StatAlign 2.0: combining statistical alignment with RNA secondary structure prediction.

MOTIVATION: Comparative modeling of RNA is known to be important for making accurate secondary structure predictions. RNA structure prediction tools such as PPfold or RNAalifold use an aligned set of sequences in predictions. Obtaining a multiple alignment from a set of sequences is quite a challenging problem itself, and the quality of the alignment can affect the quality of a prediction. By implementing RNA secondary structure prediction in a statistical alignment framework, and predicting structures from multiple alignment samples instead of a single fixed alignment, it may be possible to improve predictions. RESULTS: We have extended the program StatAlign to make use of RNA-specific features, which include RNA secondary structure prediction from multiple alignments using either a thermodynamic approach (RNAalifold) or a Stochastic Context-Free Grammars (SCFGs) approach (PPfold). We also provide the user with scores relating to the quality of a secondary structure prediction, such as information entropy values for the combined space of secondary structures and sampled alignments, and a reliability score that predicts the expected number of correctly predicted base pairs. Finally, we have created RNA secondary structure visualization plugins and automated the process of setting up Markov Chain Monte Carlo runs for RNA alignments in StatAlign. AVAILABILITY AND IMPLEMENTATION: The software is available from http://statalign.github.com/statalign/.

Oxfold: kinetic folding of RNA using stochastic context-free grammars and evolutionary information.

MOTIVATION: Many computational methods for RNA secondary structure prediction, and, in particular, for the prediction of a consensus structure of an alignment of RNA sequences, have been developed. Most methods, however, ignore biophysical factors, such as the kinetics of RNA folding; no current implementation considers both evolutionary information and folding kinetics, thus losing information that, when considered, might lead to better predictions. RESULTS: We present an iterative algorithm, Oxfold, in the framework of stochastic context-free grammars, that emulates the kinetics of RNA folding in a simplified way, in combination with a molecular evolution model. This method improves considerably on existing grammatical models that do not consider folding kinetics. Additionally, the model compares favourably to non-kinetic thermodynamic models.

Characterising RNA secondary structure space using information entropy.

Comparative methods for RNA secondary structure prediction use evolutionary information from RNA alignments to increase prediction accuracy. The model is often described in terms of stochastic context-free grammars (SCFGs), which generate a probability distribution over secondary structures. It is, however, unclear how this probability distribution changes as a function of the input alignment. As prediction programs typically only return a single secondary structure, better characterisation of the underlying probability space of RNA secondary structures is of great interest. In this work, we show how to efficiently compute the information entropy of the probability distribution over RNA secondary structures produced for RNA alignments by a phylo-SCFG, and implement it for the PPfold model. We also discuss interpretations and applications of this quantity, including how it can clarify reasons for low prediction reliability scores. PPfold and its source code are available from http://birc.au.dk/software/ppfold/.

Quantifying variances in comparative RNA secondary structure prediction.

BACKGROUND: With the advancement of next-generation sequencing and transcriptomics technologies, regulatory effects involving RNA, in particular RNA structural changes are being detected. These results often rely on RNA secondary structure predictions. However, current approaches to RNA secondary structure modelling produce predictions with a high variance in predictive accuracy, and we have little quantifiable knowledge about the reasons for these variances. RESULTS: In this paper we explore a number of factors which can contribute to poor RNA secondary structure prediction quality. We establish a quantified relationship between alignment quality and loss of accuracy. Furthermore, we define two new measures to quantify uncertainty in alignment-based structure predictions. One of the measures improves on the "reliability score" reported by PPfold, and considers alignment uncertainty as well as base-pair probabilities. The other measure considers the information entropy for SCFGs over a space of input alignments. CONCLUSIONS: Our predictive accuracy improves on the PPfold reliability score. We can successfully characterize many of the underlying reasons for and variances in poor prediction. However, there is still variability unaccounted for, which we therefore suggest comes from the RNA secondary structure predictive model itself.

Frnakenstein: multiple target inverse RNA folding.

BACKGROUND: RNA secondary structure prediction, or folding, is a classic problem in bioinformatics: given a sequence of nucleotides, the aim is to predict the base pairs formed in its three dimensional conformation. The inverse problem of designing a sequence folding into a particular target structure has only more recently received notable interest. With a growing appreciation and understanding of the functional and structural properties of RNA motifs, and a growing interest in utilising biomolecules in nano-scale designs, the interest in the inverse RNA folding problem is bound to increase. However, whereas the RNA folding problem from an algorithmic viewpoint has an elegant and efficient solution, the inverse RNA folding problem appears to be hard. RESULTS: In this paper we present a genetic algorithm approach to solve the inverse folding problem. The main aims of the development was to address the hitherto mostly ignored extension of solving the inverse folding problem, the multi-target inverse folding problem, while simultaneously designing a method with superior performance when measured on the quality of designed sequences. The genetic algorithm has been implemented as a Python program called Frnakenstein. It was benchmarked against four existing methods and several data sets totalling 769 real and predicted single structure targets, and on 292 two structure targets. It performed as well as or better at finding sequences which folded in silico into the target structure than all existing methods, without the heavy bias towards CG base pairs that was observed for all other top performing methods. On the two structure targets it also performed well, generating a perfect design for about 80% of the targets. CONCLUSIONS: Our method illustrates that successful designs for the inverse RNA folding problem does not necessarily have to rely on heavy biases in base pair and unpaired base distributions. The design problem seems to become more difficult on larger structures when the target structures are real structures, while no deterioration was observed for predicted structures. Design for two structure targets is considerably more difficult, but far from impossible, demonstrating the feasibility of automated design of artificial riboswitches. The Python implementation is available at http://www.stats.ox.ac.uk/research/genome/software/frnakenstein.

Soy protein effects on serum lipoproteins: a quality assessment and meta-analysis of randomized, controlled studies.

OBJECTIVES: Many randomized controlled trials (RCTs) have assessed the effects of soy protein on serum lipoprotein risk factors for coronary heart disease (CHD). This review and meta-analysis assessed the quality of these RCTs and estimated the effects of soy protein consumption on serum lipoproteins. DATA SOURCES: A comprehensive search using multiple databases was conducted for the years 1996 through 2008 to identify clinical trials related to soy protein intake and serum lipoprotein changes. STUDY ELIGIBILITY: RCTs were assessed that met these requirements: soy protein intake compared with nonsoy protein, provided information on serum low-density lipoprotein (LDL)-cholesterol values, provided no more than 65 g of soy protein daily, and obtained LDL-cholesterol measurements between 4 and 18 weeks of treatment. Randomized parallel and crossover studies were evaluated. METHODS: Studies were graded for quality using 12 criteria with a possible maximum grade of 24. Net changes in lipoproteins with soy protein consumption compared with nonsoy control diets were analyzed by meta-analyses and funnel plots. Confidence intervals were constructed using inverse weighting. Analyses compared parallel to crossover studies and studies with lower and higher grades. RESULTS: Analyses included 20 parallel-design studies and 23 crossover studies. Parallel studies scored significantly higher (p < 0.001) in study quality, with a mean grade of 15.8 (95% confidence interval [CI], 14.3 to 17.3) compared with 10.1 (95% CI, 8.2 to 11.9) for crossover trials. Soy protein intake was associated with net changes in serum LDL-cholesterol values of -0.23 mmol/l (95% CI, -0.28 to -0.18 mmol/l) or a 5.5% reduction in parallel studies and -0.16 mmol/l (95% CI, -0.22 to -0.11 mmol/l) or a reduction of 4.2% with crossover studies (p < 0.001 for parallel vs crossover). In parallel studies, net serum HDL-cholesterol values were 3.2% higher (p < 0.007) with soy vs control, and fasting serum triacylglycerol values were 10.7% lower (p < 0.008) for soy vs control. CONCLUSIONS AND IMPLICATIONS: Soy protein consumption with a median of 30 g/d was associated with a significant improvement in lipoprotein risk factors for CHD. Compared with crossover RCTs, parallel RCTs had significantly higher quality grades and were associated with significantly greater improvements in serum LDL-cholesterol values. Regular consumption of 1 to 2 servings of soy protein daily (15 to 30 g) has a significant favorable impact on serum lipoprotein risk factors for CHD.

Functional foods for dyslipidaemia and cardiovascular risk prevention.

A food can be regarded as 'functional' if it can demonstrate a beneficial efficacy on one or more target functions in the body in a convincing way. Beyond adequate nutritional qualities, functional foods should either improve the state of health and wellbeing and/or reduce the risk of disease. Functional foods that are marketed with claims of heart disease reduction focus primarily on the major risk factors, i.e. cholesterol, diabetes and hypertension. Some of the most innovative products are designed to be enriched with 'protective' ingredients, believed to reduce risk. They may contain, for example, soluble fibre (from oat and psyllium), useful both for lowering cholesterol and blood pressure, or fructans, effective in diabetes. Phytosterols and stanols lower LDL-cholesterol in a dose-dependent manner. Soya protein is more hypocholesterolaemic in subjects with very high initial cholesterol and recent data indicate also favourable activities in the metabolic syndrome. n-3 Fatty acids appear to exert significant hypotriacylglycerolaemic effects, possibly partly responsible for their preventive activity. Dark chocolate is gaining much attention for its multifunctional activities, useful both for the prevention of dyslipidaemia as well as hypertension. Finally, consensus opinions about tea and coffee have not emerged yet, and the benefits of vitamin E, garlic, fenugreek and policosanols in the management of dyslipidaemia and prevention of arterial disease are still controversial.

Glucagon-like peptide 1 and pancreatic polypeptide responses to feeding in normal weight and overweight children.

BACKGROUND: Glucagon-like peptide 1 (GLP-1) and pancreatic polypeptide (PP) are intestinal hormones that are involved in the post-prandial satiety response. We sought to assess meal-related changes in these hormones in young children and determine whether differences exist between normal weight (NW) and overweight (OW) children. METHODS: Seven to 11-year-old healthy NW (n=20) and OW (n=12) volunteers were given a standardized breakfast and lunch following an overnight fast and had measurements of GLP-1 and PP over 9 hours. We characterized whether GLP-1 and PP changed from the pre-prandial to the post-prandial state and whether the serum levels corresponded to reported appetite. RESULTS: GLP-1 did not increase after eating, did not decline prior to the next meal, and did not correspond to satiety ratings in either group. PP increased post-prandially in OW children after both breakfast and lunch, but in the NW group PP only increased after breakfast. PP levels did not decline in either group as the next meal approached. CONCLUSIONS: In our study of school-age children, feeding had little effect on GLP-1 secretion and a variable effect on serum PP levels. Observed differences in the GLP-1 and PP responses between the NW and OW groups do not suggest there is an intrinsic abnormality in their secretion that causes weight gain.

Blood pressure response to transcendental meditation: a meta-analysis.

BACKGROUND: Prior clinical trials suggest that the Transcendental Meditation technique may decrease blood pressure of normotensive and hypertensive individuals but study-quality issues have been raised. This study was designed to assess effects of Transcendental Meditation on blood pressure using objective quality assessments and meta-analyses. METHODS: PubMed and Cochrane databases through December 2006 and collected publications on Transcendental Meditation were searched. Randomized, controlled trials comparing blood pressure responses to the Transcendental Meditation technique with a control group were evaluated. Primary outcome measures were changes in systolic and diastolic blood pressure after practicing Transcendental Meditation or following control procedures. A specific rating system (0-20 points) was used to evaluate studies and random-effects models were used for meta-analyses. RESULTS: Nine randomized, controlled trials met eligibility criteria. Study-quality scores ranged from low (score, 7) to high (16) with three studies of high quality (15 or 16) and three of acceptable quality (11 or 12). The random-effects meta-analysis model for systolic and diastolic blood pressure, respectively, indicated that Transcendental Meditation, compared to control, was associated with the following changes: -4.7 mm Hg (95% confidence interval (CI), -7.4 to -1.9 mm Hg) and -3.2 mm Hg (95% CI, -5.4 to -1.3 mm Hg). Subgroup analyses of hypertensive groups and high-quality studies showed similar reductions. CONCLUSIONS: The regular practice of Transcendental Meditation may have the potential to reduce systolic and diastolic blood pressure by approximately 4.7 and 3.2 mm Hg, respectively. These are clinically meaningful changes.

Grain foods and health: a primer for clinicians.

UNLABELLED: Preventing many chronic diseases in North America requires substantial changes in dietary habits. Achieving a better balance of grain-based foods through the inclusion of whole grains is one scientifically supported dietary recommendation. Epidemiological and other types of research continue to document health benefits for diverse populations who have adequate intakes of both folic acid-fortified grain foods and whole grains. Folic acid fortification of grains is associated with reduced incidence of neural tube and other birth defects and may be related to decreased risk of other chronic disease. Whole grain intake is associated with reduced risk of chronic disease. Specifically, there is a decreased risk of obesity, coronary heart disease, hypertension, stroke, metabolic syndrome, type 2 diabetes, and some cancers observed among the highest whole grain eaters compared with those eating little or no whole grains. Nationally promulgated dietary recommendations such as those in the US Dietary Guidelines or by health promotion organizations such as the American Heart Association have incorporated the science on whole grains, recommending that consumers increase their whole grain intake. The US Dietary Guidelines state that consumers select half of the recommended bread and cereal servings as whole grain. Thus, the recommendations recognize the importance of adequate folic acid intake from refined, fortified grains to reduce the risk of birth defects and other disorders and to reflect the existing science on whole grains. The association between whole grains and decreased chronic disease is not surprising because whole grains are a source of vitamins, minerals, fatty acids, anti oxidants, and other phytochemicals and dietary fiber. Each of these components can act singly or in tandem to contribute to specific health-maintaining and disease-preventing mechanisms. Health professionals should be aware of these benefits and advocate these dietary strategies to help prevent chronic disease and to improve overall health. KEYWORDS: nutrition; whole grain; folic acid; disease prevention; diet; mortality; diabetes; cereal; pseudocereal; phytochemicals; anti-oxidants.

One hundred pound weight losses with an intensive behavioral program: changes in risk factors in 118 patients with long-term follow-up.

BACKGROUND: Treatment of severe obesity is difficult; in the past, lifestyle measures did not prove effective. Recently, however, intensive behavioral interventions using meal replacements and low-energy diets have enabled some severely obese persons to achieve nonobese weights. OBJECTIVE: We assessed rates of weight loss, changes in risk factors and medication requirements, and long-term weight maintenance in patients who lost >or=100 pounds (45.5 kg). DESIGN: Over a 9-y period, we prospectively identified patients who lost >or=100 pounds (45.5 kg) and actively recorded follow-up weights. Charts were systematically reviewed to assess outcome measures and side effects. The intervention included meal replacements (shakes and entrées), low-energy diets, weekly classes, and training in record keeping and physical activity. Assessments included weekly weights, laboratory studies, medication use, lifestyle behaviors, side effects, and follow-up weights. RESULTS: Sixty-three men and 55 women lost >or=100 pounds. At baseline, the subjects' average weight was 160 kg, 97% had >or=1 obesity-related comorbidity, and 74% were taking medications for comorbidities. Weight losses averaged 61 kg in 44 wk. Medications were discontinued in 66% of patients with a cost savings of $100/mo. Despite medication discontinuation, significant decreases in LDL cholesterol (20%), triacylglycerol (36%), glucose (17%), and systolic (13%) and diastolic (15%) blood pressure values were seen. Side effects were mild, and only 2 patients had severe or serious adverse events. At an average of 5 y of follow-up, patients were maintaining an average weight loss of 30 kg. CONCLUSION: Intensive behavioral intervention can be very effective with minimal risk for certain severely obese persons.

Soy compared to casein meal replacement shakes with energy-restricted diets for obese women: randomized controlled trial.

Recent studies suggest that obese individuals lose weight more rapidly and lose more total weight with soy protein than with animal protein as a major diet component. The purpose of the present study was to evaluate the weight-loss efficacy and changes in body composition, waist circumference, blood pressure, and levels of plasma glucose, insulin, serum lipids, C-reactive protein, and homocysteine from consumption of either 3 soy shakes or 3 casein shakes daily as part of a 16-week, energy-restricted diet for obese women. Forty-three women with body mass index values of 30 to 40 kg/m(2) were randomized to intensive dietary interventions using either casein (n = 21) or soy (n = 22) shakes. Subjects were instructed to consume 3 shakes, 1 prepackaged entrée, and 5 servings of fruits or vegetables daily to achieve an energy intake of 4.5 to 5.0 MJ/d. Subjects attended classes weekly or biweekly. Weight, body fat, lipid, and glucose measurements were obtained at baseline and at 8 and 16 weeks. For both groups combined, subjects lost 8.1% of initial body weight (7.7 kg) at 8 weeks and 13.4% (12.7 kg) at 16 weeks. Weight loss from baseline did not differ significantly by group and, for completing subjects, was 14.0% +/- 1.2% (mean +/- SE) for casein and 12.8% +/- 1.4% for soy. With the intention-to-treat analysis, weight losses at 16 weeks were 12.5% +/- 1.4% for casein and 11.3% +/- 1.2% for soy. Body fat losses were 23.7% +/- 2.0% for casein and 21.8% +/- 2.4% for soy and did not differ significantly. Both study groups lost significant amounts of weight with a highly structured behavioral program incorporating 4 meal replacements and vegetables and fruits. Differences in weight loss and body composition changes between casein and soy treatments were not significant.

Low-dose orlistat effects on body weight of mildly to moderately overweight individuals: a 16 week, double-blind, placebo-controlled trial.

BACKGROUND: Lifestyle measures are considered the first line of therapy for treating overweight individuals, but many are unable to achieve a meaningful weight loss. OBJECTIVE: To determine the efficacy and safety of orlistat 60 mg, given 3 times daily, for weight loss in mildly to moderately overweight individuals. METHODS: A multicenter, 16 week, randomized, double-blind, placebo-controlled study was conducted in 391 overweight subjects at 20 US centers. The main outcome measure was change in weight from baseline to week 16; secondary measures included changes in body mass index, waist circumference, blood pressure, and fasting lipoprotein and glucose levels. RESULTS: Subjects in both groups lost weight over the treatment period; however, orlistat-treated subjects lost significantly more weight than placebo-treated subjects beyond 2 weeks of treatment. Weight loss from baseline to week 16 was significantly greater in participants receiving orlistat versus those receiving placebo (3.05 vs 1.90 kg; p < 0.001, intent-to-treat analysis). Orlistat-treated subjects who completed 16 weeks of treatment lost 4.8 +/- 0.35% (mean +/- SE) of baseline weight compared with 3.1 +/- 0.38% for the placebo group (p < 0.001). Orlistat-treated subjects, compared with those receiving placebo, also demonstrated a greater relative reduction in total (-4.4% vs 0.0%; p = 0.004) and low-density lipoprotein cholesterol (-7.2% vs -0.6%; p = 0.005) and both diastolic (-3.9% vs -0.5%; p = 0.001) and systolic blood pressure (-4.7% vs -1.8%; p = 0.004). Both groups showed a similar safety profile; gastrointestinal events were significantly more common in the orlistat-treated subjects. CONCLUSIONS: The use of orlistat 60 mg by mildly to moderately overweight individuals produced significant weight loss in conjunction with a reduced calorie diet and self-instructional materials. This amount of weight loss was associated with improvements in several weight-related risk factors. Orlistat 60 mg may be a useful adjunct to lifestyle measures and has the potential to contribute significantly to weight and risk factor improvement for overweight individuals.

Private prayer associations with depression, anxiety and other health conditions: an analytical review of clinical studies.

OBJECTIVES: To critically analyze appropriate clinical studies to assess the relationship between health conditions and the frequency of private prayer. Private prayer is defined as individuals praying for themselves. METHODS: Using PubMed and other search engines, we identified over 300 articles reporting relationships between prayer and health conditions. We identified 41 observational clinical studies that evaluated the relationship between private prayer and health conditions. Prayer scores of 5 to 1 were assigned to studies, with 5 being private prayer for health and 1 being prayer in combination with meditation or Bible study. Frequency scores ranged from 3 to 1 with 3 being twice daily or more and 0 when frequency was not assessed. Studies were ranked from 8 to 1 based on the sum of Prayer and Frequency Scores. RESULTS: Twenty-one studies had Prayer-Frequency scores of 5 to 8, indicating that they evaluated private prayer (praying for one's own health) of suitable frequency in association with health conditions. Nine of 11 studies indicated that private prayer was associated with a significantly lower prevalence of depression (P value, <0.01). Optimism as well as coping were significantly improved by prayer in four studies (P value, P < 0.01). In 10 studies of mental health conditions-including anxiety and confusion-there was a significant benefit associated with prayer (P < 0.01), In the reviewed studies, prayer did not have a significant effect on physical health or blood pressure. CONCLUSION: The reported observational studies suggest that frequent private prayer is associated with a significant benefit for depression, optimism, coping, and other mental health conditions such as anxiety. Controlled clinical trials are required to critically assess the associations of private prayer and health conditions.

The ubiquitin ligase CRL2ZYG11 targets cyclin B1 for degradation in a conserved pathway that facilitates mitotic slippage.

The anaphase-promoting complex/cyclosome (APC/C) ubiquitin ligase is known to target the degradation of cyclin B1, which is crucial for mitotic progression in animal cells. In this study, we show that the ubiquitin ligase CRL2ZYG-11 redundantly targets the degradation of cyclin B1 in Caenorhabditis elegans and human cells. In C. elegans, both CRL2ZYG-11 and APC/C are required for proper progression through meiotic divisions. In human cells, inactivation of CRL2ZYG11A/B has minimal effects on mitotic progression when APC/C is active. However, when APC/C is inactivated or cyclin B1 is overexpressed, CRL2ZYG11A/B-mediated degradation of cyclin B1 is required for normal progression through metaphase. Mitotic cells arrested by the spindle assembly checkpoint, which inactivates APC/C, often exit mitosis in a process termed "mitotic slippage," which generates tetraploid cells and limits the effectiveness of antimitotic chemotherapy drugs. We show that ZYG11A/B subunit knockdown, or broad cullin-RING ubiquitin ligase inactivation with the small molecule MLN4924, inhibits mitotic slippage in human cells, suggesting the potential for antimitotic combination therapy.

Diabetes, plasma insulin, and cardiovascular disease: subgroup analysis from the Department of Veterans Affairs high-density lipoprotein intervention trial (VA-HIT).

BACKGROUND: Diabetes mellitus, impaired fasting glucose level, or insulin resistance are associated with increased risk of cardiovascular disease. OBJECTIVES: To determine the efficacy of gemfibrozil in subjects with varying levels of glucose tolerance or hyperinsulinemia and to examine the association between diabetes status and glucose and insulin levels and risk of cardiovascular outcomes. METHODS: Subgroup analyses from the Department of Veterans Affairs High-Density Lipoprotein Intervention Trial, a randomized controlled trial that enrolled 2531 men with coronary heart disease (CHD), a high-density lipoprotein cholesterol level of 40 mg/dL or less (/=271 pmol/L) was associated with a 31% increased risk of events (P =.03). Gemfibrozil was effective in persons with diabetes (risk reduction for composite end point, 32%; P =.004). The reduction in CHD death was 41% (HR, 0.59; 95% CI, 0.39-0.91; P =.02). Among individuals without diabetes, gemfibrozil was most efficacious for those in the highest fasting plasma insulin level quartile (risk reduction, 35%; P =.04). CONCLUSION: In men with CHD and a low high-density lipoprotein cholesterol level, gemfibrozil use was associated with a reduction in major cardiovascular events in persons with diabetes and in nondiabetic subjects with a high fasting plasma insulin level.

Insulin resistance and cardiovascular events with low HDL cholesterol: the Veterans Affairs HDL Intervention Trial (VA-HIT).

OBJECTIVE: To assess the effect of insulin resistance and the benefit of the fibrate, gemfibrozil, on the incidence of major cardiovascular events in subjects with low HDL cholesterol and a broad range of triglyceride values who participated in the Veterans Affairs High Density Lipoprotein Intervention Trial (VA-HIT). RESEARCH DESIGN AND METHODS: This intention-to-treat analysis, specified as a secondary objective in VA-HIT, determined using Cox proportional hazards models the 5-year combined incidence of nonfatal myocardial infarction, coronary heart disease (CHD) death, or stroke in relation to the presence or absence of insulin resistance (defined by the highest tertile of the homeostasis model assessment of insulin resistance, HOMA-IR) in conjunction with lower and higher levels of HDL cholesterol and triglycerides. The study population consisted of 2,283 men with known coronary heart disease (CHD), treated with either placebo or gemfibrozil, who could be subdivided into groups with diabetes with or without insulin resistance, with no diabetes but insulin resistance, and with neither diabetes nor insulin resistance. RESULTS: With insulin resistance there was a significantly higher relative risk (RR) of a cardiovascular event both with diabetes (RR of 1.62 with 95% CI of 1.28-2.06) and without diabetes (RR of 1.43 with 95% CI of 1.03-1.98) than without insulin resistance. Throughout both lower and higher ranges of HDL cholesterol and triglycerides, the rate of new cardiovascular events and the reduction of events with gemfibrozil was greater in subjects with insulin resistance than without, despite the finding that an increase in HDL cholesterol and a decrease in triglycerides with gemfibrozil was less with insulin resistance than without insulin resistance. CONCLUSIONS: Results show that in VA-HIT the occurrence of a new cardiovascular event and the benefit of fibrate therapy was much less dependent on levels of HDL cholesterol or triglycerides than on the presence or absence of insulin resistance.

Effect of orlistat in overweight and obese patients with type 2 diabetes treated with metformin.

OBJECTIVE: The purpose of this study was to assess the effect of orlistat, a gastrointestinal lipase inhibitor, on body weight, glycemic control, and cardiovascular risk factors in metformin-treated type 2 diabetic patients. RESEARCH DESIGN AND METHODS: A 1-year multicenter, randomized, double-blind, placebo-controlled trial of 120 mg orlistat t.i.d. (n = 249) or placebo (n = 254) combined with a reduced-calorie diet was conducted in overweight and obese patients with suboptimal control of type 2 diabetes. RESULTS: After 1 year of treatment, mean (+/-SE) weight loss was greater in the orlistat than in the placebo group (-4.6 +/- 0.3% vs. -1.7 +/- 0.3% of baseline wt, P < 0.001). Orlistat treatment caused a greater improvement in glycemic control than placebo, as evidenced by a greater reduction in serum HbA(1c), adjusted for changes in metformin and sulfonylurea therapy (-0.90 +/- 0.08 vs. -0.61 +/- 0.08, P = 0.014); a greater proportion of patients achieving decreases in HbA(1c) of > or = 0.5 and > or = 1.0% (both P < 0.01); and a greater reduction in fasting serum glucose (-2.0 +/- 0.2 vs. -0.7 +/- 0.2 mmol/l, P = 0.001). Compared with the placebo group, patients treated with orlistat also had greater decreases in total cholesterol, LDL cholesterol, and systolic blood pressure (all P < 0.05). Although more subjects treated with orlistat experienced gastrointestinal side effects than placebo (83 vs. 62%, P < 0.05), more subjects in the placebo group withdrew prematurely from the study than in the orlistat group (44 vs. 35%, P < 0.05). CONCLUSIONS: Orlistat is a useful adjunctive treatment for producing weight loss and improving glycemic control, serum lipid levels, and blood pressure in obese patients with type 2 diabetes who are being treated with metformin.

Type 2 diabetes and the vegetarian diet.

Based on what is known of the components of plant-based diets and their effects from cohort studies, there is reason to believe that vegetarian diets would have advantages in the treatment of type 2 diabetes. At present there are few data on vegetarian diets in diabetes that do not in addition have weight loss or exercise components. Nevertheless, the use of whole-grain or traditionally processed cereals and legumes has been associated with improved glycemic control in both diabetic and insulin-resistant individuals. Long-term cohort studies have indicated that whole-grain consumption reduces the risk of both type 2 diabetes and cardiovascular disease. In addition, nuts (eg, almonds), viscous fibers (eg, fibers from oats and barley), soy proteins, and plant sterols, which may be part of the vegetarian diet, reduce serum lipids. In combination, these plant food components may have a very significant impact on cardiovascular disease, one of the major complications of diabetes. Furthermore, substituting soy or other vegetable proteins for animal protein may also decrease renal hyperfiltration, proteinuria, and renal acid load and in the long term reduce the risk of developing renal disease in type 2 diabetes. The vegetarian diet, therefore, contains a portfolio of natural products and food forms of benefit for both the carbohydrate and lipid abnormalities in diabetes. It is anticipated that their combined use in vegetarian diets will produce very significant metabolic advantages for the prevention and treatment of diabetes and its complications.

Practical office strategies for weight management of the obese diabetic individual.

SUMMARY: Obesity is a key component of the insulin-resistance syndrome of type 2 diabetes, and intensifies comorbidities underlying the increased cardiovascular risk of individuals with type 2 diabetes. Weight loss leads to dramatic beneficial effects, with reductions in blood glucose levels and improvements in lipid profiles and blood pressure that often necessitate reductions in medications. Successful long-term weight loss is difficult to achieve in patients with diabetes, as standard dietary approaches often have minimal long-term impact, and intensive management strategies designed to improve glycemic control often contribute to further weight gain in these patients. This article offers a review of newer strategies for enhancing lifestyle change and weight loss in the obese diabetic individual. Use of meal replacements provides structure with portion control, and increased intake of fruits and vegetables promotes a healthier eating style for these patients. Encouraging physical activity such as walking, stair climbing, and gardening can significantly improve cardiorespiratory fitness and glycemic control, and helps patients maintain weight loss. Self-monitoring through lifestyle diaries can reinforce the healthy behaviors necessary for long-term management of obesity. Adjunctive antiobesity medication, medically-supervised intensive weight loss programs, and minimally invasive gastric bypass procedures are important options for patients unable to make significant progress with behavioral changes.