Association between mindfulness and interoceptive accuracy in patients with diabetes: Preliminary evidence from blood glucose estimates.

OBJECTIVE: Mindfulness-based interventions, which increase dispositional mindfulness, may be useful adjunctive therapies for patients with chronic diseases, including diabetes. One way that mindfulness may benefit patients with diabetes is by fostering more accurate interoception, particularly in the form of blood glucose estimate accuracy. Many people with diabetes regulate their behavior based on estimates of their blood glucose levels from interoception, but they vary in estimate accuracy. Therefore, our objective was to conduct a preliminary test of the hypothesis that, in a sample of patients with diabetes, more mindful individuals would demonstrate greater blood glucose estimate accuracy. METHODS: In a cross-sectional study, patients (N=28) with type 2 diabetes estimated their blood glucose levels immediately before their actual levels were assessed. Participants also completed two measures of mindfulness: one assessing general dispositional mindfulness and another assessing mindfulness specifically in the face of difficulty. RESULTS: Although general dispositional mindfulness was unrelated to blood glucose estimate accuracy, individuals who reported more mindfulness during difficulties were approximately four times more likely to meet established accuracy criteria. CONCLUSIONS: Mindfulness specifically during difficulties might play a role in disease-relevant interoception for patients with diabetes. Future research should aim to replicate this finding in larger and different samples, and to examine the potential role of mindfulness during difficulties in mindfulness-based interventions for patients with diabetes.

Impact of HbA1c measurement on hospital readmission rates: analysis of 70,000 clinical database patient records.

Management of hyperglycemia in hospitalized patients has a significant bearing on outcome, in terms of both morbidity and mortality. However, there are few national assessments of diabetes care during hospitalization which could serve as a baseline for change. This analysis of a large clinical database (74 million unique encounters corresponding to 17 million unique patients) was undertaken to provide such an assessment and to find future directions which might lead to improvements in patient safety. Almost 70,000 inpatient diabetes encounters were identified with sufficient detail for analysis. Multivariable logistic regression was used to fit the relationship between the measurement of HbA1c and early readmission while controlling for covariates such as demographics, severity and type of the disease, and type of admission. Results show that the measurement of HbA1c was performed infrequently (18.4%) in the inpatient setting. The statistical model suggests that the relationship between the probability of readmission and the HbA1c measurement depends on the primary diagnosis. The data suggest further that the greater attention to diabetes reflected in HbA1c determination may improve patient outcomes and lower cost of inpatient care.

Total and high-molecular weight adiponectin in women with the polycystic ovary syndrome.

Adiponectin, an adipokine with antidiabetic properties, forms multimers; and the high-molecular weight (HMW) form most closely correlates with insulin sensitivity (S(i)). Therefore, we hypothesize that HMW adiponectin levels are decreased in women with polycystic ovary syndrome (PCOS), a condition characterized by insulin resistance, compared with healthy controls and that HMW adiponectin correlates with testosterone and S(i). A cross-sectional study involving 13 women with PCOS and 13 age- and body mass index-matched healthy controls was performed. Waist-to-hip ratios (WHRs), glucose, insulin, sex hormone-binding globulin, total testosterone, and total and HMW adiponectin levels were measured after an overnight fast. Free testosterone was calculated from sex hormone-binding globulin and total testosterone, and S(i) was determined using a frequently sampled intravenous glucose tolerance test. The study's primary outcomes were differences in total and HMW adiponectin between women with PCOS and healthy control women. Total adiponectin (P < .01), HMW adiponectin (P < .01), and the ratio of HMW to total adiponectin (P = .03) were lower in women with PCOS compared with healthy women. Total and HMW adiponectin levels correlated inversely with WHR (P < .01) and free testosterone (P < .01) and positively with S(i) (P < .001). Using forward stepwise multivariate analysis, HMW adiponectin and WHR, but not PCOS status, were independent predictors of S(i). Women with PCOS have lower total and HMW adiponectin levels compared with healthy women. High-molecular weight adiponectin also comprises a smaller proportion of total circulating adiponectin in women with PCOS. Alterations in HMW adiponectin levels in women with PCOS may contribute to the insulin resistance intrinsic to the syndrome.

Relationship between alcohol use disorders, cortisol concentrations, and cytokine levels in patients with sepsis.

INTRODUCTION: Patients with alcohol use disorders (AUD) are at increased risk of developing sepsis and have higher mortality. AUD are associated with higher cortisol and anti-inflammatory cytokine profile. Higher cortisol increases risk of death in septic patients. The relationship between AUD and cortisol in septic patients is unknown. We aimed to study this relationship and postulated that AUD would be associated with higher cortisol and anti-inflammatory cytokine profile. METHODS: This was a prospective cohort study of 40 medical intensive care unit (ICU) patients admitted with sepsis. Cortisol, anti-inflammatory interleukin (IL) 10, and pro-inflammatory IL1ß, IL6, tumor necrosis factor (TNF) α were measured. RESULTS: Thirteen (32%) out of 40 patients had AUD. AUD patients had higher cortisol by univariate (39 microg/dl versus 24, P = 0.04) and multivariable analyses (44 microg/dl versus 23, P = 0.004). By univariate analyses, AUD patients had higher IL10 (198 picog/dl versus 47, P = 0.02) and IL6 (527 picog/ml versus 156, P = 0.048), but similar IL1ß and TNFα. By multivariable analyses, AUD patients had higher IL10 (182 picog/dl versus 23, P = 0.049) but similar IL1ß, IL6, and TNFα. AUD patients had lower IL1ß/IL10 (univariate 0.01 versus 0.10, P = 0.04; multivariable 0.01 versus 0.03, P = 0.04), lower TNFα/IL10 (univariate 0.15 versus 0.52, P = 0.03; multivariable 0.11 versus 0.63, P = 0.01), but similar IL6/IL10. CONCLUSIONS: AUD are common diagnoses among medical ICU patients with sepsis. Patients with AUD have higher cortisol concentrations and have differences in cytokine expression. Future studies should seek to determine if these differences may explain the higher severity of illness seen in patients with sepsis and AUD. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00615862.

Health information seeking, receipt, and use in diabetes self-management.

PURPOSE: Diabetes self-management is essential for diabetes control, yet little is known about patient preferences for sources of health information or about the extent to which information is sought directly or received passively through various media sources. The aim of this qualitative study was to identify how individuals with diabetes seek and use health care information. METHODS: Using a health information model to guide our research, we conducted 9 focus groups with 46 adults with a diagnosis of diabetes and then analyzed the transcripts and notes from these focus groups. RESULTS: Five themes emerged: (1) passive receipt of health information about diabetes is an important aspect of health information behavior; (2) patients weave their own information web depending on their disease trajectory; (3) patients' personal relationships help them understand and use this information; (4) a relationship with a health care professional is needed to cope with complicated and sometimes conflicting information; and (5) health literacy makes a difference in patients' ability to understand and use information. CONCLUSIONS: Patients make decisions about diabetes self-management depending on their current needs, seeking and incorporating diverse information sources not traditionally viewed as providing health information. Based on our findings, we have developed a new health information model that reflects both the nonlinear nature of health information-seeking behavior and the interplay of both active information seeking and passive receipt of information.

Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass.

BACKGROUND: Data on the durability of remission of type 2 diabetes mellitus (T2DM) after gastric bypass are limited. Our purpose was to identify the rate of long-term remission of T2DM and the factors associated with durable remission. METHODS: A total of 177 patients with T2DM who had undergone Roux-en-Y gastric bypass from 1993 to 2003 had 5-year follow-up data available. T2DM status was determined by interview and evaluation of the diabetic medications. Patients with complete remission or recurrence of T2DM were identified. RESULTS: Follow-up ranged from 5 to 16 years. Of the 177 patients, 157 (89%) had complete remission of T2DM with a decrease in their mean body mass index from baseline (50.2 +/- 8.2 kg/m(2)) to 31.3 +/- 7.2 kg/m(2) postoperatively (mean percentage of excess weight loss 70.0% +/- 18.6%). However, 20 patients (11.3%) did not have T2DM remission despite a mean percentage of excess weight loss of 58.2% +/- 12.3% (P <.0009). Of the 157 patients with initial remission of their T2DM, 68 (43%) subsequently developed T2DM recurrence. Remission of T2DM was durable in 56.9%. Durable (>5-year) resolution of T2DM was greatest in the patients who originally had either controlled their T2DM with diet (76%) or oral hypoglycemic agents (66%). The rate of T2DM remission was more likely to be durable in men (P = .00381). Weight regain was a statistically significant, but weak predictor, of T2DM recurrence. CONCLUSION: Early remission of T2DM occurred in 89% of patients after Roux-en-Y gastric bypass. T2DM recurred in 43.1%. Durable remission correlated most closely with an early disease stage at gastric bypass.

Glucocorticoid-induced hyperglycemia.

OBJECTIVE: To review the current literature on glucocorticoid-induced hyperglycemia and provide a strategy for its treatment. METHODS: We undertook an electronic (MEDLINE) and a library review of the existing pertinent literature published from 1950 to March 2009. RESULTS: Glucocorticoid-induced hyperglycemia is common in patients with and without diabetes. The odds ratio for new-onset diabetes mellitus in patients treated with glucocorticoids ranges from approximately 1.5 to 2.5. Total glucocorticoid dose and duration of therapy are strong predictors of diabetes induction. Other risk factors include age and body mass index. Failure to treat glucocorticoid-induced hyperglycemia is related to the presumed short duration of administration of glucocorticoid treatment and the emphasis on fasting plasma glucose only. Understanding the pharmacodynamics of glucocorticoids can lead to increased recognition and improved treatment of the condition. Recent demonstrations that even shortterm elevations in blood glucose level may be associated with adverse sequelae argue for greater attention to the condition. CONCLUSION: Glucocorticoid-induced hyperglycemia is an important clinical finding that, if recognized, can be effectively treated. We propose a relatively simple schema for the proactive management of corticosteroid-induced hyperglycemia that has been effective and easily adaptable to both the inpatient and the outpatient setting.

Prevalence of the metabolic syndrome among obese adolescents enrolled in a multidisciplinary weight management program: clinical correlates and response to treatment.

OBJECTIVE: The aim of this study was to determine the prevalence of the metabolic syndrome at baseline and after 6 months of lifestyle modification among obese adolescents referred to a multidisciplinary weight management program. METHODS: A total of 165 obese adolescents were evaluated at baseline, and measurements were repeated in 57 subjects who completed 6 months of the program. Metabolic syndrome was defined as having three or more of the following: a body mass index (BMI) >97(th) percentile, hypertension, low high-density lipoprotein cholesterol (HDL-C), hypertriglyceridemia, and impaired fasting glucose (IFG). RESULTS: The prevalence of a BMI >97(th) percentile, hypertension, hypertriglyceridemia, low HDL-C, and IFG was 92.7, 54.5, 29.1, 26.7, and 2.4%, respectively. The prevalence of the metabolic syndrome at baseline was 30.3%. After 6 months of lifestyle modification, BMI z scores, percent body fat, total cholesterol, and low-density lipoprotein cholesterol (LDL-C) decreased significantly from baseline; however, there was no significant change in the number of subjects demonstrating >or=three criteria of the metabolic syndrome. CONCLUSIONS: Approximately one third of the study subjects met the criteria of the metabolic syndrome, emphasizing the growing concern for the future development of premature cardiovascular disease in this high-risk population. Our data suggest that new strategies for lifestyle modification may be needed to improve cardiovascular risk factors significantly among adolescents with obesity.

Glucose uptake after resistance training of different intensities but of equal work volume.

High-intensity (HI) resistance exercise augments postexercise glucose uptake to a greater degree than low-intensity (LO) resistance exercise; however, few studies have equated the work volumes between intensity levels. The purpose of this study was to compare the effect of acute HI and LO resistance exercise of equal work volume on glucose uptake in resistant-trained men. Fifteen healthy male (22.9 +/- 3.8 years old), resistance-trained (6.7 +/- 3.9 years) subjects completed three treatment sessions: CON (no-exercise control), HI (3 x 8, 85% 10-RM), and LO (3 x 15, 45% 10-RM). HI and LO sessions consisted of eight exercises. Glucose uptake was measured the following morning by using the hyperinsulinemic euglycemic clamp technique. Glucose disposal was measured by analyzing the glucose infusion rate during the final 30 minutes of steady-state blood glucose concentrations. Insulin sensitivity was calculated by dividing the glucose infusion rate by the average insulin infusion. Results indicate that fasting blood glucose levels were not significantly different among treatment sessions (CON = 80.5 +/- 5.3 versus HI = 77.0 +/- 4.9 versus LO = 77.1 +/- 6.0 mg.dL). Glucose uptake was not significantly different among treatment sessions (CON = 11.3 +/- 3.0 versus HI = 11.7 +/- 2.7 versus LO = 11.4 +/- 2.8 mg.kg FFM.min). Insulin sensitivity did not change among treatment sessions (CON = 0.26 +/- 0.09 versus HI = 0.28 +/- 0.07 versus LO = 0.27 +/- 0.06 (mg.kg FFM.min)/(uU.mL)). The data indicate that the resistance training sessions did not modify acute insulin sensitivity. This may have been because of the high levels of fitness of the subjects, which allowed for the cellular adaptations for enhanced insulin sensitivity and glucose uptake that are unaffected by this volume of acute exercise.

Aerobic exercise alters postprandial lipemia in African American versus White women.

PURPOSE: To determine whether ethnicity influences postprandial lipemia after a bout of aerobic exercise. METHODS: Randomized crossover design. Healthy White (W; n=6) and African American (AA; n=6) women (age, W 27.0+/-3.3 yr, AA 21.6+/-1.4 yr; body-mass index, W 25.0+/-0.93 kg/m2, AA 25.8+/-0.79 kg/m2) participated in 2 treatments (control and exercise), each conducted over 2 d. On d 1, participants rested (control) or walked at 60% of maximal oxygen uptake for 90 min (exercise) and then consumed a meal. On d 2, after a 12-hr overnight fast, participants consumed an oral fat-tolerance test (OFTT) meal of 1.7 g fat, 1.65 g carbohydrate, and 0.25 g protein per kg fat-free mass. Blood was collected pre-meal and at 0.5, 1, 2, 3, 4, 5, and 6 hr post-OFTT and analyzed for triacylglycerol (TAG), glucose, and insulin. Areas under the curve (AUCs) were calculated for each blood variable. RESULTS: A significantly lower TAG AUC was observed for AA (0.86+/-0.24 mmol x L(-1) x 6 hr(-1)) after exercise than for W (2.25+/- .50 mmol x L(-1) x 6 hr(-1)). Insulin AUC was significantly higher for AA after exercise (366.2+/-19.9 mmol x L(-1) x 6 hr(-1)) than for the control (248.1+/-29.2 mmol x L(-1) x 6 hr(-1)). CONCLUSIONS: The data indicate that exercise performed approximately 13 hr before an OFTT significantly reduces postprandial lipemia in AA compared with W. It appears that AA women have an increased ability to dispose of TAG after exercise and a high-fat meal.

Which basal insulin should be used in patients with type 2 diabetes mellitus?

The initiation of insulin therapy is a significant event for patients with diabetes and the physicians who care for them. Reluctance to begin insulin is multifactorial, with major stumbling blocks being the perceived complexity of insulin and fear of hypoglycemia. Recent guidelines supporting earlier introduction of insulin to achieve glycemic goals in patients with type 2 diabetes mellitus will require that traditional approaches to insulin therapy be altered and a new paradigm be introduced into clinical practice. In particular, an understanding of the role of basal insulin in the regulation of glucose and the development of strategies to implement basal insulin therapy can provide a transition that is rational and highly effective in most patients. The strategy also offers a unique approach to diabetes education that permits a focused and patient-specific correction to glucose abnormalities.

Resistance exercise and postprandial lipemia: The dose effect of differing volumes of acute resistance exercise bouts.

INTRODUCTION: Resistance exercise has been shown to reduce postprandial lipemia, but no dose-response effect has been established. PURPOSE: The purpose of this study was to determine whether prior resistance exercise exhibited a dose-response effect on postprandial lipemia, while controlling for energy balance. METHODS: Subjects were healthy resistance-trained men (n = 4) and women (n = 6) aged 23.4 +/- 2.5 years. Subjects participated in 4 different treatment conditions consisting of control (no exercise), 1 set, 3 sets, and 5 sets of 8 resistance exercises in a repeated-measures design. On day 1, each exercise was performed at 75% of the subject's 1-repetition maximum for 10 repetitions. This was followed by consumption of a postexercise meal equal in caloric volume designed to maintain energy balance. On day 2, after a 12-hour overnight fast (approximately 13 hours postexercise) in the General Clinical Research Center, subjects consumed a high-fat meal consisting of 1.7 g fat, 1.65 g carbohydrate, 0.25 g-protein per kilogram of fat-free mass and equal to 95 kJ of energy per kilogram of fat-free mass. Blood collections occurred before meal, and at 0.5, 1, 2, 3, 4, 5, and 6 hours after meal consumption and were analyzed for triacylglycerol (TAG), glucose, and insulin concentrations. The lipemic response was evaluated as the area under curve (AUC) for TAG versus time. Glucose and insulin AUCs were also calculated. RESULTS: No significant differences were observed among treatments for postprandial lipemia (mmol/L per 6 hours) as measured by the TAG AUC (control 2.96 +/- 0.79, 1 set 2.52 +/- 0.60, 3 sets 2.61 +/- 0.59, 5 sets 2.45 +/- 0.58). Similarly, no differences were observed for insulin or glucose AUC or for insulin sensitivity between treatments. There was a sex effect with TAG AUC significantly lower in women for control, 1 set, and 3 sets. Conclusion The results of this investigation suggest no dose-response attenuation of the postprandial lipemic response to a high-fat meal after previous resistance exercise.

Basal insulin therapy.

The initiation of insulin therapy is a significant event for patients with diabetes and the physicians who care for them. Reluctance to begin insulin is multifactorial, with a major stumbling block being the perceived complexity of insulin. However, this complexity can be easily overcome by separation of insulin administration into its two components: basal and bolus therapy. An understanding of the role of basal insulin in the regulation of glucose and the development of strategies to implement basal insulin therapy can provide a transition that is rational and highly effective in most patients. The strategy also offers a unique approach to diabetes education, which permits a focused and patient-specific correction to glucose abnormalities.

Assessing the health of future physicians: an opportunity for preventive education.

INTRODUCTION: Research shows that physicians who model prevention are more likely to encourage preventive behaviors in their patients. Therefore, understanding the health of medical students ought to provide insight into the development of health promotion programs that influence the way these future physicians practice medicine. A university-based General Clinical Research Center (GCRC) provides a venue well suited to the health assessment and education of medical students. This research explores the utility of a GCRC in a program measuring the prevalence of clinical risk factors and related health behaviors in first-year medical students. METHODS: A 6-year cross-sectional study of first-year medical students measured clinical and behavioral variables associated with metabolic syndrome. Statistical testing was used to determine the prevalence of risk factors and the influence of gender in these variables. RESULTS: This group of medical students displayed better health indicators than did the general young adult population; however a small proportion of medical students exhibited early risk factors for chronic disease. There were significant gender differences in mean values for clinical risk factors, with males displaying higher cardiovascular risk overall. Males and females demonstrated significant differences in dietary intake and exercise programs. DISCUSSION: A GCRC can be used to provide a health assessment of medical students. Moreover, some students may benefit from health promotion programs incorporated into medical school curricula. This study provides a foundation for further research on the health of future physicians and the development of health promotion programs for this population. It also begins to explore the use of a GCRC as a teaching resource for medical students.

Differential effect of saturated and polyunsaturated fatty acids on hepatic glucose metabolism in humans.

Prolonged infusions of lipid and heparin that achieve high physiological free fatty acid (FFA) concentrations inhibit hepatic (and peripheral) insulin sensitivity in humans. These infusions are composed largely of polyunsaturated fatty acids (PUFA; linoleic and linolenic). It is not known whether fatty acid composition per se affects hepatic glucose metabolism in humans. To address this issue, we examined the impact of enteral infusions of either palm oil (48% palmitic, 35% oleic, and 8% linoleic acids) or safflower oil (6% palmitic, 12% oleic, 74% linoleic acids) in 14 obese nondiabetic subjects. (2)H(2)O was administered to determine the contribution of gluconeogenesis to endogenous glucose production (EGP), and a primed continuous infusion of [6,6-(2)H]glucose was administered to assess glucose appearance. As a result of the lipid infusions, plasma FFA concentrations increased significantly in both the palm oil (507.5 +/- 47.4 to 939.3 +/- 61.3 micromol/l, P < 0.01) and safflower oil (588.2.0 +/- 43.0 to 857.8 +/- 68.7 micromol/l, P < 0.01) groups after 4 h. EGP was similar at baseline (12.4 +/- 1.8 vs. 11.2 +/- 1.0 micromol x kg FFM(-1) x min(-1)). During a somatostatin-insulin clamp, the glucose infusion rate was significantly lower (AUC glucose infusion rate 195.8 +/- 50.7 vs. 377.8 +/- 38.0 micromol/kg FFM, P < 0.01), and rates of EGP were significantly higher (10.7 +/- 1.4 vs. 6.5 +/- 1.5 micromol x kg FFM(-1) x min(-1), P < 0.01) after palm oil compared with safflower oil, respectively. Baseline rates of gluconeogenesis and glycogenolysis were also similar. However, after lipid infusion, rates of glycogenolysis were suppressed by safflower oil but not by palm oil. Thus these studies demonstrate, for the first time in humans, a differential effect of saturated fatty acids and PUFA on hepatic glucose metabolism.

Dietary n-3 polyunsaturated fatty acids decrease hepatic triglycerides in Fischer 344 rats.

Dietary fatty acid composition modifies hepatic lipid metabolism. To determine the effects of fatty acids on hepatic triglyceride storage, rats were fed diets enriched in carbohydrates (control), fish oil, or lard. After 4 weeks, the animals were fasted overnight. In the morning, the animals were either sacrificed or fed 8 g of their respective diets before sacrifice. Animals ingested more food calories with diets containing fish oil than with other diets. However, fish oil-fed animals weighed less and had less body fat. In fish oil-fed animals, liver triglyceride was lower by 27% (P <.05) and 73% (P <.01) than in control- and lard-fed animals, respectively. Fish oil altered the postprandial gene expression of hepatic regulators of fatty acid degradation and synthesis. Fish oil feeding blunted the normal postprandial decline in fatty acid degradation genes (PPARalpha, CPT1, and ACO) and blunted the normal postprandial rise in triglyceride synthesis genes (SREBP1-c, FAS, SCD-1). Therefore, the direct postprandial effect of fish oil ingestion decreases the propensity for hepatic triglyceride storage. In conclusion, n-3 polyunsaturated fatty acids decrease total body weight, total body fat, and hepatic steatosis.

Diabetes and hypertension in severe obesity and effects of gastric bypass-induced weight loss.

OBJECTIVE: To evaluate the preoperative relationships of hypertension and diabetes mellitus in severe obesity and the effects of gastric bypass (GBP)-induced weight loss. SUMMARY BACKGROUND DATA: Severe obesity is associated with multiple comorbidities, particularly hypertension and type 2 diabetes mellitus, that may affect life expectancy. METHODS: The database of patients who had undergone GBP by one general surgeon at a university hospital between September 1981 and January 2000 was queried as to weight, body mass index (BMI), pre- and postoperative diabetes, hypertension, and other comorbidities, including sleep apnea, hypoventilation, gastroesophageal reflux, degenerative joint disease, urinary incontinence, venous stasis, and pseudotumor cerebri. RESULTS: Of 1,025 patients treated, 15% had type 2 diabetes mellitus and 51% had hypertension. Of those with diabetes, 75% also had hypertension. There was a progressive increase in age between patients who had neither diabetes nor hypertension, either diabetes or hypertension, or both diabetes and hypertension. At 1 year after GBP (91% follow-up), patients lost 66 +/- 18% excess weight (%EWL) or 35 +/- 9% of their initial weight (%WL). Hypertension resolved in 69% and diabetes in 83%. Patients who resolved their hypertension or diabetes had greater %EWL and %WL than those who did not. African-American patients had a higher risk of hypertension than whites before GBP and were less likely to correct their hypertension after GBP. There was significant resolution of other obesity comorbidity problems. At 5 to 7 years after GBP (50% follow-up), %EWL was 59 +/- 24 and %WL was 31 +/- 13; resolution of hypertension was 66% and diabetes 86%. CONCLUSIONS: These data suggest that type 2 diabetes mellitus and hypertension may be indirectly related to each other through the effects of obesity, but not directly as to cause and effect. The longer a person remains severely obese, the more likely he or she is to develop diabetes, hypertension, or both. GBP-induced weight loss is effective in correcting diabetes, hypertension, and other comorbidities but is related to the %EWL achieved. Severely obese African-Americans were more likely to have hypertension and respond less well to GBP surgery than whites. These data suggest that GBP surgery for severe obesity should be provided earlier to patients to prevent the development of diabetes and hypertension and their complications.

The role of plasma fatty acid composition in endogenous glucose production in patients with type 2 diabetes mellitus.

Hepatic insulin resistance and increased endogenous glucose production (EGP) are associated with increased plasma free fatty acids (FFA). However, the contribution of FFA composition to the regulation of EGP is not known. Six obese nondiabetic subjects and 6 patients with type 2 diabetes mellitus (DM2) were studied after an overnight and a 3-day fast. Plasma insulin concentrations after an overnight fast were similar in the DM2 and nondiabetic patients (88.8 +/- 26.4 v 57.6 +/- 12.6 pmol/L, not significant [NS]) despite increased plasma glucose (9.9 +/- 1.8 v 5.1 +/- 0.1 mmol/L, P <.01) and EGP (510.3 +/- 77.7 v 298.3 +/- 18.3 micromol x m(-2) x min(-1), P <.05) in the patients with DM2. Absolute rates of gluconeogenesis using the heavy water method were also increased in the patients with DM2 (346.8 +/- 74.9 v 198.8 +/- 16.4 micromol x m(-2). min(-1), P <.05). No differences were observed in plasma polyunsaturated fatty acids (PUFA) between the diabetic and nondiabetic subjects. However, total saturated fatty acid (SFA) concentrations (350 +/- 37.4 v 230.9 +/- 33.3 micromol/L, P <.02) were significantly increased in the diabetic subjects. Rates of EGP were correlated with total plasma FFA concentration (r =.71, P <.01) and the concentration of SFA (r =.71, P <.01), but not monounsaturated fatty acids or PUFA. Rates of gluconeogenesis were also correlated with plasma FFA (r =.64, P <.05) and SFA (r =.67, P <.05). We observed no relationship between EGP and either total FFA or fatty acid composition after a 3-day fast. We conclude that increases in EGP are associated with concentrations of plasma SFA after an overnight fast.

Relation of diabetic patients' health-related control appraisals and physician-patient interpersonal impacts to patients' metabolic control and satisfaction with treatment.

Desire for healthcare control, health locus of control, perceived control over diabetes, satisfaction with diabetes treatment, and general personality traits were assessed in 54 Type 1 and Type 2 diabetic patients of the same male endocrinologist during a regularly scheduled office visit. At the end of the consultation, both patients and the physician completed a measure describing the interpersonal impacts produced in each by the other's control and affiliation behaviors. Patient success at diabetes control was assessed via glycosylated hemoglobin A1C (HA1C) level on the day of the visit and variability in HA1C levels across several visits. Patients' satisfaction with treatment was unrelated to diabetes control measures. Patients' desire for behavioral involvement in their own healthcare and NEO Agreeableness scores were positively associated with diabetes control. Better diabetes control also resulted when the physician perceived patients to be more controlling and less submissive, and when there was more reciprocity in patient and physician's perceptions of the other's controlling interpersonal behavior. Findings support the conclusion that both a patient's self-reported desire for involvement in his or her healthcare and the transactional fit of patient-physician interpersonal behaviors are potentially important contributors to better diabetes outcomes.

Lipid metabolism and resistin gene expression in insulin-resistant Fischer 344 rats.

The interrelationship between insulin and leptin resistance in young Fischer 344 (F344) rats was studied. Young F344 and Sprague-Dawley (SD) rats were fed regular chow. F344 animals had two- to threefold higher insulin and triglyceride concentrations and increased stores of triglycerides within liver and muscle. F344 animals gained more body fat. Both acyl-CoA oxidase (ACO) and carnitine palmitoyltransferase I gene expression were 20-50% less in F344 animals than in age-matched SD animals. Peroxisome proliferator-activated receptor-alpha gene expression was reduced in 70-day-old F344 animals. Finally, resistin gene expression was similar in 70-day-old SD and F344 animals. Resistin gene expression increased fivefold in F344 animals and twofold in SD animals from 70 to 130 days, without a change in insulin sensitivity. We conclude that young F344 animals have both insulin and leptin resistance, which may lead to diminished fatty oxidation and accumulation of triglycerides in insulin-sensitive target tissues. We did not detect a role for resistin in the etiology of insulin resistance in F344 animals.