Consensus report: Definition and interpretation of remission in type 2 diabetes.

Improvement of glucose levels into the normal range can occur in some people living with diabetes, either spontaneously or after medical interventions, and in some cases can persist after withdrawal of glucose-lowering pharmacotherapy. Such sustained improvement may now be occurring more often due to newer forms of treatment. However, terminology for describing this process and objective measures for defining it are not well established, and the long-term risks versus benefits of its attainment are not well understood. To update prior discussions of this issue, an international expert group was convened by the American Diabetes Association to propose nomenclature and principles for data collection and analysis, with the goal of establishing a base of information to support future clinical guidance. This group proposed "remission" as the most appropriate descriptive term, and HbA1c <6.5% (48 mmol/mol) measured at least 3 months after cessation of glucose-lowering pharmacotherapy as the usual diagnostic criterion. The group also made suggestions for active observation of individuals experiencing a remission and discussed further questions and unmet needs regarding predictors and outcomes of remission.

Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes.

Improvement of glucose levels into the normal range can occur in some people living with diabetes, either spontaneously or after medical interventions, and in some cases can persist after withdrawal of glucose-lowering pharmacotherapy. Such sustained improvement may now be occurring more often due to newer forms of treatment. However, terminology for describing this process and objective measures for defining it are not well established, and the long-term risks versus benefits of its attainment are not well understood. To update prior discussions of this issue, an international expert group was convened by the American Diabetes Association to propose nomenclature and principles for data collection and analysis, with the goal of establishing a base of information to support future clinical guidance. This group proposed "remission" as the most appropriate descriptive term, and HbA1c < 6.5% (48 mmol/mol) measured at least 3 months after cessation of glucose-lowering pharmacotherapy as the usual diagnostic criterion. The group also made suggestions for active observation of individuals experiencing a remission and discussed further questions and unmet needs regarding predictors and outcomes of remission.

An Extract of Russian Tarragon Prevents Obesity-Related Ectopic Lipid Accumulation.

SCOPE: The primary disorder underlying metabolic syndrome is insulin resistance due to excess body weight and abdominal visceral fat accumulation. In this study, it is asked if dietary intake of an ethanolic extract from Russian tarragon (Artemisia dracunculus L., termed PMI5011), shown to improve glucose utilization by enhancing insulin signaling in skeletal muscle, could prevent obesity-induced insulin resistance, skeletal muscle metabolic inflexibility, and ectopic lipid accumulation in the skeletal muscle and liver. METHODS AND RESULTS: Male wild-type mice are fed a high-fat diet alone or supplemented with PMI5011 (1% w/w) over 3 months. Dietary intake of PMI5011 improved fatty acid oxidation and metabolic flexibility in the skeletal muscle, reduced insulin levels, and enhanced insulin signaling in the skeletal muscle and liver independent of robust changes in expression of factors that control fatty acid oxidation. This corresponds with significantly reduced lipid accumulation in the skeletal muscle and liver, although body weight gain is comparable to a high-fat diet alone. CONCLUSION: Previous studies showed that PMI5011 enhances insulin sensitivity in the setting of established obesity-induced insulin resistance. The current study demonstrates that dietary intake of PMI5011 prevents high-fat diet-induced insulin resistance, metabolic dysfunction, and ectopic lipid accumulation in the skeletal muscle and liver without reducing body weight.

Advances in the Science, Treatment, and Prevention of the Disease of Obesity: Reflections From a Diabetes Care Editors' Expert Forum.

As obesity rates increase, so too do the risks of type 2 diabetes, cardiovascular disease, and numerous other detrimental conditions. The prevalence of obesity in U.S. adults more than doubled between 1980 and 2010, from 15.0 to 36.1%. Although this trend may be leveling off, obesity and its individual, societal, and economic costs remain of grave concern. In June 2014, a Diabetes Care Editors' Expert Forum convened to review the state of obesity research and discuss the latest prevention initiatives and behavioral, medical, and surgical therapies. This article, an outgrowth of the forum, offers an expansive view of the obesity epidemic, beginning with a discussion of its root causes. Recent insights into the genetic and physiological factors that influence body weight are reviewed, as are the pathophysiology of obesity-related metabolic dysfunction and the concept of metabolically healthy obesity. The authors address the crucial question of how much weight loss is necessary to yield meaningful benefits. They describe the challenges of behavioral modification and predictors of its success. The effects of diabetes pharmacotherapies on body weight are reviewed, including potential weight-neutral combination therapies. The authors also summarize the evidence for safety and efficacy of pharmacotherapeutic and surgical obesity treatments. The article concludes with an impassioned call for researchers, clinicians, governmental agencies, health policymakers, and health-related industries to collectively embrace the urgent mandate to improve prevention and treatment and for society at large to acknowledge and manage obesity as a serious disease.

Impact of Lowering BMI Cut Points as Recommended in the Revised American Diabetes Association's Standards of Medical Care in Diabetes-2015 on Diabetes Screening in Asian Americans.

OBJECTIVE: This study estimated the screening prevalence of prediabetes and diabetes using a lower BMI cutoff of 23 kg/m(2) in Asians in the U.S. using the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2012. RESEARCH DESIGN AND METHODS: A cross-sectional analysis was conducted of non-Hispanic Asians, aged 45 years and older, with available BMI, HbA1c, and fasting glucose data. These overall criteria were met by 341 participants. RESULTS: Lowering the screening BMI to 23 kg/m(2) increased the sensitivity of screening for prediabetes and diabetes from 50.2 to 74.1% (P < 0.0001) but decreased the specificity from 62.9 to 38.7% (P < 0.0001). CONCLUSIONS: Although this will add additional health care costs resulting from more widespread screening, early identification of these conditions may be beneficial for primary and secondary prevention in this unique population that develops prediabetes and diabetes at lower BMI levels.

Adipocyte iron regulates leptin and food intake.

Dietary iron supplementation is associated with increased appetite. Here, we investigated the effect of iron on the hormone leptin, which regulates food intake and energy homeostasis. Serum ferritin was negatively associated with serum leptin in a cohort of patients with metabolic syndrome. Moreover, the same inverse correlation was observed in mice fed a high-iron diet. Adipocyte-specific loss of the iron exporter ferroportin resulted in iron loading and decreased leptin, while decreased levels of hepcidin in a murine hereditary hemochromatosis (HH) model increased adipocyte ferroportin expression, decreased adipocyte iron, and increased leptin. Treatment of 3T3-L1 adipocytes with iron decreased leptin mRNA in a dose-dependent manner. We found that iron negatively regulates leptin transcription via cAMP-responsive element binding protein activation (CREB activation) and identified 2 potential CREB-binding sites in the mouse leptin promoter region. Mutation of both sites completely blocked the effect of iron on promoter activity. ChIP analysis revealed that binding of phosphorylated CREB is enriched at these two sites in iron-treated 3T3-L1 adipocytes compared with untreated cells. Consistent with the changes in leptin, dietary iron content was also directly related to food intake, independently of weight. These findings indicate that levels of dietary iron play an important role in regulation of appetite and metabolism through CREB-dependent modulation of leptin expression.

Body mass index and the risk of all-cause mortality among patients with type 2 diabetes mellitus.

BACKGROUND: Several prospective studies have evaluated the association between body mass index (BMI) and death risk among patients with diabetes mellitus; however, the results have been inconsistent. METHODS AND RESULTS: We performed a prospective cohort study of 19 478 black and 15 354 white patients with type 2 diabetes mellitus. Cox proportional hazards regression models were used to estimate the association of different levels of BMI stratification with all-cause mortality. During a mean follow-up of 8.7 years, 4042 deaths were identified. The multivariable-adjusted (age, sex, smoking, income, and type of insurance) hazard ratios for all-cause mortality associated with BMI levels (18.5-22.9, 23-24.9, 25-29.9, 30-34.9 [reference group], 35-39.9, and ≥40 kg/m(2)) at baseline were 2.12 (95% confidence interval [CI], 1.80-2.49), 1.74 (95% CI, 1.46-2.07), 1.23 (95% CI, 1.08-1.41), 1.00, 1.19 (95% CI, 1.03-1.39), and 1.23 (95% CI, 1.05-1.43) for blacks and 1.70 (95% CI, 1.42-2.04), 1.51 (95% CI, 1.27-1.80), 1.07 (95% CI, 0.94-1.21), 1.00, 1.07 (95% CI, 0.93-1.23), and 1.20 (95% CI, 1.05-1.38) for whites, respectively. When stratified by age, smoking status, patient type, or the use of antidiabetic drugs, a U-shaped association was still present. When BMI was included in the Cox model as a time-dependent variable, the U-shaped association of BMI with all-cause mortality risk did not change. CONCLUSIONS: The present study indicated a U-shaped association of BMI with all-cause mortality risk among black and white patients with type 2 diabetes mellitus. A significantly increased risk of all-cause mortality was observed among blacks with BMI <30 kg/m(2) and ≥35 kg/m(2) and among whites with BMI <25 kg/m(2) and ≥40 kg/m(2) compared with patients with BMI of 30 to 34.9 kg/m(2).

Screening native botanicals for bioactivity: an interdisciplinary approach.

OBJECTIVE: Plant-based therapies have been used in medicine throughout recorded history. Information about the therapeutic properties of plants often can be found in local cultures as folk medicine is communicated from one generation to the next. The aim of this study was to identify native Louisiana plants from Creole folk medicine as a potential source of therapeutic compounds for the treatment of insulin resistance, type 2 diabetes, and related disorders. METHODS: We used an interdisciplinary approach combining expertise in disciplines ranging from cultural anthropology and botany to biochemistry and endocrinology to screen native southwest Louisiana plants. Translation of accounts of Creole folk medicine yielded a list of plants with documented use in treating a variety of conditions, including inflammation. These plants were collected, vouchered, and catalogued before extraction of soluble components. Extracts were analyzed for bioactivity in regulating inflammatory responses in macrophages or fatty acid-induced insulin resistance in C2C12 skeletal muscle cells. RESULTS: Several extracts altered gene expression of inflammatory markers in macrophages. Multiplex analysis of kinase activation in insulin-signaling pathways in skeletal muscle also identified a subset of extracts that alter insulin-stimulated protein kinase B phosphorylation in the presence of fatty-acid-induced insulin resistance. CONCLUSION: An interdisciplinary approach to screening botanical sources of therapeutic agents can be successfully applied to identify native plants used in folk medicine as potential sources of therapeutic agents in treating insulin resistance in skeletal muscle or inflammatory processes associated with obesity-related insulin resistance.

Artemisia dracunculus L. polyphenols complexed to soy protein show enhanced bioavailability and hypoglycemic activity in C57BL/6 mice.

OBJECTIVE: Scientifically validated food-based interventions are a practical means of addressing the epidemic of metabolic syndrome. An ethanolic extract of Artemisia dracunculus L. (PMI-5011) containing bioactive polyphenols, such as 2', 4'-dihydroxy-4-methoxydihydrochalcone (DMC-2), improved insulin resistance in vitro and in vivo. Plant polyphenols are concentrated and stabilized when complexed to protein-rich matrices, such as soy protein isolate (SPI), which act as effective food-based delivery vehicles. The aim of this study was to compare the bioaccessibility, bioavailability, and efficacy of polyphenols extracted from A. dracunculus and delivered as PMI-5011 (ethanolic extract alone), formulated with the non-food excipient Gelucire(®), (5011- Gelucire), or sorbed to SPI (5011-Nutrasorb(®)). METHODS: PMI-5011, 5011-Gelucire or 5011-Nutrasorb each containing 162 µg of DMC-2 was delivered to the TNO intestinal model-1 of the human upper gastrointestinal tract to compare the effect of delivery vehicle on DMC-2 bioaccessibility. C57BL6/J mice were orally administered 5011-Nutrasorb or PMI-5011 to compare effects of polyphenol-protein complexation on acute hypoglycemic activity and bioavailability of DMC-2 in serum. RESULTS: At 500 mg/kg, 5011-Nutrasorb and PMI-5011 had similar hypoglycemic activity in a high-fat diet-induced diabetes mouse model despite the fact that 5011-Nutrasorb delivered 15 times less DMC-2 (40 versus 600 µg/kg). This can be partially explained by eight times greater DMC-2 absorption into serum from 5011-Nutrasorb than from PMI-5011. TNO intestinal model-1 experiments confirmed higher total bioaccessibility of DMC-2 in vitro when delivered in 5011-Nutrasorb (50.2%) or Gelucire-5011 (44.4%) compared with PMI-5011 (27.1%; P = 0.08). CONCLUSION: Complexation with soy protein makes antidiabetic A. dracunculus polyphenols more bioavailable and bioaccessible.

Bioactives of Artemisia dracunculus L. enhance insulin sensitivity by modulation of ceramide metabolism in rat skeletal muscle cells.

OBJECTIVE: An increase in ectopic lipids in peripheral tissues has been implicated in attenuating insulin action. The botanical extract of Artemisia dracunculus L. (PMI 5011) improves insulin action, yet the precise mechanism is unknown. The aim of this study was to determine whether the mechanism by which the bioactive compounds in PMI 5011 improve insulin signaling is through regulation of ceramide metabolism. METHODS: L6 Myotubes were separately preincubated with 250 µM palmitic acid with or without PMI 5011 or four bioactive compounds isolated from PMI 5011 and postulated to be responsible for the effect. The effects on insulin signaling, ceramide, and glucosylceramide profiles were determined. RESULTS: Treatment of L6 myotubes with palmitic acid resulted in increased levels of total ceramides and glucosylceramides, and cell surface expression of gangliosides. Palmitic acid also inhibited insulin-stimulated phosphorylation of protein kinase B/Akt and reduced glycogen accumulation. Bioactives from PMI 5011 had no effect on ceramide formation but one active compound (DMC-2) and its synthetic analog significantly reduced glucosylceramide accumulation and increased insulin sensitivity via restoration of Akt phosphorylation. CONCLUSIONS: The observations suggest that insulin sensitization by PMI 5011 is partly mediated through moderation of glycosphingolipid accumulation.

Lipid in skeletal muscle myotubes is associated to the donors' insulin sensitivity and physical activity phenotypes.

OBJECTIVE: This study investigated the relationship between in vitro lipid content in myotubes and in vivo whole body phenotypes of the donors such as insulin sensitivity, intramyocellular lipids (IMCL), physical activity, and oxidative capacity. DESIGN AND METHODS: Six physically active donors were compared to six sedentary lean and six T2DM. Lipid content was measured in tissues and myotubes by immunohistochemistry. Ceramides, triacylglycerols, and diacylglycerols (DAGs) were measured by LC-MS-MS and GC-FID. Insulin sensitivity was measured by hyperinsulinemic-euglycemic clamp (80 mU min⁻¹ m⁻²), maximal mitochondrial capacity (ATPmax) by ³¹P-MRS, physical fitness by VO2max and physical activity level (PAL) by accelerometers. RESULTS: Myotubes cultured from physically active donors had higher lipid content (0.047 ± 0.003 vs. 0.032 ± 0.001 and 0.033 ± 0.001AU; P < 0.001) than myotubes from lean and T2DM donors. Lipid content in myotubes was not associated with IMCL in muscle tissue but importantly, correlated with in vivo measures of ATPmax (r = 0.74; P < 0.001), insulin sensitivity (r = 0.54; P < 0.05), type-I fibers (r = 0.50; P < 0.05), and PAL (r = 0.92; P < 0.0001). DAGs and ceramides in myotubes were inversely associated with insulin sensitivity (r = -0.55, r = -0.73; P < 0.05) and ATPmax (r = -0.74, r = -0.85; P < 0.01). CONCLUSIONS: These results indicate that cultured human myotubes can be used in mechanistic studies to study the in vitro impact of interventions on phenotypes such as mitochondrial capacity, insulin sensitivity, and physical activity.

HbA1c and lower-extremity amputation risk in low-income patients with diabetes.

OBJECTIVE: Diabetes confers a very high risk of lower-extremity amputation (LEA); however, few studies have assessed whether blood glucose control can reduce LEA risk among patients with diabetes, especially in practice settings where low-income patients predominate. RESEARCH DESIGN AND METHODS: We performed a prospective cohort study (2000-2009) on patients with diabetes that included 19,808 African Americans and 15,560 whites. The cohort was followed though 31 May 2012. Cox proportional hazards regression models were used to estimate the association of HbA1c with LEA risk. RESULTS: During a mean follow-up of 6.83 years, 578 LEA incident cases were identified. The multivariable-adjusted hazard ratios of LEA associated with different levels of HbA1c at baseline (<6.0% [reference group], 6.0-6.9, 7.0-7.9, 8.0-8.9, 9.0-9.9, and ≥10.0%) were 1.00, 1.73 (95% CI 1.07-2.80), 1.65 (0.99-2.77), 1.96 (1.14-3.36), 3.02 (1.81-5.04), and 3.30 (2.10-5.20) (P trend <0.001) for African American patients with diabetes and 1.00, 1.16 (0.66-2.02), 2.28 (1.35-3.85), 2.38 (1.36-4.18), 2.99 (1.71-5.22), and 3.25 (1.98-5.33) (P trend <0.001) for white patients with diabetes, respectively. The graded positive association of HbA1c during follow-up with LEA risk was observed among both African American and white patients with diabetes (all P trend <0.001). With stratification by sex, age, smoking status, blood pressure, LDL cholesterol, BMI, use of glucose-lowering agents, and income, this graded association of HbA1c with LEA was still present. CONCLUSIONS: The current study conducted in a low-income population suggests a graded association between HbA1c and the risk of LEA among both African American and white patients with type 2 diabetes.

The importance of waist circumference and BMI for mortality risk in diabetic adults.

OBJECTIVE: We aimed to determine the associations of waist circumference (WC) and BMI with all-cause mortality among patients with diabetes. RESEARCH DESIGN AND METHODS: The sample included 847 white and 553 African American patients (18-69 years of age) with diabetes. Height, weight, and WC were measured, and the BMI (kg/m2) was calculated. Cox regression was used to analyze the associations of BMI and WC with mortality, adjusting for age, sex, race, examination year, smoking status, alcohol consumption, and physical activity. Hazard ratios (HRs) are expressed per standard deviation of each independent variable. RESULTS: A total of 86 deaths occurred during 6.7 years of follow-up. After adjustment for covariates, WC (HR 1.40 [95% CI 1.14-1.72]) and BMI (1.29 [1.04-1.61]) demonstrated significant relationships with mortality. CONCLUSIONS: The results indicate that maintaining a healthy WC and BMI are both important for individuals living with diabetes.

Modulation of cellular insulin signaling and PTP1B effects by lipid metabolites in skeletal muscle cells.

Normal glucose regulation is achieved by having adequate insulin secretion and effective glucose uptake/disposal. Excess lipids in peripheral tissues - skeletal muscle, liver and adipose tissue - may attenuate insulin signaling through the protein kinase B (AKt) pathway and up-regulate protein tyrosine phosphatase 1B (PTP1B), a negative regulator of insulin signaling. We studied accumulation of lipid metabolites [triglycerides (TAGs), diglycerides (DAGs)] and ceramides in relation to insulin signaling and expression and phosphorylation of PTP1B by preincubating rat skeletal muscle cells (L6 myotubes) with three saturated and three unsaturated free fatty acids (FFAs) (200 µM). Cells were also evaluated in the presence of wortmannin, an inhibitor of phosphatidylinositol 3-kinases and thus AKt (0-100 nM). Unsaturated FFAs increased DAGs, TAGs and PTP1B expression significantly, but cells remained insulin sensitive as assessed by robust AKt and PTP1B phosphorylation at serine (Ser) 50, Ser 398 and tyrosine 152. Saturated palmitic and stearic acids increased ceramides, up-regulated PTP1B, and had AKt and PTP1B phosphorylation at Ser 50 impaired. We show a significant correlation between phosphorylation levels of AKt and of PTP1B at Ser 50 (R(2)=0.84, P<.05). The same was observed with increasing wortmannin dose (R(2)=0.73, P<.05). Only FFAs that increased ceramides caused impairment of AKt and PTP1B phosphorylation at Ser 50. PTP1B overexpression in the presence of excess lipids may not directly cause insulin resistance unless it is accompanied by decreased PTP1B phosphorylation. A clear relationship between PTP1B phosphorylation levels at Ser 50 and its negative effect on insulin signaling is shown.

Adipocyte iron regulates adiponectin and insulin sensitivity.

Iron overload is associated with increased diabetes risk. We therefore investigated the effect of iron on adiponectin, an insulin-sensitizing adipokine that is decreased in diabetic patients. In humans, normal-range serum ferritin levels were inversely associated with adiponectin, independent of inflammation. Ferritin was increased and adiponectin was decreased in type 2 diabetic and in obese diabetic subjects compared with those in equally obese individuals without metabolic syndrome. Mice fed a high-iron diet and cultured adipocytes treated with iron exhibited decreased adiponectin mRNA and protein. We found that iron negatively regulated adiponectin transcription via FOXO1-mediated repression. Further, loss of the adipocyte iron export channel, ferroportin, in mice resulted in adipocyte iron loading, decreased adiponectin, and insulin resistance. Conversely, organismal iron overload and increased adipocyte ferroportin expression because of hemochromatosis are associated with decreased adipocyte iron, increased adiponectin, improved glucose tolerance, and increased insulin sensitivity. Phlebotomy of humans with impaired glucose tolerance and ferritin values in the highest quartile of normal increased adiponectin and improved glucose tolerance. These findings demonstrate a causal role for iron as a risk factor for metabolic syndrome and a role for adipocytes in modulating metabolism through adiponectin in response to iron stores.

Proteomic analysis reveals cellular pathways regulating carbohydrate metabolism that are modulated in primary human skeletal muscle culture due to treatment with bioactives from Artemisia dracunculus L.

Insulin resistance is a major pathophysiologic abnormality that characterizes metabolic syndrome and type 2 diabetes. A well characterized ethanolic extract of Artemisia dracunculus L., termed PMI 5011, has been shown to improve insulin action in vitro and in vivo, but the cellular mechanisms remain elusive. Using differential proteomics, we have studied mechanisms by which PMI 5011 enhances insulin action in primary human skeletal muscle culture obtained by biopsy from obese, insulin-resistant individuals. Using iTRAQ™ labeling and LC-MS/MS, we have identified over 200 differentially regulated proteins due to treatment with PMI 5011 and insulin stimulation. Bioinformatics analyses determined that several metabolic pathways related to glycolysis, glucose transport and cell signaling were highly represented and differentially regulated in the presence of PMI 5011 indicating that this extract affects several pathways modulating carbohydrate metabolism, including translocation of GLUT4 to the plasma membrane. These findings provide a molecular mechanism by which a botanical extract improves insulin stimulated glucose uptake, transport and metabolism at the cellular level resulting in enhanced whole body insulin sensitivity.

Skeletal muscle protein tyrosine phosphatase 1B regulates insulin sensitivity in African Americans.

Protein tyrosine phosphatase 1B (PTP1B) is postulated to modulate insulin action by dephosphorylating the insulin receptor signaling proteins and attenuating insulin signaling. We sought to determine the relationship of skeletal muscle PTP1B to whole-body insulin sensitivity. We studied 17 African Americans with type 2 diabetes mellitus (T2DM) and 16 without diabetes. PTP1B gene expression and protein abundance were determined in the biopsied skeletal muscles at the baseline of a hyperinsulinemic-euglycemic clamp. PTP1B gene expression was significantly higher in subjects with T2DM versus control (P < 0.0001) and remained significantly different after adjusting for age and insulin sensitivity (P = 0.05). PTP1B gene expression was positively related to protein abundance (r(s) = 0.39; P = 0.03; adjusted for age and insulin sensitivity) and negatively related to insulin sensitivity (r(s) = -0.52; P = 0.002; adjusted for age). Overexpression and interference RNA of PTP1B were performed in primary human skeletal muscle culture. PTP1B overexpression resulted in reduction of Akt phosphorylation in the control subjects. Moreover, interference RNA transfection downregulated PTP1B expression and enhanced Akt phosphorylation in subjects with T2DM. These data show that skeletal muscle PTP1B gene expression is increased in African American subjects with T2DM, is negatively associated with whole-body insulin sensitivity, and contributes to modulation of insulin signaling.

Inactivation of the mitochondrial carrier SLC25A25 (ATP-Mg2+/Pi transporter) reduces physical endurance and metabolic efficiency in mice.

An ATP-Mg(2+/)P(i) inner mitochondrial membrane solute transporter (SLC25A25), which is induced during adaptation to cold stress in the skeletal muscle of mice with defective UCP1/brown adipose tissue thermogenesis, has been evaluated for its role in metabolic efficiency. SLC25A25 is thought to control ATP homeostasis by functioning as a Ca(2+)-regulated shuttle of ATP-Mg(2+) and P(i) across the inner mitochondrial membrane. Mice with an inactivated Slc25a25 gene have reduced metabolic efficiency as evidenced by enhanced resistance to diet-induced obesity and impaired exercise performance on a treadmill. Mouse embryo fibroblasts from Slc25a25(-/-) mice have reduced Ca(2+) flux across the endoplasmic reticulum, basal mitochondrial respiration, and ATP content. Although Slc25a25(-/-) mice are metabolically inefficient, the source of the inefficiency is not from a primary function in thermogenesis, because Slc25a25(-/-) mice maintain body temperature upon acute exposure to the cold (4 °C). Rather, the role of SLC25A25 in metabolic efficiency is most likely linked to muscle function as evidenced from the physical endurance test of mutant mice on a treadmill. Consequently, in the absence of SLC25A25 the efficiency of ATP production required for skeletal muscle function is diminished with secondary effects on adiposity. However, in the absence of UCP1-based thermogenesis, induction of Slc25a25 in mice with an intact gene may contribute to an alternative thermogenic pathway for the maintenance of body temperature during cold stress.