Use of once-weekly semaglutide in patients with type 2 diabetes in routine clinical practice: Results from the SURE Canada multicentre, prospective, observational study.

AIM: To investigate once-weekly (OW) semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1RA), in patients with type 2 diabetes (T2D) in routine clinical practice. METHODS: The SURE Canada study was a multicenter, prospective, observational study. Adults with T2D and one or more documented HbA1c values 12 weeks or less before semaglutide initiation were enrolled. The primary endpoint was change in HbA1c from baseline to end of study (EOS; ~30 weeks). Secondary endpoints included change in body weight (BW), waist circumference and patient-reported outcomes (PROs) and the proportion of patients achieving HbA1c of less than 7.0%, weight loss (WL) of 5% or higher, and a composite of HbA1c reduction of 1% or higher and WL of 3% or higher at EOS. Data were analysed and presented for patients on semaglutide at EOS overall and for the following baseline medication subgroups: oral antihyperglycaemic drugs (OADs) only; GLP-1RA experienced; insulin ± OADs without GLP-1RA. RESULTS: In total, 452 patients initiated semaglutide and 356 completed the study on treatment. For the 452 patients, mean baseline HbA1c was 8.1%; 86 (19.0%) patients had HbA1c of less than 7.0%. Mean dose of semaglutide at EOS was 0.76 ± 0.31 mg. Mean HbA1c was reduced by 0.9%-point (95% confidence interval [CI]: 0.97; 0.78). Mean BW was reduced by 4.3 kg (95% CI: 4.79; 3.76). At EOS, 46.9% of patients achieved HbA1c of less than 7.0%, 40.9% achieved WL of 5% or higher and 24.1% achieved the composite endpoint. PROs improved from baseline to EOS. No new safety concerns were reported. CONCLUSIONS: In SURE Canada, patients treated with OW semaglutide in routine clinical practice experienced clinically significant improvements in HbA1c, BW and other outcomes, supporting semaglutide use in routine clinical practice.

No association between frequent apheresis donation and risk of fractures: a retrospective cohort analysis from Sweden.

BACKGROUND: Citrate anticoagulation during apheresis induces transient alterations in calcium homeostasis. It is unknown whether the repeated, transient alterations in calcium homeostasis experienced by repeated apheresis donors affects bone turnover to increase fracture risk. Our aim was to investigate the risk of osteoporotic and nonosteoporotic fracture among voluntary, frequent apheresis donors. STUDY DESIGN AND METHODS: All apheresis donors were identified from the Scandinavian Donations and Transfusions database (SCANDAT2), which includes information on over 1.6 million blood donors from Sweden and Denmark from the years 1968 and 1981, respectively. Only data from Sweden were used for these analyses. Information on fractures was obtained by linking SCANDAT2 to hospital registers. Poisson regression was used to compute incidence rate ratios of fractures in relation to the cumulative number of apheresis donations, both overall and in fixed time windows. RESULTS: In total, 140,289 apheresis donors (67,970 women and 72,319 men) were identified from the SCANDAT2 database and were followed for up to 23 years. We observed no association between the frequency of apheresis donation and the risk of fracture either in the overall study period or during fixed-length time windows. The incidence rate ratio of fractures in donors who had made 100 or more cumulative apheresis donations was 0.99 (95% confidence interval, 0.92-1.06) compared with donors who had made from 9 to 24 donations. The results were similar in analyses stratified by sex and restricted to postmenopausal women. CONCLUSIONS: The absence of an association between repeated apheresis donation and fracture risk indicates that apheresis collection is safe with regard to bone health.

Liver histology is associated with long-term clinical outcomes in patients with metabolic dysfunction-associated steatohepatitis.

BACKGROUND: Few studies have examined the risk of long-term clinical outcomes in patients with metabolic dysfunction-associated steatohepatitis in relation to liver histology. We aimed to study this using a real-world cohort. METHODS: Adults (N = 702) recorded on Vanderbilt University Medical Center's Synthetic Derivative database (1984-2021) with evidence of metabolic dysfunction-associated steatohepatitis on liver biopsy were followed from the first biopsy until the first clinical event or last database entry (median: 4.7 y). Risks of cirrhosis (N = 650), other noncirrhotic liver-related (N = 702) and cardiovascular-related outcomes (N = 660), and mortality due to liver, cardiovascular, or cancer events (N = 660) were determined as a function of baseline histology (fibrosis stage [F], lobular inflammation grade [LI], hepatocyte ballooning grade [HB], and steatosis score) adjusting for sex, age, diabetes, and weight-loss surgery. RESULTS: Cirrhosis risk was reduced for lower versus higher fibrosis stage (HR: F0-1 vs. F3: 0.22 [95% CI: 0.12-0.42]), LI1 versus LI2-3 (0.42 [0.19-0.97]), and HB1 versus HB2 (0.20 [0.08-0.50]). Lower fibrosis stage was associated with significantly lower risks of liver-related outcomes versus F4 cirrhosis (eg, F0-1: 0.12 [0.05-0.25]), whereas no differences were seen across baseline lobular inflammation, hepatocyte ballooning, and steatosis grades/scores. Lower versus higher lobular inflammation grade was associated with lower risks for liver-related outcomes in patients with weight-loss surgery. There was a trend for lower risks for cardiovascular-related and any long-term outcomes with lower versus higher fibrosis stage. CONCLUSIONS: Fibrosis stage and lobular inflammation and hepatocyte ballooning grades predict the risk of long-term outcomes, supporting the use of these histological features as potential surrogate markers of disease progression or clinical outcomes.

Hospitalisation for infection prior to diagnosis of acute lymphoblastic leukaemia in children.

BACKGROUND: It has been proposed that infections in infancy and early childhood are associated with a reduced risk of childhood acute lymphoblastic leukaemia (ALL). We tested this hypothesis in a register-based study of hospitalisations for infectious diseases prior to diagnosis of childhood ALL. PROCEDURE: A nation-wide cohort encompassing all Danish children aged 0-14 years and born between 1977 and 2008 (N = 1,778,129) was established and followed for hospitalisations for infectious diseases and risk of childhood ALL. The exposure was lagged 1 year to limit reverse causality. In the statistical analyses exposure was defined as (time dependent) number of early or late (before 2 or at/after 2 years of age) hospitalisations to further explore possible age-dependent associations. RESULTS: A total of 815 children were diagnosed with ALL during follow-up. Risk of ALL was associated neither with hospitalisations for infectious diseases before (incidence rate ratio = 0.92, 95% confidence interval 0.78-1.07) nor at/after 2 years of age (incidence rate ratio = 1.04, 95% confidence interval 0.81-1.32). This also applied to subsets of ALL supposedly initiated prenatally. CONCLUSION: The absence of association between hospitalisation for infections and risk of childhood ALL directs future investigations of the role of infections in development of childhood ALL towards exploration of less severe infections.

A genetic risk factor for low serum ferritin levels in Danish blood donors.

BACKGROUND: Iron deficiency is a frequent side effect of blood donation. In recent years, several studies have described genetic variants associated with iron concentrations. However, the impact of these variants on iron levels is unknown in blood donors. Knowledge of genetic variants that predispose donors to iron deficiency would allow bleeding frequency and iron supplementation to be tailored to the individual donor. STUDY DESIGN AND METHODS: The genotypes of five specific single-nucleotide polymorphisms (SNPs) in three genes that have been previously associated with iron status and/or restless leg syndrome (RLS) were investigated in two groups of female blood donors. The first group had low iron stores (serum ferritin ≤ 12 µg/L, n = 657), and the second group had normal to high iron stores (serum ferritin > 30 µg/L, n = 645). Genotype distribution for each of the SNPs was compared between the two groups. RESULTS: Homozygosity for the T-allele of BTBD9 rs9296249 was associated with lower serum ferritin. The odds ratio for low serum ferritin was 1.35 (95% confidence interval, 1.02-1.77; p = 0.03) when comparing donors with the TT genotype with donors with the CT genotype. CONCLUSION: A frequent polymorphism in BTBD9 was significantly associated with serum ferritin. This polymorphism has previously been associated with RLS, but not low iron stores in blood donors.

Long-term follow-up among Danish transfusion recipients identified in the national hepatitis C lookback.

BACKGROUND: In 1996, a national lookback study was performed in Denmark identifying 1018 patients exposed to hepatitis C virus (HCV) by transfusion before 1991. The objective of this study was to describe morbidity and mortality during extended follow-up among patients in the Danish HCV lookback cohort alive in 1996. STUDY DESIGN AND METHODS: In a retrospective cohort study of 230 patients exposed to HCV by blood transfusion and alive in 1996 we extracted data from national registers and compared these with a matched group of unexposed transfusion recipients. RESULTS: Among 230 HCV-exposed recipients alive in 1996, 124 (53.9%) had chronic hepatitis C, 43 (18.7%) were not infected, and 63 (27.4%) had incomplete HCV data. In 2009, 121 (52.6%) were still alive a median of 21.8 years after transfusion. The mortality rate among the HCV-exposed recipients followed from 1996 was 4.9 per 100 person-years (PY). The incidence of liver cirrhosis and decompensated cirrhosis was 1.0 per 100 PY and 0.4 per 100 PY, respectively; 16.5% had cirrhosis at death. Among HCV-exposed recipients, no difference in all-cause or liver-related mortality was observed between HCV-infected and HCV-uninfected recipients. Further, there was no difference in mortality between HCV-exposed and -unexposed transfusion recipients (mortality rate ratio [MRR], 1.06; 95% confidence interval [CI], 0.96-1.17; p = 0.47), but liver-related mortality was significantly higher among HCV-exposed patients (MRR, 10.0; 95% CI, 7.20-17.7; p < 0.001). CONCLUSION: Two decades after exposure to blood products from HCV-infected donors, only 121(11.8%) of 1018 recipients remained alive. For HCV-exposed recipients no excess all-cause mortality was observed, but liver-related mortality was significantly increased.

Overall glycaemic index and glycaemic load of habitual diet and risk of heart disease.

OBJECTIVE: To test the hypothesis that diets with high glycaemic index (GI) and glycaemic load (GL) increase the risk of heart disease. DESIGN: Overall GI and GL were assessed from 7 d diet records or diet history interviews. SETTING: Information on hospitalization and death due to CVD and CHD was obtained from the National Register of Cause of Death and the National Register of Patients. SUBJECTS: In total 3959 adult Danes were - depending on time of entry - followed for 6-25 years until 31 December 1999. RESULTS: Overall GI was inversely associated with heart disease in men. The hazard ratios (95 % CI) for the 10th and 90th GI percentiles compared with the median were 1.38 (1.13, 1.68) and 0.90 (0.76, 1.07) for CVD morbidity, 1.45 (1.05, 1.99) and 0.81 (0.62, 1.06) for CVD mortality, and 1.31 (0.97, 1.76) and 0.65 (0.51, 0.84) for CHD morbidity. In male subjects GL was not associated with either outcome. In women no clear association between overall GI and heart disease was found, whereas positive non-linear associations were found for GL: at very high levels of GL, increase in GL was associated with increasing CVD and CHD morbidity. CONCLUSIONS: In men low-GI diets were associated increased risk of heart disease and GL was not associated with heart disease. In women there was no clear association between GI and heart disease, but to some extent a positive association between GL and heart disease was observed as hypothesized.

Real-world use of once-weekly semaglutide in patients with type 2 diabetes: Results from the SURE Switzerland multicentre, prospective, observational study.

AIMS: SURE Switzerland (NCT03631186) investigated real-world once-weekly (OW) semaglutide use in adults with type 2 diabetes (T2D). METHODS: This multicentre, prospective, observational study enrolled adults with T2D with ≥ 1 documented HbA1c value ≤ 12 weeks before semaglutide initiation. Primary endpoint was change in HbA1c from baseline to end of study (EOS; ~30 weeks). Secondary endpoints included changes in body weight (BW) and waist circumference (WC), and the proportion of patients achieving HbA1c < 8.0%, <7.5% and <7.0% at EOS. Semaglutide dose at EOS was a prespecified exploratory endpoint. RESULTS: Overall, 214 patients initiated semaglutide (baseline HbA1c 7.8% [62 mmol/mol], BW 99.9 kg and WC 117.4 cm); 187 attended the EOS visit. At EOS, 175 (81.8%) were still receiving semaglutide (mean [SD] dose 0.78 [0.29] mg); in those patients, mean HbA1c reduced by -0.8 [95% CI - 1.01;-0.68] %-points (-9 [-11;-7] mmol/mol), BW by -5.0 kg [-5.73;-4.24] and WC by -4.8 cm [-5.75;-3.79] (all p < 0.0001). At EOS, 85.9%, 76.5% and 55.9% patients achieved, respectively, HbA1c < 8.0%, <7.5% and < 7.0%. No new safety signals were identified. CONCLUSIONS: Patients with T2D in Switzerland initiating OW semaglutide experienced clinically relevant glycaemic control and BW improvements in a real-world setting, supporting semaglutide use in routine clinical practice.

Real-world use of once-weekly semaglutide in patients with type 2 diabetes: Results from the SURE Denmark/Sweden multicentre, prospective, observational study.

AIMS: As part of the SURE programme, SURE Denmark/Sweden aimed to study the real-world use of once-weekly (OW) semaglutide in adults with type 2 diabetes (T2D) in Denmark/Sweden. METHODS: SURE Denmark/Sweden was an ∼30-week, prospective, multicentre, open-label, observational study, enrolling adults with T2D and ≥1 documented HbA1c value ≤12 weeks before initiating semaglutide at their physician's discretion. Primary (change in HbA1c) and secondary (including change in body weight, glycaemic and weight-loss target achievement) endpoints were assessed between baseline and end of study (EOS). RESULTS: Of the 331 patients initiating semaglutide, 282 (85%) completed the study on treatment. For the latter, estimated mean changes [95% confidence interval] in HbA1c and body weight between baseline and EOS were -1.2 [-1.3; -1.1]%-points (-13 [-14; -12] mmol/mol) and -5.4 [-6.0; -4.7] kg (both p < 0.0001), respectively, with similar results in Denmark and Sweden. At EOS, 67.5% of patients achieved HbA1c <7%; 49.4% achieved a weight reduction of ≥5%. Reported adverse events were consistent with the known safety profile of semaglutide. CONCLUSIONS: In routine clinical practice in Denmark/Sweden, use of OW semaglutide was associated with glycaemic and weight-loss benefits in a wide range of adults with T2D, supporting real-world use. CLINICALTRIALS. GOV IDENTIFIER: NCT03648281.

Soluble urokinase plasminogen activator receptor as a marker for use of antidepressants.

OBJECTIVES: Inflammation is involved in the pathogenesis of depression. A few cross-sectional population-based studies have found that depression is associated with increased levels of inflammatory markers. Soluble urokinase plasminogen activation receptor (suPAR) is known to be a stable marker for inflammation. We investigated the bidirectional association between suPAR levels and use of antidepressants. METHODS: suPAR level was measured in 9305 blood donors and analysed in relation to 5-years follow-up data on purchase of antidepressants and hospital diagnoses of depression from a nationwide Danish register. RESULTS: For men and women without prior use of antidepressants we found a significantly higher risk for incident use of antidepressants with higher suPAR values. For men, the risk of first use of antidepressants increased by 72% from the 1st to the 4th quartile (HR = 1.72, 95% CI: 1.11-2.69). For women, it increased by 108% from the 1st to the 4th quartile (HR = 2.08, 95% CI: 1.45-2.98). Previous use of antidepressants was also significantly associated with higher suPAR levels (p = 0.002). CONCLUSIONS: High suPAR levels are associated with an increased risk for both previous and future use of antidepressants in healthy men and women. High suPAR are also associated with increased risk for a hospital diagnosis of depression.

Clinical correlates of weight loss and attrition during a 10-week dietary intervention study: results from the NUGENOB project.

OBJECTIVE: The aim of this study was to identify the pre-treatment subject characteristics and weight loss changes as determinants of weight loss and attrition during a 10-week dietary intervention study. METHODS: A total of 771 obese subjects (BMI 35.6 kg/m(2)) of both genders were included from 8 clinical centres in 7 European countries, who underwent a 10-week dietary intervention study comparing two hypo-energetic (-600 kcal/day) diets varying in fat content. RESULTS: The multiple regression model showed that weight loss at week 10 was predicted by: 6.55 + 1.27 × early weight loss (kg) at week 1 + 1.35 × gender (R(2) = 0.28, p < 0.001). When performing the corresponding model with half-way weight loss (week 5) as covariate, the regression equation was: weight loss (kg) at week 10 = 1.88 + 1.38 × half-way weight loss (kg) (week 5) + 0.42 × gender (R(2) = 0.77, p < 0.001). A cut-off target of ≥ 4 kg weight loss at week 5 emerged as an optimal predictor for reaching at least 10% weight loss at week 10. Greater attrition likelihood was predicted by high-fat diet, decreased early and half-way weight losses. CONCLUSION: Early and half-way weight losses are associated with and could contribute to prediction of the final weight loss and attrition.

SDCCAG8 obesity alleles and reduced weight loss after a lifestyle intervention in overweight children and adolescents.

Genome-wide association analyses (GWAS) contributed to the detection of a number of single-nucleotide polymorphisms (SNPs) associated with obesity. However, little is known about the impact of the obesity-risk alleles on weight loss-related phenotypes after lifestyle interventions. A recent meta-analysis of GWAS reported five genomic loci near or in the genes FTO, MC4R, TMEM18, SDCCAG8, TNKS/MSRA that were associated with obesity in children and adolescents. Here, we analyzed the effect of the 10 SNPs representative of the five loci on measures of weight loss and cardiometabolic risk after a 1-year lifestyle intervention in 401 children and adolescents (mean age 10.74 years; 55.4% female; mean BMI 27.42 kg/m(2), mean BMI-standard deviation score (SDS) 2.37). For confirmation of one locus genotyping of three intronic SNPs in SDCCAG8 was performed in 626 obese adults who completed the 10-week hypoenergetic diet program. Intronic variants of SDCCAG8, which are associated with early onset obesity, are associated with reduced weight loss after a 1-year lifestyle intervention in overweight children and adolescents even after adjusting for age, sex, baseline measurement, or multiple testing (all P < 10(-6)). However, our results could not be confirmed in 626 obese adults undertaking a hypoenergetic diet intervention.

Allelic variants of melanocortin 3 receptor gene (MC3R) and weight loss in obesity: a randomised trial of hypo-energetic high- versus low-fat diets.

INTRODUCTION: The melanocortin system plays an important role in energy homeostasis. Mice genetically deficient in the melanocortin-3 receptor gene have a normal body weight with increased body fat, mild hypophagia compared to wild-type mice. In humans, Thr6Lys and Val81Ile variants of the melanocortin-3 receptor gene (MC3R) have been associated with childhood obesity, higher BMI Z-score and elevated body fat percentage compared to non-carriers. The aim of this study is to assess the association in adults between allelic variants of MC3R with weight loss induced by energy-restricted diets. SUBJECTS AND METHODS: This research is based on the NUGENOB study, a trial conducted to assess weight loss during a 10-week dietary intervention involving two different hypo-energetic (high-fat and low-fat) diets. A total of 760 obese patients were genotyped for 10 single nucleotide polymorphisms covering the single exon of MC3R gene and its flanking regions, including the missense variants Thr6Lys and Val81Ile. Linear mixed models and haplotype-based analysis were carried out to assess the potential association between genetic polymorphisms and differential weight loss, fat mass loss, waist change and resting energy expenditure changes. RESULTS: No differences in drop-out rate were found by MC3R genotypes. The rs6014646 polymorphism was significantly associated with weight loss using co-dominant (p = 0.04) and dominant models (p = 0.03). These p-values were not statistically significant after strict control for multiple testing. Haplotype-based multivariate analysis using permutations showed that rs3827103-rs1543873 (p = 0.06), rs6014646-rs6024730 (p = 0.05) and rs3746619-rs3827103 (p = 0.10) displayed near-statistical significant results in relation to weight loss. No other significant associations or gene*diet interactions were detected for weight loss, fat mass loss, waist change and resting energy expenditure changes. CONCLUSION: The study provided overall sufficient evidence to support that there is no major effect of genetic variants of MC3R and differential weight loss after a 10-week dietary intervention with hypo-energetic diets in obese Europeans.

TCF7L2 rs7903146-macronutrient interaction in obese individuals' responses to a 10-wk randomized hypoenergetic diet.

BACKGROUND: Transcription factor 7-like 2 (TCF7L2) rs7903146 associates with type 2 diabetes and may operate via impaired glucagon-like peptide 1 secretion, which is stimulated more by fat than by carbohydrate ingestion. OBJECTIVE: The objective was to examine the interaction between TCF7L2 rs7903146 and dietary fat and carbohydrate [high-fat, low-carbohydrate: 40-45% of energy as fat (HF); compared with low-fat, high-carbohydrate: 20-25% of energy as fat (LF)] in obese individuals' responses to a 10-wk hypoenergetic diet (-600 kcal/d). DESIGN: European, obese participants (n = 771) were randomly assigned to receive an HF or an LF diet. Body weight, fat mass (FM), fat-free mass (FFM), waist circumference (WC), resting energy expenditure (REE), fasting fat oxidation in percentage of REE (FatOx), homeostasis model assessed insulin release (HOMA-beta), and HOMA-insulin resistance (HOMA-IR) were determined at baseline and after the intervention; 739 individuals were genotyped for rs7903146. RESULTS: Average weight loss was 6.9 kg with the LF and 6.6 kg with the HF (difference between diets, NS) diet. Among individuals who were homozygous for the T-risk allele, those in the HF diet group experienced smaller weight losses (Deltaweight) (2.6 kg; P = 0.009; n = 622), smaller DeltaFFM (1.6 kg; P = 0.027; n = 609), smaller DeltaWC (3.3 cm; P = 0.010; n = 608), and a smaller DeltaHOMA-IR (1.3 units; P = 0.004; n = 615) than did the LF diet group. For C allele carriers, there were no differences between the HF and LF diet groups. For the HF diet group, each additional T allele was associated with a reduced loss of FM (0.67 kg; P = 0.019; n = 609). TCF7L2 rs7903146 was not associated with DeltaREE, DeltaFatOx, DeltaHOMA-beta, or dropout. CONCLUSION: Our results suggest that obese individuals who are homozygous for the TCF7L2 rs7903146 T-risk allele are more sensitive to LF than to HF weight-loss diets.

Should glycemic index and glycemic load be considered in dietary recommendations?

High glycemic index (GI) and glycemic load (GL) have been proposed to be associated with increased risk of lifestyle diseases. Since protein intake varies little in humans, adherence to the common recommendation to reduce fat intake probably leads to increases in carbohydrate intake, which emphasizes the need to investigate the effects of carbohydrate on diet-related conditions and diseases. This review examines the epidemiological literature linking GI and GL to heart disease, insulin sensitivity, type 2 diabetes, dyslipidemia, and obesity among initially healthy people. The evidence for associations between GI and particularly GL and health among free-living populations is mixed. Only the positive association between GI and development of type 2 diabetes was consistent across cross-sectional and longitudinal studies for both sexes. Low GI/GL may protect against heart disease in women, and cross-sectional studies indicate low GI/GL may reduce high-density-lipoprotein cholesterol and triacylglycerol levels in both sexes. Based on the evidence found in this review, it seems premature to include GI/GL in dietary recommendations.

Effects of TCF7L2 polymorphisms on obesity in European populations.

The transcription factor 7-like 2 (TCF7L2) rs7903146 T allele was previously associated with type 2 diabetes (T2D) and decreased BMI whereas haplotypes carrying the rs7903146 C and rs10885406 A alleles (HapA) were associated with increased BMI. The functional relevance of TCF7L2 polymorphisms and their effects on T2D and obesity remained to be further investigated. In white European populations, we found that the rs7903146 T allele was more associated with T2D in 3,547 non-obese individuals (odds ratio (OR) = 1.88 (1.69-2.10)) than in 1,110 class III obese subjects (OR = 1.24 (1.03-1.50)). No direct effect of the rs7903146 C allele and HapA was found on any form of obesity in 3,507 normal glucose tolerant (NGT) individuals, 1,106 pedigrees with familial obesity and 5,512 individuals from the French general population. However, in T2D subjects, the rs7903146 C allele was less prevalent in the 1,111 non-obese individuals (55.2%) compared to 659 class III obese subjects (67.5% OR = 1.69 (1.46-1.95)). Functional studies showed that the rs7903146 T allele is less prone to be bound by protein factors than the C allele in 3T3-L1, HepG2 and beta-TC3 cell lines and that TCF7L2 expression decreases in subcutaneous adipose tissue from NGT obese T/T carriers under calorie restriction. In conclusion, TCF7L2 is not a risk factor for obesity in European populations, but its effect on T2D risk is modulated by obesity. Furthermore, our data suggest that the rs7903146 T allele may be possibly functional and associated with a nominal decrease in TCF7L2 expression in adipose tissue of individuals under calorie restriction.