HbA1c in nondiabetic Dutch infants aged 8-12 months: the GECKO-Drenthe birth cohort study

OBJECTIVE

An international committee of experts recommended using HbA(1c) for diagnostic testing for diabetes. Little is known about normal values of HbA(1c) in infants. The aim of this study is to describe the distribution of HbA(1c) in 8- to 12-month-old nondiabetic infants.

RESEARCH DESIGN AND METHODS

HbA(1c) was measured in 86 infants participating in the Groningen Expert Center for Kids with Obesity (GECKO)-Drenthe birth cohort study. Anthropometric measurements were performed at Well Baby Clinics. Data on parents and children were collected prospectively using questionnaires.

RESULTS

HbA(1c) was normally distributed with a mean (SD) HbA(1c) level of 5.38% (0.24), range 4.8-6.0% or 35.29 mmol/mol (2.65), range 29.1-42.1 mmol/mol. Age, sex, birth weight, duration of breastfeeding, anthropometric measurements, and maternal BMI were not associated with HbA(1c).

CONCLUSIONS

We found a normal distribution of HbA(1c) with a relatively high mean HbA(1c) of 5.38%. No significant association between risk factors for type 2 diabetes and HbA(1c) levels was found.

Parental factors affecting the weights of the placenta and the offspring

AIM

To determine parental, especially paternal factors associated with the weight of the placenta and offspring.

METHODS

This population-based birth-cohort study includes 2947 singleton children born from April 2006 to 2007 and living in Drenthe, The Netherlands. Placental weight and birth weight were measured and questionnaires were filled out for this cohort. Associations between parental factors, and the weight of the placenta and the offspring were evaluated using univariate and multivariate linear regression models.

RESULTS

Univariate regression revealed that the paternal birth weight and body mass index (BMI) of the father were predictors for placental and birth weight of the offspring. However, they were not independent predictors. Independent predictors for placental weight were the maternal factors of pre-pregnancy BMI, birth weight, and diabetes. The maternal factors of weight gain during pregnancy, birth weight, smoking during pregnancy, and diabetes were independent predictors for birth weight of the offspring.

CONCLUSION

Paternal as well as maternal factors influence the weight of the placenta and the offspring.

Physical activity, adiposity, and diabetes risk in middle-aged and older Chinese population: the Guangzhou Biobank Cohort Study

OBJECTIVE

Physical activity may modify the association of adiposity with type 2 diabetes. We investigated the independent and joint association of adiposity and physical activity with fasting plasma glucose, impaired fasting glucose, and type 2 diabetes in a Chinese population.

RESEARCH DESIGN AND METHODS

Middle-aged and older Chinese (n=28,946, ≥50 years, 72.4%women) from the Guangzhou Biobank Cohort Study were examined in 2003-2008. Multivariable regression was used in a cross-sectional analysis.

RESULTS

BMI, waist circumference, and waist-to-hip ratio (WHR) were positively associated with type 2 diabetes after multiple adjustment, most strongly for WHR with odds ratio (OR) of 3.99 (95% CI 3.60-4.42) for highest compared with lowest tertile. Lack of moderate-to-vigorous physical activity, but not walking, was associated with diabetes with an OR of 1.29 (1.17-1.41). The association of moderate-to-vigorous activity with fasting glucose varied with WHR tertiles (P=0.01 for interaction). Within the high WHR tertile, participants who had a lack of moderate-to-vigorous activity had an OR of 3.87 (3.22-4.65) for diabetes, whereas those who were active had an OR of 2.94 (2.41-3.59).

CONCLUSIONS

In this population, WHR was a better measure of adiposity-related diabetes risk than BMI or waist circumference. Higher moderate-to-vigorous activity was associated with lower diabetes risk, especially in abdominally obese individuals.

Cost-effectiveness of a screening strategy for Q fever among pregnant women in risk areas: a clustered randomized controlled trial

Background

In The Netherlands the largest human Q fever outbreak ever reported in the literature is currently ongoing with more than 2300 notified cases in 2009. Pregnant women are particularly at risk as Q fever during pregnancy may cause maternal and obstetric complications. Since the majority of infected pregnant women are asymptomatic, a screening strategy might be of great value to reduce Q fever related complications. We designed a trial to assess the (cost-)effectiveness of a screening program for Q fever in pregnant women living in risks areas in The Netherlands.

Methods/design

We will conduct a clustered randomized controlled trial in which primary care midwife centres in Q fever risk areas are randomized to recruit pregnant women for either the control group or the intervention group. In both groups a blood sample is taken around 20 weeks postmenstrual age. In the intervention group, this sample is immediately analyzed by indirect immunofluorescence assay for detection of IgG and IgM antibodies using a sensitive cut-off level of 1:32. In case of an active Q fever infection, antibiotic treatment is recommended and serological follow up is performed. In the control group, serum is frozen for analysis after delivery. The primary endpoint is a maternal (chronic Q fever or reactivation) or obstetric complication (low birth weight, preterm delivery or fetal death) in Q fever positive women. Secondary aims pertain to the course of infection in pregnant women, diagnostic accuracy of laboratory tests used for screening, histo-pathological abnormalities of the placenta of Q fever positive women, side effects of therapy, and costs. The analysis will be according to the intention-to-screen principle, and cost-effectiveness analysis will be performed by comparing the direct and indirect costs between the intervention and control group.

Discussion

With this study we aim to provide insight into the balance of risks of undetected and detected Q fever during pregnancy.

Trial registration

ClinicalTrials.gov, protocol record NL30340.042.09.

Association between alcohol consumption and diabetic retinopathy and visual acuity-the AdRem Study

AIMS

We investigated the association between alcohol consumption and diabetic retinopathy and deterioration of visual acuity in individuals with Type 2 diabetes.

METHODS

We conducted a cohort analysis of 1239 participants with Type 2 diabetes aged 55-81 years enrolled in the AdRem study, a sub-study of the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial. Current and past consumption of wine, spirits and beer was measured by self-report. Moderate and heavy alcohol consumption was defined as 1-14 and >14 drinks/week, respectively. Diabetic retinopathy, measured by mydriatic stereoscopic seven-field retinal photography, was defined by a 2-step progression in the Early Treatment of Diabetic Retinopathy Study (ETDRS) score or the presence of any retinal vascular lesions. Deterioration of visual acuity was defined by a decrease of two lines in best vision in either eye, measured corrected, or through a pinhole using a Snellen chart.

RESULTS

In a mean follow-up of 5.5 years, we identified 182 participants with a 2-step progression in the ETDRS score, 640 participants with the presence of any retinal vascular lesions and 693 participants with a deterioration of visual acuity. Current moderate consumption of alcohol, compared with no current consumption, was not associated with presence or progression of diabetic retinopathy; however, it was associated with higher risk of deterioration of visual acuity (multivariable-adjusted OR 1.83; 95% CI 1.34-2.48; P<0.001).

CONCLUSIONS

Alcohol consumption is associated with increased risk of deterioration of visual acuity, but not with retinopathy in individuals with Type 2 diabetes.

Plasma procalcitonin is associated with obesity, insulin resistance, and the metabolic syndrome

CONTEXT

Procalcitonin, a well-known biomarker of sepsis and bacterial infections, is produced by adipose tissue and has potential as a marker for chronic low-grade inflammation.

OBJECTIVES

The objective of this study was to investigate whether plasma procalcitonin levels in the normal range are associated with obesity, insulin resistance, and metabolic syndrome (MS) in the general population.

METHODS

Plasma procalcitonin (0.006-0.1 ng/ml) was measured in 3197 men and 3638 women (aged 28-75 yr) of the Prevention of Renal and Vascular End-Stage Disease (PREVEND) study using an ultrasensitive immunoluminometric assay. MS was defined according to Adult Treatment Panel III criteria.

RESULTS

Median (interquartile range) plasma procalcitonin was 0.018 (0.015-0.022) ng/ml in men and 0.014 (0.012-0.017) ng/ml in women (P < 0.001). Plasma procalcitonin was positively associated with body mass index and waist circumference. In both sexes, cross-sectional associations of plasma procalcitonin with insulin resistance and components of the MS remained significant after adjustment for age, body mass index, waist circumference, and other covariates. The age-adjusted odds ratio (OR) for MS was 3.2 [95% confidence interval (CI) = 2.5-4.2) in men and 4.1 (95% CI = 3.0-5.5) in women, when comparing the highest with the lowest quartile of plasma procalcitonin. The multivariate-adjusted OR for MS was 1.9 (95% CI = 1.4-2.6) in men and 2.3 (95% CI = 1.6-3.3) in women. The multivariate-adjusted OR for insulin resistance was 3.3 (95% CI = 2.4-4.3) in men and 2.5 (95% CI = 1.9-3.4) in women.

CONCLUSIONS

Elevated plasma procalcitonin levels in the normal range are associated with measures of obesity, insulin resistance, and MS in the general population.

Association between birth weight and visceral fat in adults

BACKGROUND

Several studies reported inverse associations between birth weight and central adiposity in adults. However, few studies investigated the contributions of different abdominal fat compartments.

OBJECTIVE

We examined associations between birth weight and adult visceral and subcutaneous abdominal fat in the population-based Fenland study.

DESIGN

A total of 1092 adults (437 men and 655 women) aged 30-55 y had available data on reported birth weight, standard anthropometric measures, and visceral and subcutaneous abdominal fat estimated by ultrasound. In a subgroup (n = 766), dual-energy X-ray absorptiometry assessment of total abdominal fat was performed. Linear regression models were used to analyze relations between birth weight and the various fat variables adjusted for sex, age, education, smoking, and body mass index (BMI).

RESULTS

After adjustment for adult BMI, there was an inverse association between birth weight and total abdominal fat [B (partial regression coefficient expressed as SD/1-kg change in birth weight) = -0.09, P = 0.002] and visceral fat (B = -0.07, P = 0.01) but not between birth weight and subcutaneous abdominal fat (B = -0.01, P = 0.3). Tests for interaction showed that adult BMI modified the association between birth weight and visceral fat (P for interaction = 0.01). In stratified analysis, the association between birth weight and visceral fat was apparent only in individuals with the highest BMI tertile (B = -0.08, P = 0.04).

CONCLUSIONS

The inverse association between birth weight and adult abdominal fat appeared to be specific to visceral fat. However, associations with birth weight were apparent only after adjustment for adult BMI. Therefore, we suggest that rapid postnatal weight gain, rather than birth weight alone, leads to increased visceral fat.

MRI-determined fat content of human liver, pancreas and kidney

AIM: To assess and correlate the lipid content of various organs in obese subjects and in persons with a normal body weight.

METHODS: Magnetic resonance spectroscopy and a previously validated gradient echo magnetic resonance imaging method with Dixon’s two point technique were used in this study to quantify fat in liver, pancreas as well as kidney.

RESULTS: In 36 volunteers with body mass index (BMI) ranging from 20.0 to 42.9 kg/m², the median fat content of liver, pancreas and kidney was 2.3% (interquartile range: 0.2%-7.8%), 2.7% (1.0%-6.5%) and 0.7% (0.1%-1.4%), respectively. BMI and subcutaneous fat correlated significantly with liver and pancreas fat content. We show for the first time the significant correlation of liver and pancreas fat content in healthy controls (r = 0.43, P < 0.01). These observations are related to body weight as measured by BMI and the amount of subcutaneous fat. Kidney fat content is very low and correlates with none of the other fat depots.

CONCLUSION: Renal lipid accumulation, unlike the coupled accumulations of fat in liver and pancreas, is not observed in obese subjects. Unlike suggestions made in previous studies, renal lipid accumulation appears not to be involved in the pathogenesis of renal disease in humans.

Cardiometabolic treatment decisions in patients with type 2 diabetes: the role of repeated measurements and medication burden

PURPOSE

Clinical guidelines for cardiometabolic risk management indicate a simple threshold-based strategy for treatment, but physicians and their patients may be reluctant to modify drug treatment after a single elevated measurement. We determined how repeated measurements of blood pressure, cholesterol and haemoglobin A1c affect general practitioners' decisions to start or intensify medication in patients with type 2 diabetes. We also evaluated whether medication burden altered these decisions.

METHODS

We conducted a cohort study in 3029 patients managed by 62 general practitioners (GPs). We assessed the predictive value of the last risk factor measurement, the number of successive measurements above target level and the percentage change between the last two measurements. Medication burden was assessed as the number of drugs concurrently used. Effects on treatment decisions were estimated by multilevel logistic regression analysis, correcting for clustering at GP level.

RESULTS

Repeated high levels of diastolic blood pressure increased the likelihood to start antihypertensive medication (OR=2.08, CI 1.37 to 3.17). Repeated high haemoglobin A1c levels affected intensification of oral glucose-lowering medication (OR=1.71, CI 1.44 to 2.03). Modification of lipid-lowering medication was limited, and only affected by the last total cholesterol level. Starting treatment for all three risk factors, as well as intensifying antihypertensive treatment, was more likely in patients already using more drugs for other chronic diseases.

CONCLUSIONS

Waiting for the next measurement before deciding to change medication can explain in part the apparent undertreatment for hypertension and hyperglycaemia, but not for hypercholesterolaemia. Medication burden was not a barrier for treatment modification.

Ultrasound measurements of visceral and subcutaneous abdominal thickness to predict abdominal adiposity among older men and women

Accurate measures of visceral and abdominal subcutaneous fat are essential for investigating the pathophysiology of obesity. Classical anthropometric measures such as waist and hip circumference cannot distinguish between these two fat depots. Direct imaging methods such as computed tomography and magnetic resonance imaging (MRI) are restricted in large-scale studies due to practical and ethical issues. We aimed to establish whether ultrasound is a valid alternative method to MRI for the quantitative assessment of abdominal fat depots in older individuals. The study population comprised 74 white individuals (41 men and 33 women, aged 67-76 years) participating in the Hertfordshire Birth Cohort Physical Activity trial. Anthropometry included height, weight, waist and hip circumferences. Abdominal fat was measured by ultrasound in two compartments: visceral fat defined as the depth from the peritoneum to the lumbar spine; and subcutaneous fat defined as the depth from the skin to the abdominal muscles and compared to reference measures by MRI (10-mm single-slice image). Ultrasound measures were positively correlated with MRI measures of visceral and subcutaneous fat (visceral: r = 0.82 and r = 0.80 in men and women, respectively; subcutaneous: r = 0.63 and 0.68 in men and women, respectively). In multiple regression models, the addition of ultrasound measures significantly improved the prediction of visceral fat and subcutaneous fat in both men and women over and above the contribution of standard anthropometric variables. In conclusion, ultrasound is a valid method to estimate visceral fat in epidemiological studies of older men and women when MRI and computed tomography are not feasible.

Influence of common variants near INSIG2, in FTO, and near MC4R genes on overweight and the metabolic profile in adolescence: the TRAILS (TRacking Adolescents' Individual Lives Survey) Study

BACKGROUND

Overweight is a complex trait in which both environmental and genetic factors play a role.

OBJECTIVE

We aimed to evaluate the influence of common genetic variants identified by genome-wide association studies on overweight and the metabolic profile in adolescence.

DESIGN

In a population-based cohort of 663 girls and 612 boys aged 16 y, weight, height, skinfold thicknesses, percentage body fat, waist circumference, blood pressure, glucose, insulin, lipid profile, and DNA were obtained. We defined overweight according to international criteria. We performed multiple linear and logistic regression analyses to assess the influence of candidate single nucleotide polymorphisms near the INSIG2, in the FTO, and near the MC4R genes and repeated-measures analyses of available body mass index (BMI) and skinfold thickness data across 3 visits at ages 11, 13.5, and 16 y.

RESULTS

A total of 15.1% of participants were overweight or obese at age 16 y. No associations with INSIG2 were found. Common variation in the FTO gene was associated with sex-specific z scores of BMI (B: 0.11; 95% CI: 0.03, 0.19), sum of skinfold thicknesses (B: 0.12; 95% CI: 0.04, 0.20), percentage body fat (B: 0.11; 95% CI: 0.03, 0.19), waist circumference (B: 0.11; 95% CI: 0.03, 0.19), fasting glucose (B: 0.10; 95% CI: 0.00, 0.20), and overweight (odds ratio: 1.34; 95% CI: 1.06, 1.69) at age 16 y. Repeated-measures analyses confirmed the associations for BMI and sum of skinfold thicknesses, and physical activity did not modify these associations. Common variation near the MC4R gene was associated with BMI in cross-sectional (B: 0.11; 95% CI: 0.02, 0.20) and repeated-measures (B: 0.12; 95% CI: 0.03, 0.20) analyses.

CONCLUSIONS

Common variation in the FTO gene is associated with overall and abdominal adiposity. Variation near the MC4R gene is associated with BMI. These findings in adolescents strengthen and extend the results from previous research.

How do parents of 4- to 5-year-old children perceive the weight of their children?

INTRODUCTION

A heavier weight in adults is becoming the norm rather than an abnormal weight. Whether the same trend is happening in children is unknown.

OBJECTIVE

To assess the perception of the weight of 4- to 5-year-old children and the recognition of overweight by both parents.

DESIGN

Population-based survey.

PARTICIPANTS

A questionnaire was sent to parents of 1155 4- to 5-year-old children.

RESULTS

In total, 439 questionnaires (35%) were returned. Of all, 90% of the children had a normal weight, 9.3% were overweight and 4.1% were obese. For all weight classes, the parents depicted the child as lighter on both the verbal and visual scale. Of all, 75% of mothers of overweight children stated that the child had a normal weight. In obese children, 50% of the mothers believed that the child had a normal weight.

CONCLUSION

Children with a weight in the normal range were considered by their parents as a little too light or too light. Overweight was considered as normal weight, and obesity as normal or a little too heavy. The perception of a normal weight in children at 4-5 years is distorted.

Markers of the hepatic component of the metabolic syndrome as predictors of mortality in renal transplant recipients

Cardiovascular disease (CVD) is a leading cause of mortality in renal transplant recipients (RTRs). Metabolic syndrome (MS) is highly prevalent in RTRs. Nonalcoholic fatty liver disease (NAFLD) is considered the hepatic component of MS. We investigated associations of NAFLD markers with MS and mortality. RTRs were investigated between 2001 and 2003. NAFLD markers, alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT) and alkaline phosphatase (AP) were measured. Bone and nonbone fractions of AP were also determined. Death was recorded until August 2007. Six hundred and two RTRs were studied (age 52+/-12 years, 55% men). At baseline 388 RTRs had MS. Prevalence of MS was positively associated with liver enzymes. During follow-up for 5.3[4.5-5.7] years, 95 recipients died (49 cardiovascular). In univariate Cox regression analyses, GGT (HR=1.43[1.21-1.69], p<0.001) and AP (HR=1.34[1.11-1.63], p=0.003) were associated with mortality, whereas ALT was not. Similar associations were found for cardiovascular mortality. Adjustment for potential confounders, including MS, diabetes and traditional risk factors did not materially change these associations. Results for nonbone AP mirrored that for total AP. ALT, GGT and AP are associated with MS. Of these three enzymes, GGT and AP are associated with mortality, independent of MS. These findings suggest that GGT and AP are independently related to mortality in RTRs.

The analysis of longitudinal quality of life measures with informative drop-out: a pattern mixture approach

Purpose

The analysis of longitudinal health-related quality of life measures (HRQOL) can be seriously hampered due to informative drop-out. Random effects models assume Missing At Random and do not take into account informative drop-out. We therefore aim to correct the bias due to informative drop-out.

Methods

Analyses of data from a trial comparing standard-dose and high-dose chemotherapy for patients with breast cancer with respect to long-term impact on HRQOL will serve as illustration. The subscale Physical Function (PF) of the SF36 will be used. A pattern mixture approach is proposed to account for informative drop-out. Patterns are defined based on events related to HRQOL, such as death and relapse. The results of this pattern mixture approach are compared to the results of the commonly used random effects model.

Results

The findings of the pattern mixture approach are well interpretable, and different courses over time in different patterns are distinguished. In terms of estimated differences between standard dose and high dose, the results of both approaches are slightly different, but have no consequences for the clinical evaluation of both doses.

Conclusion

Under the assumption that drop-out is at random within the patterns, the pattern mixture approach adjusts the estimates to a certain degree. This approach accounts in a relatively simple way for informative drop-out.

Ultrasonography to quantify hepatic fat content: validation by 1H magnetic resonance spectroscopy

An abundance of fat stored within the liver, or steatosis, is the beginning of a broad hepatological spectrum, usually referred to as fatty liver disease (FLD). For studies on FLD, quantitative hepatic fat ultrasonography would be an appealing study modality. Objective of this study was to develop a technique for quantifying hepatic fat content by ultrasonography and validate this using proton magnetic resonance spectroscopy ((1)H MRS) as gold standard. Eighteen white volunteers (BMI range 21.0-42.9) were scanned by both ultrasonography and (1)H MRS. Altered ultrasound characteristics, present in the case of FLD, were assessed using a specially developed software program. Various attenuation and textural based indices of FLD were extracted from ultrasound images. Using linear regression analysis, the predictive power of several models (consisting of both attenuation and textural based measures) on log 10-transformed hepatic fat content by (1)H MRS were investigated. The best quantitative model was compared with a qualitative ultrasonography method, as used in clinical care. A model with four ultrasound characteristics could modestly predict the amount of liver fat (adjusted explained variance 43.2%, P = 0.021). Expanding the model to seven ultrasound characteristics increased adjusted explained variance to 60% (P = 0.015), with r = 0.789 (P < 0.001). Comparing this quantitative model with qualitative ultrasonography revealed a significant advantage of the quantitative model in predicting hepatic fat content (P < 0.001). This validation study shows that a combination of computer-assessed ultrasound measures from routine ultrasound images can be used to quantitatively assess hepatic fat content.

Population ageing research: a family of disciplines

To study life course trajectories and ageing, scientific expertise is needed beyond epidemiology. More specifically, appropriate models of life course require a theoretical micro-foundation, need to incorporate multi-level context conditions and the interplay between them. It also requires the application of additional social scientific research methods that go beyond the application of statistical methods based on the multi-stage life table. These research theories and methods are available in disciplines like sociology, cultural anthropology, psychology, demography and economics. To effectively study healthy ageing of populations the individual approach of epidemiology has to be extended with the macro-population and socio-cultural approach of (social) demography and the institutional and network approaches of sociology.

Which factors are important in adults' uptake of a (pre)pandemic influenza vaccine?

Since 2008, (pre)pandemic vaccines against H5N1 influenza have been available and pandemic vaccines against new influenza H1N1 are currently produced. In The Netherlands, the vaccination call for seasonal influenza among the recommended groups approximates 70%. These statistics raise the question if adults in Western societies are willing to get a (pre)pandemic influenza vaccination, for example, against avian H5N1 or swine-like H1N1 virus. A questionnaire was performed to determine the predictors of a negative intention to be immunized against pandemic influenza among adults. Demographical, behavioural and organisational determinants were studied. Thirty-four and five percent of the respondents were negatively intended to get a pandemic influenza vaccination in a pre-pandemic or pandemic phase, respectively. On the basis of six behavioural determinants negative intention to get a pandemic influenza vaccination can be predicted correctly in almost 80% of the target group. These determinants should be targeted in pandemic preparedness plans.

Effects of blood pressure lowering and intensive glucose control on the incidence and progression of retinopathy in patients with type 2 diabetes mellitus: a randomised controlled trial

AIMS/HYPOTHESIS

The aim of the present study was to investigate the effect of blood pressure lowering and intensive glucose control on the incidence and progression of retinopathy in type 2 diabetic patients.

METHODS

The Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) Retinal Measurements study, a substudy of ADVANCE, is a randomised (using a central, computer-based procedure) controlled 2 x 2 factorial trial comprising a double-blind comparison of blood pressure lowering with perindopril-indapamide vs placebo, and an open comparison of standard vs intensive glucose control targeting a HbA(1c) of < or = 6.5% in 1,602 diabetic patients from ADVANCE centres with access to retinal cameras conducted from 2001 to 2008. At baseline and the final visit, seven-field stereoscopic retinal photographs were taken and graded by blinded readers (gradeable baseline and final photographs from 1,241 patients). Progression of > or =2 steps in the Early Treatment of Diabetic Retinopathy Study classification (using the eye with worst grading) was the primary outcome.

RESULTS

Retinopathy progressed in 59 (4.8%) patients and developed in 128 (10.3%) patients over 4.1 years. Fewer patients on blood pressure-lowering treatment (n = 623) experienced incidence or progression of retinopathy compared with patients on placebo (n = 618), but the difference was not significant (OR 0.78; 95% CI 0.57-1.06; p = 0.12). Blood pressure-lowering treatment reduced the occurrence of macular oedema (OR 0.50; 95% CI 0.29-0.88; p = 0.016) and arteriovenous nicking compared with placebo (OR 0.60; 95% CI 0.38-0.94; p = 0.025). Compared with standard glucose control (n = 611), intensive glucose control (n = 630) did not reduce (p = 0.27) the incidence and progression of retinopathy (OR 0.84; 95% CI 0.61-1.15). Lower, borderline significant risks of microaneurysms, hard exudates and macular oedema were observed with intensive glucose control, adjusted for baseline retinal haemorrhages. These effects of the two treatments were independent and additive. Adverse events in the ADVANCE study are reported elsewhere.

CONCLUSIONS/INTERPRETATION

Blood pressure lowering or intensive glucose control did not significantly reduce the incidence and progression of retinopathy, although consistent trends towards a benefit were observed, with significant reductions in some lesions observed with both interventions.

TRIAL REGISTRATION

ClinicalTrials.gov ID no. NCT00145925.

FUNDING

Grants from Servier and the National Health and Medical Research Council of Australia.

Non-alcoholic fatty liver disease is associated with cardiovascular disease risk markers

Recognition of the link between non-alcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD) has boosted research in this area. The main objective of this paper is to review the literature on NAFLD in the context of CVD, focussing on underlying mechanisms and treatment. Besides excessive fatty acid influx, etiologic factors may include components of the metabolic syndrome, cytokines and mitochondrial dysfunction. NAFLD is associated with both hepatic and systemic insulin resistance. In the case of NAFLD, the liver overproduces several atherogenic factors, notably inflammatory cytokines, glucose, lipoproteins and coagulation factors, and factors increasing blood pressure. Intervention studies on diet and laparoscopic surgery revealed improvements of hepatic fat content and CVD risk profile. Pharmacological approaches with potential benefit have been developed as well, but effects are often confounded by weight change. NAFLD is associated with an increased CVD risk profile (and hepatic risk). In order to improve CVD risk profile, prevention and treatment of NAFLD seem advisable. However, well-designed intervention studies, randomized clinical trials and long-term follow-up studies are scarce.

Bivariate genetic modelling of the response to an oral glucose tolerance challenge: a gene x environment interaction approach

AIMS/HYPOTHESIS

Twin and family studies have shown the importance of genetic factors influencing fasting and 2 h glucose and insulin levels. However, the genetics of the physiological response to a glucose load has not been thoroughly investigated.

METHODS

We studied 580 monozygotic and 1,937 dizygotic British female twins from the Twins UK Registry. The effects of genetic and environmental factors on fasting and 2 h glucose and insulin levels were estimated using univariate genetic modelling. Bivariate model fitting was used to investigate the glucose and insulin responses to a glucose load, i.e. an OGTT.

RESULTS

The genetic effect on fasting and 2 h glucose and insulin levels ranged between 40% and 56% after adjustment for age and BMI. Exposure to a glucose load resulted in the emergence of novel genetic effects on 2 h glucose independent of the fasting level, accounting for about 55% of its heritability. For 2 h insulin, the effect of the same genes that already influenced fasting insulin was amplified by about 30%.

CONCLUSIONS/INTERPRETATION

Exposure to a glucose challenge uncovers new genetic variance for glucose and amplifies the effects of genes that already influence the fasting insulin level. Finding the genes acting on 2 h glucose independently of fasting glucose may offer new aetiological insight into the risk of cardiovascular events and death from all causes.