A Behavioral Lifestyle Intervention to Improve Frailty in Overweight or Obese Older Adults with Type 2 Diabetes: A Feasibility Study

BACKGROUND

Older adults with Type 2 diabetes (T2D) are more likely to be frail, which increases the risk for disability and mortality.

OBJECTIVES

To determine the feasibility of a behavioral lifestyle intervention, enhanced with mobile health technology for self-monitoring of diet and activity, to improve frailty in overweight/obese older adults (≥65 years) diagnosed with T2D.

DESIGN, SETTING, AND PARTICIPANTS

Single arm, 6-month study of a behavioral lifestyle intervention in 20 overweight/obese (BMI>25) older adults (≥ 65 years) with self-reported T2D diagnosis who owned a smartphone. A Fitbit tracker was provided to all participants for self-monitoring of diet and physical activity. Our primary outcome of feasibility was measured by session attendance, adherence to Fitbit usage to self-monitor diet and physical activity, and study retention. Secondary outcomes included the preliminary efficacy of the intervention on frailty, physical function, quality of life, and T2D-related outcomes.

RESULTS

Eighteen participants completed the study. The mean age was 71.5 (SD ± 5.3) years, 56% were female, and half were Hispanic. At baseline, 13 (72%) were pre-frail, 4 (22%) were frail, and 1 (6%) were non-frail. At follow-up, frailty scores improved significantly from 1.61 ± 1.15 to 0.94 ± 0.94 (p=0.01) and bodyweight improved from 205.66 ± 45.52 lbs. to 198.33 ± 43.6 lbs. (p=<0.001).

CONCLUSION

This study provides evidence for the feasibility of a behavioral lifestyle intervention in overweight/obese older adults with T2D and preliminary results support its potential efficacy in improving frailty score.

Development Review of the BACE1 Inhibitor Lanabecestat (AZD3293/LY3314814)

Several ongoing clinical development programs are investigating potential disease-modifying treatments for Alzheimer's disease (AD), including lanabecestat (AZD3293/LY3314814). Lanabecestat is a brain-permeable oral inhibitor of human beta-site amyloid (Aβ) precursor protein-cleaving enzyme 1 (BACE1) that reduces Aβ production. As a potent BACE1 inhibitor, lanabecestat significantly reduced soluble Aβ species and soluble amyloid precursor proteins (sAPPβ) in mouse, guinea pig, and dog in a time- and dose-dependent manner. Significant reductions in plasma and cerebrospinal fluid (CSF) Aβ1-40 and Aβ1-42 were observed in Phase 1 studies of healthy subjects and AD patients treated with lanabecestat. Three lanabecestat trials are ongoing and intended to support registration in Early AD: (1) Phase 2/3 study in patients with mild cognitive impairment (MCI) due to AD and mild AD dementia (AMARANTH, NCT02245737); (2) Delayed-start extension study (AMARANTH-EXTENSION, NCT02972658) for patients who have completed treatment in the AMARANTH Study; and (3) Phase 3 study in mild AD dementia (DAYBREAK-ALZ, NCT02783573). This review will discuss the development of lanabecestat, results from the completed nonclinical and clinical studies, as well as describe the ongoing Phase 3 clinical trials.

Spectrum of novel ATP2A2 mutations in patients with Darier's disease

Darier's disease (DD) is an autosomal dominantly inherited skin disorder characterized by loss of adhesion between epidermal cells (acantholysis) and abnormal keratinization. Recently, we identified ATP2A2 encoding the sarco/endoplasmic reticulum Ca(2+)ATPase isoform 2 as the defective gene in DD. Now we report a spectrum of ATP2A2 mutations in 19 families and six sporadic cases with DD and investigate genotype-phenotype correlations. All 21 exons and flanking intron boundaries were amplified and screened for mutations by conformation-sensitive gel electrophoresis and direct sequencing. We identified 24 novel mutations that are scattered throughout the ATP2A2 gene. Two families shared an identical mutation on a common disease-associated haplotype, suggesting inheritance from a common ancestor. The majority of the mutations (54%; 13/24) led to a premature termination codon which further supports the proposal that haploin-sufficiency is a common molecular mechanism for DD. Thirty-eight per cent of mutations (9/24) result in non-conservative amino acid substitutions at highly conserved positions. Two mutations predict mutated polypeptides lacking or carrying additional amino acids. Marked inter- and intrafamilial phenotypic variability of the disease was observed. These results illustrate the considerable diversity of ATP2A2 mutations causing DD and suggest that additional factors are important contributors to the clinical phenotype.

Mutations in ATP2A2, encoding a Ca2+ pump, cause Darier disease

Darier disease (DD) is an autosomal-dominant skin disorder characterized by loss of adhesion between epidermal cells (acantholysis) and abnormal keratinization. Recently we constructed a 2.4-Mb, P1-derived artificial chromosome contig spanning the DD candidate region on chromosome 12q23-24.1. After screening several genes that mapped to this region, we identified mutations in the ATP2A2 gene, which encodes the sarco/endoplasmic reticulum Ca2(+)-ATPase type 2 isoform (SERCA2) and is highly expressed in keratinocytes. Thirteen mutations were identified, including frameshift deletions, in-frame deletions or insertions, splice-site mutations and non-conservative missense mutations in functional domains. Our results demonstrate that mutations in ATP2A2 cause DD and disclose a role for this pump in a Ca(2+)-signalling pathway regulating cell-to-cell adhesion and differentiation of the epidermis.

Response to intradialytic parenteral nutrition

Malnutrition is a major clinical problem in patients receiving maintenance hemodialysis and has adverse effects on survival. Nutritional intervention is indicated, and there is evidence that intradialytic parenteral nutrition can be beneficial. We describe the application of a formal policy regarding the use of intradialytic parenteral nutrition and the beneficial effects on nutrition in the first four patients managed in this fashion. However, the fifth patient did not respond to parenteral nutrition, despite adequate dialysis. This prompted further investigation, and the patient was shown to have extensive gastric malignancy. This report shows that establishing a protocol for intradialytic parenteral nutrition is possible in a medium-sized hemodialysis unit. In these circumstances, nonresponse to this intervention should always be investigated to determine if there is another underlying cause of malnutrition unrelated to renal failure.

Refined genetic mapping of the darier locus to a <1-cM region of chromosome 12q24.1, and construction of a complete, high-resolution P1 artificial chromosome/bacterial artificial chromosome contig of the critical region

Darier disease (DD) (MIM 124200) is an autosomal dominant skin disorder characterized by loss of adhesion between epidermal cells and by abnormal keratinization. We present linkage analysis showing, in four families, key recombination events that refine the location of the DD locus on chromosome 12q23-24.1 to a region of <1 cM. We have constructed a YAC/P1 artificial chromosome (PAC)/bacterial artificial chromosome (BAC)-based physical map that encompasses this refined DD region. The map consists of 35 YAC, 69 PAC, 16 BAC, and 2 cosmid clones that were ordered by mapping 54 anonymous sequence-tagged sites. The critical region is estimated to be 2.4 Mb in size, with an average marker resolution of 37.5 kb. The refinement of the critical interval excludes the ALDH2, RPL6, PTPN11, and OAS genes, as well as seven expressed sequence tags (ESTs) previously mapped in the DD region. The three known genes (ATP2A2, PPP1CC, and SCA2) and the 10 ESTs mapped within the critical region are not obvious candidates for the DD gene. Therefore, this detailed integrated physical, genetic, and partial transcript map provides an important resource for the isolation of the DD gene and, possibly, other disease genes.

A sequence-ready physical map of a region of 12q24.1

We developed a sequence-ready map of a part of human chromosome 12q24.1. We utilized a number of sequence-tagged site (STS) markers from 12q24.1 to screen large insert bacterial chromosome libraries and a chromosome 12-specific cosmid library. The clones were assembled into contiguous sets (contigs) by STS-content analysis. Contigs were extended by obtaining end sequences of bacterial clones, generation of additional STSs, rescreening the libraries, and screening the additional clones for the presence of STSs. The resulting contig covers nearly 2 Mb of DNA and provides an average marker resolution of 16 kb. Based on the STS content, we developed fingerprints of a subset of clones. The STS content and fingerprint data allowed us to define a minimal tiling path of clones. These clones are being used to sequence this part of chromosome 12. This contig contains the Ataxin 2 gene, and it covers the interval harboring the gene responsible for Darier disease.

A chamber system for maintaining a hyperbaric environment for long-term animal studies

An experimental hyperbaric chamber system is described whereby animals, including nonhuman primates, can be cared for under altered environmental conditions for periods in excess of 1 wk. The chamber itself is capable of a working pressure of 200 atm abs, used with various mixtures of gases which can be varied independently. The novel approach of vertical mounting enables cages to be lowered into position, and food and water can be supplied from above while excreta can be removed from below, irrespective of the internal pressure. The chamber has an integrated life support system such that temperature, both of the chamber and of the mass of gas inside, humidity, oxygen, carbon dioxide, and noise levels can be accurately and finely controlled, all within a pathogen-free environment.

Effect of exposing mice to 50 ATA helium pressure at different stages of pregnancy

Pregnant T-O mice were exposed to 50 ATA He-O2 pressure for 4 days at different stages of gestation: 4-7, 6-9, and 9-12 days gestation. Controls were exposed to 1 atmosphere absolute (ATA) air. After the exposure period, pregnancy continued until 18 days gestation when the mice were killed and autopsied. Data were collected relating to the litters and placentas (Litter size, percent resorptions, placental weight, fetal-to-placental ratio) and fetuses (weight, crown-rump length, sex, skeletal abnormalities) and analyzed using analysis of variance. Results showed a small but significant increase in the percent resorptions in the pressure group and also a decrease in crown-rump length and placental weight. None of these changes were related to the stage of gestation in which the mice were exposed. No teratogenic effects of pressure were seen. We conclude that exposure to 50 ATA He-O2 during pregnancy in mice produces a small nonselective effect on fetal growth and development but does not affect any specific event taking place during these stages of embryogenesis.

Sperm maturation associated with subfertility following hyperbaric exposure of mice

Mice exposed to 50 ATA heliox pressure during one spermatogenic cycle subsequently exhibit subfertility which can recover over an 8-wk period. This study was designed to investigate the changes in spermatid and testicular histology associated with these phenomena. Electron microscopy of testicular tissue from hyperbaric-exposed animals revealed a significant effect on spermatogenesis including disorganization and patchy necrosis of the epithelium. Two weeks after exposure to pressure, abnormalities were more difficult to find and tissues taken from animals 8 wk after exposure were indistinguishable from normal. These data directly confirm our earlier hypothesis that chronic hyperbaric exposure has a deleterious effect on sperm maturation, which is subsequently manifest as a failure in fertilizing capacity.

Assessment of recovery from hyperbaric-induced subfertility in male mice

This study was designed to investigate whether subfertility in male mice produced by exposure to high pressures of heliox showed any recovery. Male mice were exposed to 50 ATA heliox (controls exposed to 1 ATA air) during one spermatogenic cycle; subsequently each male was housed with 10 untreated females. After 14 days males were removed and housed with 10 more females. This was repeated four times. Male libido, pregnancy rate, pre- or early implantation loss, and fetal survival were determined for each mating. Results showed that all variables were significantly reduced in the pressure group during the first mating, but there were differing rates of recovery. Male libido was consistently reduced (12%) and showed no recovery trend. Pregnancy rate showed continuing improvement throughout all matings but did not reach control levels after 8 wk. Pre/early implantation loss and fetal survival had returned to control values by the fourth mating. These data suggest that pressure-induced subfertility is largely reversible, and at least two separate events contribute to it.

Reduction in fertility of male mice after exposure to high environmental pressure

Male mice were exposed to 50 ATA heliox pressure to study whether their functional fertility was affected. In series I, control mice were exposed to 1 ATA air; in series II controls were exposed to 5 ATA heliox, which enabled the PO2 and environmental temperature to be maintained at equivalent levels to the pressure group. After exposure during one spermatogenic cycle, the mice were mated with untreated females. There was a dramatic reduction in fertility in the pressure groups, with males in both series I and II showing a 65% reduction in fertility. Overall results were as follows: 19.5% pregnant females mated with the pressure groups compared with 55% pregnant in the control groups. Litter sizes in the pressure groups were reduced by 44%, but there was no evidence of any pressure-related teratological effect. This reduction in fertility appears to be due to high pressure per se and not to the high environmental temperature and PO2 associated with heliox atmospheres.