Persisting benefits 12-18 months after discontinuation of pubertal metformin therapy in low birthweight girls.

BACKGROUND: Discontinuation of metformin therapy, if started beyond menarche in adolescents or young women with hyperinsulinaemia following low birthweight, is rapidly followed by rebound deteriorations in body fat, insulin resistance and blood lipid profile. OBJECTIVE: We hypothesized that early commencement of metformin and its continuation throughout puberty might have more persisting benefits. PATIENTS AND MEASUREMENTS: We followed up on a previously reported randomized study cohort at 12 months and 18 months after treatment discontinuation, including body composition by absorptiometry, fasting insulin, glucose and blood lipids. In that open-labelled, prospective study, 22 low birthweight girls with early normal puberty (Stage 2 breast development at age 8-9 years) were randomized to remain untreated (N = 12] or to receive metformin (850 mg/day; N = 10) for 36 months (between time -36 months to 0 month). RESULTS: The significant improvements previously reported at the end of the 36-month active treatment period in per cent body fat, abdominal fat mass, fasting insulin sensitivity, high density lipoprotein (HDL) cholesterol and triglyceride levels all persisted at follow-up 12 months after treatment discontinuation. Further anthropometry at 18 months off therapy confirmed the persistence of benefits in height, body mass index (BMI) and waist circumference in the previously metformin-exposed girls. CONCLUSION: In low birth weight girls with early normal onset of puberty, metformin treatment for 3 years across puberty resulted in auxological, endocrine and metabolic benefits that persisted for at least 1 year after metformin withdrawal. Further follow-up and longer-term studies are needed to explore the possibility that insulin sensitization therapy during puberty might reprogramme predisposition to metabolic disease

Association between long telomere length and insulin sensitization in adolescent girls with hyperinsulinemic androgen excess

Research letterThe centile of telomere length from early adulthood until senescence is mainly set between early gestation and adolescence.1 Hyperinsulinemic androgen excess (HIAE) is the most prevalent endocrinopathy of adolescent girls and is frequently driven by an absolute or relative excess of fat.2 Hyperinsulinemic androgen excess in adolescence is associated with a higher risk for a broad range of endocrine, metabolic, and cardiovascular complications later in life.

Low-Dose Spironolactone-Pioglitazone-Metformin Normalizes Circulating Fetuin-A Concentrations in Adolescent Girls with Polycystic Ovary Syndrome

Background: Fetuin-A is a glycoprotein produced in the liver and related to metabolic syndrome; fetuin-A secretion is divergently regulated in different pathological conditions. In girls with polycystic ovary syndrome (PCOS), insulin sensitization results in a more favorable endocrine-metabolic outcome than oral contraception; we assessed whether those differences are underscored by changes in circulating fetuin-A. Methods: Fetuin-A concentration endocrine-metabolic markers and hepatovisceral fat were measured longitudinally in 35 PCOS girls [age, 16 yr; body mass index (BMI), 23 kg/m2] randomized to receive either oral contraception [ethinylestradiol-levonorgestrel (n = 18)] or a low-dose combination of spironolactone, pioglitazone, and metformin (SPIOMET, n = 17) over 12 months. Healthy adolescent girls (age- and BMI-matched) were used as controls (n = 25). Results: Pretreatment fetuin-A serum levels in PCOS girls were lower than those in controls. After 12 months on treatment, fetuin-A raised to control levels only in the SPIOMET subgroup (P = 0.009, versus oral contraception); this increase was paralleled by a healthier metabolic profile with less hepatic fat (by MRI); baseline serum fetuin-A as well as the changes over 12 months was inversely related to hepatic adiposity. Conclusions: A low-dose combination of insulin sensitizers and an antiandrogen-but not oral contraception-normalizes fetuin-A levels in adolescent girls with PCOS. This trial is registered with ISRCTN29234515.This study was supported by a grant from the ISCIII and the Fondo Europeo de Desarrollo Regional (FEDER), Madrid, Spain (PI15/01078) and by MINECO (SAF2014-55725

Low-dose spironolactone-pioglitazone-metformin normalizes circulating fetuin-a concentrations in adolescent girls with polycystic ovary syndrome

BACKGROUND: Fetuin-A is a glycoprotein produced in the liver and related to metabolic syndrome; fetuin-A secretion is divergently regulated in different pathological conditions. In girls with polycystic ovary syndrome (PCOS), insulin sensitization results in a more favorable endocrine-metabolic outcome than oral contraception; we assessed whether those differences are underscored by changes in circulating fetuin-A. METHODS: Fetuin-A concentration endocrine-metabolic markers and hepatovisceral fat were measured longitudinally in 35 PCOS girls [age, 16 yr; body mass index (BMI), 23 kg/m2] randomized to receive either oral contraception [ethinylestradiol-levonorgestrel (n = 18)] or a low-dose combination of spironolactone, pioglitazone, and metformin (SPIOMET, n = 17) over 12 months. Healthy adolescent girls (age- and BMI-matched) were used as controls (n = 25). RESULTS: Pretreatment fetuin-A serum levels in PCOS girls were lower than those in controls. After 12 months on treatment, fetuin-A raised to control levels only in the SPIOMET subgroup (P = 0.009, versus oral contraception); this increase was paralleled by a healthier metabolic profile with less hepatic fat (by MRI); baseline serum fetuin-A as well as the changes over 12 months was inversely related to hepatic adiposity. CONCLUSIONS: A low-dose combination of insulin sensitizers and an antiandrogen-but not oral contraception-normalizes fetuin-A levels in adolescent girls with PCOS. This trial is registered with ISRCTN29234515

Placental and cord blood methylation of genes involved in energy homeostasis: association with fetal growth and neonatal body composition.

Low weight at birth associates with subsequent susceptibility to diabetes. Epigenetic modulation is among the mechanisms potentially mediating this association. We performed a genome-wide DNA methylation analysis in placentas from term infants born appropriate-for-gestational-age (AGA) or small-for-gestational-age (SGA), to identify new genes related to fetal growth and neonatal body composition. Candidate genes were validated by bisulfite pyrosequencing (30 AGA, 21 SGA) and also analyzed in cord blood. Gene expression analyses were performed by RT-PCR. Neonatal body composition was assessed by dual X-ray absorptiometry at age 2 weeks. The ATG2B, NKX6.1 and SLC13A5 genes (respectively related to autophagy, beta-cell development and function, and lipid metabolism) were hypermethylated in placenta and cord blood from SGA newborns, whereas GPR120 (related to free fatty acid regulation) was hypomethylated in placenta and hypermethylated in cord blood. Gene expression levels were opposite to methylation status, and both correlated with birth weight, with circulating IGF-I, and with total and abdominal fat at age 2 weeks. In conclusion, alterations in methylation and expression of genes involved in the regulation of energy homeostasis were found to relate to fetal growth and neonatal body composition, and may thus be among the early mechanisms modulating later susceptibility to diabetes

Dlk1 expression relates to visceral fat expansion and insulin resistance in male and female rats with postnatal catch-up growth

Background: Although prenatal and postnatal programming of metabolic diseases in adulthood is well established, the mechanims underpinning metabolic programming are not. DLK1, a key regulator of fetal development, inhibits adipocyte differentiation and restricts fetal growth. Methods: Assess Dlk1 expression in Wistar rat model of catch-up growth following intrauterine restriction. Dams fed ad libitum deliverd control pups (C) and dams on a 50% calorie-restricted diet delivered pups with low birth weight (R). Restricted offspring fed a standard rat chow showd catch-up growth (R/C) but those kept on a calorie-restricted diet did not (R/R). Results: Decreased Dlk1 expression was observed in adipose tissue and skeletal muscle of R/C pups along with excessive visceral fat accumulation, decreased circulating adiponectin, increased triglycerides and HOMA-IR (from p<0.05 to p<0.001). Moreover, in R/C pups, the reduced Dlk1 expression in adipose tissue and skeletal muscle correlated with visceral fat (r= -0.820; p<0.0001) and HOMA-IR (r= -0.745; p=0.002). Conclusions: Decreased Dlk1 expression relates to visceral fat expansion and insulin resistance in a rat model of catch-up growth following prenatal growth restriction. Modulation of Dlk1 expression could be among the targets of the early prevention of fetal preogramming of adult metabolic disorders

Circulating fatty acid synthase in pregnant women: relationship to blood pressure, maternal metabolism and newborn parameters.

The enzyme FASN (fatty acid synthase) is potentially related with hypertension and metabolic dysfunction. FASN is highly expressed in the human placenta. We aimed to investigate the relationship circulating FASN has with blood pressure, maternal metabolism and newborn parameters in healthy pregnant women. Circulating FASN was assessed in 115 asymptomatic pregnant women in the second trimester of gestation along with C-peptide, fasting glucose and insulin, post-load glucose lipids, HMW-adiponectin and blood pressure (the latter was assessed in each trimester of gestation). At birth, newborns and placentas were weighed. FASN expression was also able to be assessed in 80 placentas. Higher circulating FASN was associated with lower systolic blood pressure (SBP), with a more favourable metabolic phenotype (lower fasting glucose and insulin, post load glucose, HbAc1, HOMA-IR and C-peptide), and with lower placental and birth weight (all p < 0.05 to p < 0.001). Placental FASN expression related positively to circulating FASN (p < 0.005) and negatively to placental weight (p < 0.05). Our observations suggest a physiological role of placental FASN in human pregnancy. Future studies will clarify whether circulating FASN of placental origin does actually regulate placental and fetal growth, and (thereby) has a favourable influence on the pregnant mother's insulin sensitivity and blood pressure

Bone Morphogenetic Protein-8B levels at birth and in the first year of life: relation to metabolic-endocrine variables and brown adipose tissue activity

Objective: Bone morphogenetic protein-8B (BMP8B) is an adipokine produced by brown adipose tissue (BAT) contributing to thermoregulation and metabolic homeostasis in rodent models. In humans, BAT activity is particularly relevant in newborns and young infants. We assessed BMP8B levels and their relationship with BAT activity and endocrine-metabolic parameters in young infants to ascertain its potentiality as biomarker in early life. Methods and Materials: BMP8B concentrations were assessed longitudinally by ELISA in a cohort of 27 girls and 23 boys at birth, and at age 4 and 12 months, together with adiposity parameters (DXA), and circulating endocrine-metabolic variables. BAT activity was measured by infrared thermography. BMP8B gene expression (qRT-PCR) was determined in BAT, white fat, and liver samples from neonatal necropsies, and in placenta and cord blood. Results: BMP8B levels were high at birth, particularly in boys (P=0.04 vs girls), declined progressively, and remained well above those in healthy adults and pregnant women at age one year (P<0.05 and P<0.001, respectively). Neonatal BMP8B transcript levels were higher in BAT than in white fat, liver and cord blood. Circulating BMP8B levels during the first year of life marginally correlated with bone mineral density and gains in lean mass. Conclusion: BMP8B levels are high at birth and decline progressively over the first year of life remaining above adult levels. Although changes in BMP8B concentrations overall reflect those in BAT activity during development, BMP8B levels are unlikely to be useful to predict individual variations in endocrine-metabolic status and BAT activity in healthy young infants

A randomised controlled trial of early insulin therapy in very low birth weight infants, "NIRTURE" (neonatal insulin replacement therapy in Europe).

BACKGROUND: Studies in adult intensive care have highlighted the importance of insulin and improved glucose control on survival, with 32% reduction in mortality, 22% reduction in intensive care stay and halving of the incidence of bacteraemia. Very low birth weight infants requiring intensive care also have relative insulin deficiency often leading to hyperglycaemia during the first week of life. The physiological influences on insulin secretion and sensitivity, and the potential importance of glucose control at this time are not well established. However there is increasing evidence that the early postnatal period is critical for pancreatic development. At this time a complex set of signals appears to influence pancreatic development and beta cell survival. This has implications both in terms of acute glucose control but also relative insulin deficiency is likely to play a role in poor postnatal growth, which has been associated with later motor and cognitive impairment, and fewer beta cells are linked to risk of type 2 diabetes later in life. METHODS: A multi-centre, randomised controlled trial of early insulin replacement in very low birth weight babies (VLBW, birth weight < 1500 g). 500 infants will be recruited from 10 centres in the UK and Europe. Babies will be randomised to receive a continuous insulin infusion (0.05 units/kg/h) or to receive standard neonatal care from the first day of life and for the next 7 days. If blood glucose (BG) levels fall infants will receive 20% dextrose titrated to maintain normoglycaemia (4-8 mmol/l). If BG is consistently above 10 mmol/l babies will receive standard treatment with additional insulin infusion. The primary end point will be mortality on or before expected date of delivery, secondary end points will be markers of morbidity and include episodes of sepsis, severity of retinopathy, chronic lung disease and growth