beta cells, and susceptibility is determined by a combination of genetic and environmental factors. The environmental agents implicated include viruses and dietary factors, although none has yet been shown to be directly responsible for triggering beta cell autoimmunity. The genetic factors that influence disease risk have been subjected to more intensive study and two gene regions of major importance have been identified: the human leucocyte antigen locus and the insulin gene. This review will focus on the mechanisms by which these genes might influence the risk of developing type 1 diabetes.

Differences in adiponectin protein expression: effect of fat depots and type 2 diabetic status

Adiponectin is an adipocyte-derived hormone associated with insulin sensitivity and atherosclerotic risk. As central rather than gluteofemoral fat is known to increase the risk of type 2 diabetes and cardiovascular disease, we investigated the mRNA and protein expression of adiponectin in human adipose tissue depots. RNA was extracted from 46 human adipose tissue samples from non-diabetic subjects aged 44.33 +/- 12.4 with a BMI of 28.3 +/- 6.0 (mean +/- SD). The samples were as follows: 21 abdominal subcutaneous, 13 omentum, 6 thigh; samples were also taken from diabetic subjects aged 66.6 +/- 7.5 with BMI 28.9 +/- 3.17; samples were: 6 abdominal subcutaneous; 3 thigh. Quantitative PCR and Western analysis was used to determine adiponectin content. Protein content studies determined that when compared with non-diabetic abdominal subcutaneous adipose tissue (Abd Sc AT) (values expressed as percentage relative to Abd Sc AT -100 %). Adiponectin protein content was significantly lower in non-diabetic omental AT (25 +/- 1.6 %; p < 0.0001, n = 6) and in Abd Sc AT from diabetic subjects (36 +/- 1.5 %; p < 0.0001, n = 4). In contrast, gluteal fat maintained high adiponectin protein content from non-diabetic patients compared with diabetic patients. An increase in BMI was associated with lower adiponectin protein content in obese ND Abd Sc AT (25 +/- 0.4 %; p < 0.0001). These findings were in agreement with the mRNA expression data. In summary, this study indicates that adiponectin protein content in non-diabetic subjects remains high in abdominal subcutaneous fat, including gluteal fat, explaining the high serum adiponectin levels in these subjects. Omental fat, however, expresses little adiponectin. Furthermore, abdominal and gluteal subcutaneous fat appears to express significantly less adiponectin once diabetic status is reached. In conclusion, the adipose tissue depot-specific expression of adiponectin may influence the pattern of serum adiponectin concentrations and subsequent disease risk.

Long-term expression of an HLA-DQ molecule in the EBV-transformed bare lymphocyte cell line, BLS-1, using a plasmid vector

The HLA class II molecule, DQ6, confers strong natural protection against the development of type 1 diabetes. The mechanism of disease protection is unknown, but is likely to be related to the function of the molecule in antigen presentation. In order to investigate this function, we have created an in vitro model which expresses DQ6 in isolation by introducing the relevant DQ alleles into an Epstein-Barr virus (EBV)-transformed, human leucocyte antigen (HLA) class II-deficient B cell line, bare lymphocyte syndrome (BLS)-1. A recent report suggested that the expression of transferred genes in human EBV-transformed B cells might be limited in duration. We present a plasmid-based transfection method that allows long-term stable expression of the DQ molecule. The DQA1*0102 and DQB1*0602 alleles were cloned into the pCIneo expression vector and the constructs were introduced into BLS-1 by electroporation. Stable transfectants were selected using magnetic sorting and cloned by limiting dilution. Two clones were shown to express functionally active DQ6 molecules even after 14 months of continuous culture. These clones will be used in functional studies to investigate the antigen binding and T-cell activation properties of the DQ6 molecule.

The regulation of HSL and LPL expression by DHT and flutamide in human subcutaneous adipose tissue

Clinical observations suggest a role for testosterone in the accumulation of central adiposity and with an associated increased risk of disease. To date, no human study has analysed the role of dihydrotestosterone (DHT) on adipose tissue mass regulation in vitro. This study investigated the role of DHT and androgen receptors (AR) in the regulation of lipolysis and lipogenesis by examining the key enzymes hormone sensitive lipase (HSL) and lipoprotein lipase (LPL) respectively. Isolated abdominal subcutaneous adipocytes (Scad) (n = 15) were treated with either DHT (10(-7)-10(-9) m), an antiandrogen, flutamide (FLT: 10(-7)-10(-9) m) or a combination of DHT (10(-7)-10(-9) m) with FLT (10(-8) m). Relative protein expression of HSL, LPL and AR was determined. In Scad, DHT inhibited HSL expression maximally at 10(-9) m (0.7 +/- 0.4**; p < 0.01**) compared with control (control: 1.0 +/- (s.e.m.) 0.0), whereas LPL protein expression was stimulated at DHT10(-9) m (2.22 +/- 0.48*; p < 0.05*). Glycerol release assay results correlated with HSL expression data. LPL expression was reduced at all doses with combinations of DHT + FLT compared with DHT alone. Androgen receptor expression studies showed an inverse correlation with DHT, whereas DHT + FLT reduced AR expression. These studies indicate that DHT may alter HSL and LPL expression, whereas only LPL expression appears mediated by AR. These findings suggest a physiological role for DHT in the control of adipose tissue mass in women, and indicate that androgens may also play an important role in regulating lipid metabolism.

Rationale and design of diabetics exposed to telmisartan and enalapril (DETAIL) study

The DETAIL (diabetics exposed to telmisartan and enalapril) study will compare the long-term renal outcome of treatment with the angiotensin II receptor antagonist (ARA) telmisartan versus the angiotensin-converting enzyme (ACE) inhibitor enalapril in patients with mild-to-moderate hypertension and diabetic nephropathy. In short-term clinical studies, ACE inhibitors reduce microalbuminuria and, in the longer term, they are superior to conventional therapies in maintaining normal renal function. ARAs also appear to be renoprotective in diabetic animals. In this double-blind, parallel-group study, 252 patients with Type 2 diabetes and concurrent hypertension (mean seated systolic blood pressure < or = 180 mm Hg, on treatment seated diastolic blood pressure < or = 95 mm Hg) have been randomised to once-daily telmisartan 40 mg or enalapril 10 mg; doses are mandatorily titrated to 80 and 20 mg once daily, respectively, after 4 weeks. The primary endpoint will be the change from baseline in glomerular filtration rate (GFR) after 5 years of therapy, using the iohexol method and central laboratory analysis. The secondary endpoints to be evaluated will be: changes in GFR in relation to baseline after 1-4 years of therapy; percentage changes in albumin excretion rate after 1-5 years; and incidences of end-stage renal disease, cardiovascular events, all-cause mortality, and adverse events. The planned date for the completion of the study is 2005.

Sequencing of the second exon of the MHC class II DQ6 alleles in patients with type 1 diabetes

The MHC class II molecule DQ6 is strongly associated with protection from type 1 diabetes. A small number of diabetic subjects have been typed as positive for DQ6, but it has been suggested that these individuals may possess a mutant form of the molecule, which is structurally altered in such a way as to abrogate its protective effect. In order to test this hypothesis, eight diabetic individuals positive for DQ6 were investigated. The second exons of the alleles encoding DQ6, DQA1*0102 and DQB1*0602, were sequenced using fluorescently labelled dideoxynucleotides. No mutations were found. This suggests that all the subjects possessed the "wild-type" second exons of the DQ6 alleles and, hence, that the protective effect associated with the antigen-binding domain of DQ6 is not absolute.

HLA-DQ and DRB1 polymorphism and susceptibility to type 1 diabetes in Jamaica

Genetic susceptibility to type 1 diabetes is determined by a combination of HLA-DQ and DRB1 alleles. In the present study, HLA associations with type 1 diabetes were investigated in the Jamaican population. DRB1 and DQ genotyping was performed on 45 type 1 diabetic patients and 132 control subjects born and resident in Jamaica. The small number of patients available for study reflected the low prevalence of type 1 diabetes in Jamaica. The results were compared with those from other African heritage populations and white Caucasians. The highest relative risk was associated with the DRB1*03-DQ2/DRB1*04-DQ8 genotype. Both DRB1*0401-DQ8 and DRB1*0408-DQ8 were positively associated with disease. DRB1*0408-DQ8 is uncommon amongst white Caucasians, where DRB1*0401-DQ8 is the major predisposing haplotype. The DRB1*1503-DQ6 haplotype was associated with protection from diabetes in the Jamaican population. This haplotype is rare amongst white Caucasians, where DRB1*1501-DQ6 is the protective haplotype. Data from African heritage populations suggest that DRB1*1503-DQ6 might be less protective than DRB1*1501-DQ6. DRB1*03-DQA1*0401-DQB1*0402 was associated with protection from diabetes in the Jamaican population, whereas in white Caucasians DRB1*08-DQA1*0401-DQB1*0402 is predisposing. These data demonstrate that comparison of genetic associations with type 1 diabetes in races with population-specific DRB1-DQ haplotypes provides new information as to the exact determinants of disease susceptibility. Further support is provided for roles of the DQ genes and the DRB1 gene (or a gene in linkage disequilibrium with it) in determining susceptibility to type 1 diabetes.

The role of angiotensin II receptor antagonists in the management of diabetes

Diabetic nephropathy, which develops in about 30% of patients with diabetes, is a progressive condition. It is characterized by increased blood pressure, declining glomerular filtration rate and albuminuria. Lowering of blood pressure in diabetic patients is associated with reduced cardiovascular risk and renal protection. Inhibitors of angiotensin-converting enzyme (ACE) are the current gold standard treatment for hypertension in patients with type I diabetes because, in addition to their blood pressure lowering ability, they are thought to oppose the increased intraglomerular pressure that is mediated in part by angiotensin II. The angiotensin II receptor antagonists, a more recently developed class of antihypertensive agents, appear to be as effective as ACE inhibitors in delaying the progression of renal injury in animal models of diabetes. They act by selectively blocking the binding of angiotensin II to the AT1 receptor and may, therefore, offer a more complete blockade of the renin-angiotensin system than ACE inhibitors. The renal and antihypertensive effects of this class of drug in patients with diabetes are now being investigated in long-term clinical trials. The multicentre Diabetics Exposed to Telmisartan And EnalaprIL (DETAIL) study is a randomized, double-blind, parallel-group comparison of the renal and antihypertensive effects of the angiotensin II receptor antagonist telmisartan and the ACE inhibitor enalapril in 272 patients with type II diabetes. The primary outcome is change in glomerular filtration rate over the 5 years of the study.

Resistin, central obesity, and type 2 diabetes

Resistin, an adipocyte-derived cytokine, causes insulin resistance and glucose intolerance in mice. We investigated whether resistin expression was higher in human abdominal adipose tissue than other adipose tissue depots. We extracted RNA from 32 adipose tissue samples (13 subcutaneous abdominal, seven omentum, six thigh, and six breast). Quantitative PCR was used to determine resistin mRNA expression. Resistin mRNA concentrations were similar in both the subcutaneous abdominal and omental depots. The abdominal depots showed a 418% increase in resistin mRNA expression compared with the thigh. Increased resistin expression in abdominal fat could explain the increased risk of type 2 diabetes associated with central obesity.

Insulin-sensitizing agents--thiazolidinediones (glitazones)

Insulin resistance is a fundamental feature of type 2 diabetes and is also associated with increased cardiovascular risk. The thiazolidinediones are insulin sensitizing agents which improve insulin resistance by combining with an intranuclear hormone receptor. They have been shown in human studies to both reduce insulin resistance and improve pancreatic beta-cell function. They are effective both as monotherapy and in combination with sulphonylureas or metformin in improving glycaemia, with evidence of improvement in other features of metabolic syndrome. They are generally well tolerated, do not cause hypoglycaemia and have the potential to provide sustained diabetic control and reduce cardiovascular risk. They appear to be an important advance in diabetes management but further work is still required to determine their true potential.

HRT in women with diabetes--review of the effects on glucose and lipid metabolism

Hormone replacement therapy (HRT) is prescribed less frequently to women with diabetes. In this article, we review the effects of HRT on glucose metabolism and plasma lipids in women with type 2 diabetes. Current evidence is reassuring about the effects of HRT in women with diabetes, although as in all women, HRT should be prescribed on an individual basis with appropriate consideration given to advantages and disadvantages of therapy.

The effects of androgens and estrogens on preadipocyte proliferation in human adipose tissue: influence of gender and site

The gender-specific differences in body fat distribution suggest that sex steroids play an important role in regulating body fat distribution. Sex steroids may regulate adipose tissue mass by altering adipocyte number and size. The effects of various sex steroids on in vitro proliferation of preadipocytes from both sc and omental fat depots was investigated in men and women. Abdominal sc and omental preadipocytes from men (n = 14) and women (8 premenopausal and 7 postmenopausal) were cultured in the presence of 17beta-E2 (10(-7)-10(-9) M), estrone (10(-7)-10(-9) M), or dehydrotestosterone (DHT) (10(-7)-10(-9) M), and the rate of proliferation was measured over time (1-96 h) by DNA accumulation assays (micromoles per microg) and [(3)H]thymidine incorporation (disintegrations per min). In sc preadipocytes the rate of proliferation was increased between 24-48 h with E2 (10(-7) M) in both men (P = 0.028) and women (P = 0.017). Subcutaneous preadipocytes from women were more responsive to E2 in stimulating proliferation than those from men (women vs. men, DNA assay, 24 h, P = 0.014). In omental preadipocytes the increase in the rate of proliferation occurred at 24 h with E2 (10(-7) M) in women (P = 0.034) and at 48 h in men (P = 0.031). Gender appeared to influence the rate of proliferation by E2 in omental preadipocytes, with maximal stimulation of proliferation at 48 h in preadipocytes from women treated with E2 (10(-7) M; p = 0.007) compared with 72 h in preadipocyte cells from men (P = 0.048), as shown by DNA assay. Both estrone and the androgen DHT had no significant gender- or site-specific effect on the rate of proliferation at any time point. All DNA content data were further validated by thymidine incorporation analysis. In summary, E2 stimulates the rate of proliferation of preadipocytes in a dose-dependent manner, with significant gender- and site-specific differences. Neither estrone nor DHT affected adipocyte mass through proliferation of preadipocytes in this study. In conclusion, E2 may act as an important local factor influencing the proliferation of preadipocytes that may affect fat cell number in a depot- and gender-specific pattern in human abdominal sc and omental adipose tissue.

Site-specific regulation of oestrogen receptor-alpha and -beta by oestradiol in human adipose tissue

AIM

To examine the expression of oestrogen receptors alpha and beta (ERalpha and ERbeta) and their regulation by 17beta-oestradiol (E2) in stromal cells and adipocytes from human subcutaneous (s.c.) and omental (o.m.) adipose tissue.

METHODS

Subcutaneous and o.m. abdominal adipose tissues were obtained from 10 women (mean age 63.5 +/- 4.8 years; mean weight 75.6 +/- 6.7 kg) undergoing elective or cosmetic surgery. Immunohistochemistry and RT-PCR analysis were used to detect the presence of ERalpha and ERbeta. The regulation of ERalpha and ERbeta by E(2) (10(-7) M to 10(-9) M) was examined using Western immunoblotting analysis in both s.c. and o.m. stromal cells and mature adipocytes cultured in serum-free, phenol red-free medium.

RESULTS

Immunostaining of s.c. and o.m. adipose tissue showed that the ER subtypes were localized predominantly within the nucleus. Western analysis demonstrated that E2 treatments differentially altered ERalpha and ERbeta expression in s.c. and o.m. adipocytes. In s.c. and o.m. stromal cells, E(2) (10(-8) M) produced a significant up regulation relative to control of 66 kDa ERalpha (s.c.:1.87 +/- 0.22; o.m.:1.97 +/- 0.17; p < 0.05) and 60 kDa ERbeta (s.c.:1.66 +/- 0.3; o.m.: 1.68 +/- 0.16; p < 0.05). In s.c. adipocytes, however, ERalpha expression significantly decreased with E(2) 10(-8) M relative to control while ERbeta expression increased (ERalpha 0.58 +/- 0.06, ERbeta: 1.47 +/- 0.11; p < 0.05). In o.m. adipocytes, the inhibition of ERalpha with E(2) was not observed (ERalpha 1.86 +/- 0.36, ERbeta:1.03 +/- 0.15, p < 0.05)

CONCLUSIONS

ERalpha and ERbeta are expressed but differentially regulated by E(2) in s.c. and o.m. adipocytes and stromal cells. The upregulation of ERbeta by E(2) suggests that E(2) maintains the expression of these receptors. The feed-back inhibition of ERalpha expression by E(2) in s.c. but not o.m. adipocytes observed in vitro is consistent with the data from ERalpha knock out mice where s.c. fat is increased. Selective ER modulators may have different effects in different adipose sites.

A correlation between the relative predisposition of MHC class II alleles to type 1 diabetes and the structure of their proteins

In human type 1 diabetes (T1D) and in its murine model, the major histocompatibility complex (MHC) class II molecules, human leukocyte antigens (HLA)-DQ and -DR and their murine orthologues, IA and IE, are the major genetic determinants. In this report, we have ranked HLA class II molecule-associated T1D risk in a two-sided gradient from very high to very low. Very low risk corresponded to dominant protection from T1D. We predicted the protein structure of DQ by using the published crystal structures of different allotypes of the murine orthologue of DQ, IA. We discovered marked similarities both within, and cross species between T1D protective class II molecules. Likewise, the T1D predisposing molecules showed conserved similarities that contrasted with the shared patterns observed between the protective molecules. We also found striking inter-isotypic conservation between protective DQ, IA allotypes and protective DR4 subtypes. The data provide evidence for a joint action of the class II peptide-binding pockets P1, P4 and P9 in disease susceptibility and resistance with a main role for P9 in DQ/IA and for P1 and P4 in DR/IE. Overall, these results suggest shared epitope(s) in the target autoantigen(s), and common pathways in human and murine T1D.

Genetics of type 1 diabetes

Type 1 diabetes mellitus is a T-cell-mediated autoimmune disease characterized by the selective destruction of pancreatic beta cells. Susceptibility to the disease is determined by a combination of genetic and environmental factors. The genetic factors are termed 'susceptibility genes' as they modify the risk of diabetes but are neither necessary nor sufficient for disease to develop. A large number of chromosomal regions have been identified as containing potential diabetes susceptibility genes. The IDDM1 locus, which encompasses the major histocompatibility complex on chromosome 6, is the major genetic risk factor. The HLA-DQ genes are the primary susceptibility genes within this region, although other genes may also contribute. The IDDM2 locus maps to a variable number of tandem repeats in the insulin gene region on chromosome 11. Further research is necessary to determine the precise location and identity of other diabetes susceptibility genes.

Dexamethasone inhibits tumor necrosis factor-alpha-induced apoptosis and interleukin-1 beta release in human subcutaneous adipocytes and preadipocytes

Tumor necrosis factor-alpha (TNF alpha) can decrease adipose tissue mass, but in obesity, adipose tissue hypertrophy persists despite increased TNF alpha expression. The hormonal milieu of obesity may antagonize the adipostat effects of TNF alpha. We examined the effects of insulin and the synthetic glucocorticoid, dexamethasone (Dex), on TNF alpha-induced apoptosis and gene expression in human adipocytes and preadipocytes. Using RT multiplex PCR, the expression of the proapoptotic genes interleukin-1 beta (IL-1 beta)-converting enzyme (ICE) and TNF alpha and the antiapoptotic genes bcl-2, nuclear factor-kappa B (NF kappa B), and NF kappa B inhibitory subunit, I kappa B, were examined. The expression and release of IL-1 beta, a postulated downstream effector of ICE-mediated apoptosis, were also determined. TNF alpha increased the messenger ribonucleic acid levels of ICE, TNF alpha, IL-1 beta, bcl-2, and NF kappa B in preadipocytes and adipocytes (P < 0.01). Dex inhibited TNFalpha-induced messenger ribonucleic acid expression of ICE, TNF alpha, and IL-1 beta (P < 0.01), but not that of bcl-2 and NF kappa B. TNF alpha stimulated IL-1 beta release from preadipocytes and adipocytes up to 20-fold, but the effect was abrogated by Dex. Apoptosis induced by TNF alpha was reduced to control levels (P < 0.01) by Dex. Insulin had no significant effect on TNF alpha-induced apoptosis and gene expression. In obesity, glucocorticoids may reduce TNF alpha actions in adipose tissue by inhibiting TNF alpha-induced apoptosis, IL-1 beta release, and TNF alpha expression.

Hormone replacement therapy for postmenopausal women with diabetes

BACKGROUND

Recent studies have shown only 17% of postmenopausal women in the UK receive prescriptions for hormone replacement therapy (HRT), with diabetic women being prescribed HRT 30% less often than non-diabetic women. Up to 80% of women experience menopausal symptoms, however, so it is expected that by using HRT many would gain benefit from symptom relief, in addition to benefiting from its effects in disease prophylaxis.

METHODS

We conducted a questionnaire survey of the attitudes to HRT prescribing of 178 local general practitioners (GPs) and 47 hospital doctors, working in diabetes and gynaecology.

RESULTS

Responses were received from 98 (55%) GPs and 39 (83%) hospital doctors. One hundred and thirty-six (99%) would advise HRT for menopausal symptoms, with 133 (97%) advising HRT for a spontaneous premature menopause and 126 (92%) for a surgically induced menopause. One hundred and thirty-four (98%) would advise HRT for diabetic women with menopausal symptoms, with 122 (89%) indicating that HRT had no adverse effect on glycaemic control. For disease prophylaxis, all hospital doctors and 93 (95%) GPs would advise HRT for prevention of osteoporosis, although only 91 (93%) GPs would advise HRT to diabetic women for this indication. Thirty-three (85%) hospital doctors would advise HRT as prophylaxis against cardiovascular disease compared with 66 (67%) of GPs. For this indication in diabetic women, 32 (82%) hospital doctors and 67 (68%) GPs would advise HRT. Oral HRT was the most widely recommended preparation although GPs also frequently recommended patches. Topical gel, implants and other preparations were less commonly advised. Hospital doctors predominantly advised HRT for menopausal symptoms to be continued for between 1 and 5 years, although more GPs recommended HRT to be continued for longer than 5 years. The majority of doctors from both groups advised that HRT used for disease prophylaxis be continued for more than 5 years.

CONCLUSION

More doctors than anticipated indicated they would recommend HRT, especially to diabetic women. Concerns among doctors about the side-effects of HRT and, in particular, the metabolic effects of HRT, do not appear to deter them from advising HRT. Willingness to prescribe a drug, however, is different from actually prescribing it and responses to questionnaires tend to be those regarded as being acceptable. Low patient demand for HRT due to fear or lack of awareness may also be contributing. Organizational change with the development of more menopause clinics may facilitate wider use of HRT.

The HLA-DPB1--associated component of the IDDM1 and its relationship to the major loci HLA-DQB1, -DQA1, and -DRB1

The major histocompatibility complex (MHC) HLA region on chromosome 6p21 contains the major locus of type 1 diabetes (IDDM1). Common allelic variants at the class II HLA-DRB1, -DQA1, and -DQB1 loci account for the major part of IDDM1. Previous studies suggested that other MHC loci are likely to contribute to IDDM1, but determination of their relative contributions and identities is difficult because of strong linkage disequilibrium between MHC loci. One prime candidate is the polymorphic HLA-DPB1 locus, which (with the DPA1 locus) encodes the third class II antigen-presenting molecule. However, the results obtained in previous studies appear to be contradictory. Therefore, we have analyzed 408 white European families (200 from Sardinia and 208 from the U.K.) using a combination of association tests designed to directly compare the effect of DPB1 variation on the relative predisposition of DR-DQ haplotypes, taking into account linkage disequilibrium between DPB1 and the DRB1, DQA1, and DQB1 loci. In these populations, the overall contribution of DPB1 to IDDM1 is small. The main component of the DPB1 contribution to IDDM1 in these populations appears to be the protection associated with DPB1*0402 on DR4-negative haplotypes. We suggest that the HLA-DP molecule itself contributes to IDDM1.