Journal Club
Look AHEAD Research Group,
Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.
N Engl J Med. 2013 Jul 11;369(2):145-54. doi: 10.1056/NEJMoa1212914.
Rönn T, Volkov P, Davegårdh C, Dayeh T, Hall E, Olsson AH, Nilsson E,
Tornberg A, Dekker Nitert M, Eriksson KF, Jones HA, Groop L, Ling C.
A Six Months Exercise Intervention Influences the Genome-wide DNA
Methylation Pattern in Human Adipose Tissue.
PLoS Genet. 2013 Jun;9(6):e1003572. doi: 10.1371/journal.pgen.1003572.
2013年7月18日 8:30-8:55
８階 医局
埼玉医科大学 総合医療センター 内分泌・糖尿病内科
Department of Endocrinology and Diabetes,
Saitama Medical Center, Saitama Medical University
松田 昌文
Matsuda, Masafumi
Look AHEAD: No CVD benefit with lifestyle intervention in diabetics
June 24, 2013 Michael O‘Riordan – Hard outcomes will be a focus at the
American Diabetes Association meeting here, particularly from the Look
AHEAD trial's lifestyle intervention in type 2 diabetes.
Heart Disease and Stroke
The Look AHEAD trial was halted early at the end of last year when an
analysis showed no difference in the rate of nonfatal MI, nonfatal stroke,
death, or hospitalization for angina among patients randomized to the
intensive lifestyle intervention group vs the control group of education
alone. There were, however, significant reductions in weight and
improvements in physical-fitness levels among those in the intensive group.
Slide Source:
Lipids Online Slide Library
www.lipidsonline.org
Rena R. Wing, Ph.D., Weight Control and Diabetes Research Center, Warren Alpert Medical School of Brown University and Miriam Hospital, Providence, RI; Paula Bolin, R.N., M.C., National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Frederick L. Brancati,* M.D., M.H.S., Johns Hopkins School of Medicine, Baltimore; George A. Bray, M.D.,
Pennington Biomedical Research Center, Baton Rouge, LA; Jeanne M. Clark, M.D., M.P.H., Johns Hopkins School of Medicine, Baltimore; Mace Coday, Ph.D., Department of Preventive Medicine,
University of Tennessee Health Sciences Center, Memphis; Richard S. Crow,* M.D., Division of Epidemiology and Community Health, University of Minnesota, Minneapolis; Jeffrey M. Curtis, M.D.,
M.P.H., NIH/NIDDK Southwest American Indian Center, Phoenix, AZ; Caitlin M. Egan, M.S., Weight Control and Diabetes Research Center, Warren Alpert Medical School of Brown University and
Miriam Hospital, Providence, RI; Mark A. Espeland, Ph.D., Department of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC; Mary Evans, Ph.D., NIH/NIDDK,
Bethesda, MD; John P. Foreyt, Ph.D., Department of Medicine, Baylor College of Medicine, Houston; Siran Ghazarian, M.D., Roybal Comprehensive Health Center, Los Angeles; Edward W. Gregg,
Ph.D., Centers for Disease Control and Prevention, Atlanta; Barbara Harrison, M.S., NIH/NIDDK, Bethesda, MD; Helen P. Hazuda, Ph.D., Department of Clinical Epidemiology, University of Texas
Health Science Center at San Antonio, San Antonio; James O. Hill, Ph.D., Center for Human Nutrition, University of Colorado Health Sciences Center, Aurora; Edward S. Horton, M.D., Joslin
Diabetes Center, Boston; Van S. Hubbard, M.D., Ph.D., NIH/NIDDK, Bethesda, MD; John M. Jakicic, Ph.D., Department of Health and Physical Activity, University of Pittsburgh, Pittsburgh; Robert W.
Jeffery, Ph.D., Division of Epidemiology and Community Health, University of Minnesota, Minneapolis; Karen C. Johnson, M.D., M.P.H., Department of Preventive Medicine, University of Tennessee
Health Sciences Center, Memphis; Steven E. Kahn, M.B., Ch.B., Department of Medicine, University of Washington, Seattle; Abbas E. Kitabchi, Ph.D., M.D., Department of Preventive Medicine,
University of Tennessee Health Sciences Center, Memphis; William C. Knowler, M.D., Dr.P.H., NIH/NIDDK Southwest American Indian Center, Phoenix, AZ; Cora E. Lewis, M.D., M.S.P.H., Division
of Preventive Medicine, University of Alabama at Birmingham, Birmingham; Barbara J. Maschak-Carey, M.S.N., C.D.E., Weight and Eating Disorder Program, University of Pennsylvania,
Philadelphia; Maria G. Montez, R.N., M.S.H.P., C.D.E., Department of Clinical Epidemiology, University of Texas Health Science Center at San Antonio, San Antonio; Anne Murillo, B.S., Department
of Medicine, University of Washington, Seattle; David M. Nathan, M.D., Diabetes Unit, Massachusetts General Hospital, Boston; Jennifer Patricio, M.S., Department of Medicine, St. Luke’s–
Roosevelt Hospital, New York; Anne Peters, M.D., Roybal Comprehensive Health Center, Los Angeles; Xavier Pi-Sunyer, M.D., Department of Medicine, St. Luke’s–Roosevelt Hospital, New York;
Henry Pownall, Ph.D., Department of Medicine, Baylor College of Medicine, Houston; David Reboussin, Ph.D., Department of Biostatistical Sciences, Wake Forest University School of Medicine,
Winston-Salem, NC; Judith G. Regensteiner, Ph.D., Center for Women’s Health Research, University of Colorado Health Sciences Center, Aurora; Amy D. Rickman, Ph.D., R.D., L.D.N., Department
of Health and Physical Activity, University of Pittsburgh, Pittsburgh; Donna H. Ryan, M.D., Pennington Biomedical Research Center, Baton Rouge, LA; Monika Safford, M.D., Division of Preventive
Medicine, University of Alabama at Birmingham, Birmingham; Thomas A. Wadden, Ph.D., Weight and Eating Disorder Program, University of Pennsylvania, Philadelphia; Lynne E. Wagenknecht,
Dr.P.H., Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC; Delia S. West, Ph.D., Department of Health Behavior and Health Education, College of
Public Health, University of Arkansas for Medical Sciences, Little Rock; David F. Williamson, Ph.D., Centers for Disease Control and Prevention, Atlanta; and Susan Z. Yanovski, M.D., NIH/NIDDK,
Bethesda, MD.
N Engl J Med. 369:145-54, 2013.
Background
Weight loss is recommended for overweight
or obese patients with type 2 diabetes on
the basis of short-term studies, but longterm effects on cardiovascular disease
remain unknown. We examined whether an
intensive lifestyle intervention for weight
loss would decrease cardiovascular
morbidity and mortality among such patients.
Methods
In 16 study centers in the United States, we
randomly assigned 5145 overweight or obese
patients with type 2 diabetes to participate in an
intensive lifestyle intervention that promoted
weight loss through decreased caloric intake and
increased physical activity (intervention group) or
to receive diabetes support and education
(control group). The primary outcome was a
composite of death from cardiovascular causes,
nonfatal myocardial infarction, nonfatal stroke, or
hospitalization for angina during a maximum
follow-up of 13.5 years.
Eligibility Criteria
Gender Men and women are eligible. Look AHEAD will endeavor to recruit approximately equal numbers of men and
women.
Type 2 diabetes mellitus Diabetes mellitus will be determined by self-report with verification (medical records, current
treatment, verification from personal health care provider, or test results meeting the 1997 American Diabetes Association
criteria of fasting glucose > 126 mg/dl, symptoms of hyperglycemia with casual plasma glucose > 200 mg/dl or two-hour
plasma glucose > 200 mg/dl after a 75 gram oral glucose load). In an effort to identify individuals with type 2 diabetes (the
population that would be most responsive to weight loss), individuals who have a clinical history strongly suggestive of
Type 1 diabetes will be excluded. Individuals taking oral hypoglycemic medication or insulin and those who are treated
with diet and exercise are eligible. No more than 30% of the study population will be using insulin at entry into the study.
Body mass index Overweight individuals, with body mass index of 25 kg/m2 or greater (27 kg/m2 if currently taking
insulin) are eligible. Weight loss is recommended for overweight individuals with one or more cardiovascular risk factors,
including diabetes mellitus. There is no upper eligibility criterion for body mass index, however an upper limit on weight
has been set (Section 4.2.1).
Age Individuals aged 45-75 years old are eligible. Individuals older than 75 years of age are excluded due to their
increased risk of competing mortality and potential safety concerns related to weight loss.
Ethnicity All ethnic groups are eligible for the study. Look AHEAD has the goal of recruiting 33% of the study cohort from
ethnic minority groups including African Americans, Hispanic Americans, American Indians, and Asian Americans. Data
from NHANES III indicate that April 16, 2001 18 approximately 23% of individuals meeting the eligibility criteria for Look
AHEAD will be from ethnic minorities.89
Blood pressure Look AHEAD will enroll individuals whose blood pressure is under at least moderate control: treated or
untreated resting systolic/diastolic blood pressure less than 160/100 mmHg. Individuals whose blood pressure exceeds
these levels during screening will be told to seek treatment. Such individuals may be rescreened after three months to reassess blood pressure eligibility.
Glycemic control Look AHEAD will enroll individuals whose HbA1c is less than 11%. Individuals whose HbA1c exceeds
this level may require more urgent care and will be told to seek treatment. Such individuals may be re-screened after three
months to re-assess HbA1c eligibility.
Lipid control Individuals with a fasting triglycerides concentration less than 600 mg/dl are eligible. Individuals whose
fasting triglycerides concentration exceeds this level may be rescreened after three months to re-assess triglycerides
eligibility.
History of cardiovascular disease Look AHEAD will recruit individuals both with and without a history of cardiovascular
disease. Data from NHANES III indicate that approximately 29% of individuals meeting the eligibility criteria defined by the
trial will have a history of cardiovascular disease.85 Cardiovascular event rates in diabetic individuals with heart disease
are expected to be approximately twice those of diabetic individuals without a history of heart disease.
Figure 1. Changes in Weight, Physical Fitness, Waist Circumference, and Glycated Hemoglobin Levels during 10 Years of
Follow-up. Shown are the changes from baseline in overweight or obese patients with type 2 diabetes who participated in an
intensive lifestyle intervention (intervention group) or who received diabetes support and education (control group). The reported
main effect is the average of all between-group differences after baseline. Means were estimated with the use of generalized linear
models for continuous measures. MET denotes metabolic equivalents; asterisks indicate P<0.05 for the between-group comparison.
Data from 107 visits during year 11 were not included in the analyses.
Figure 2. Cumulative Hazard Curves for the Primary Composite End Point. Shown are Kaplan–Meier
estimates of the cumulative proportion of patients with a primary event. The primary outcome was a composite of
death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for angina.
The numbers below the graph are the numbers of patients at risk in each study group at years 2, 4, 6, and 8 and
at 10.4 years, when the last observed event occurred. The inset shows the same data on an expanded y axis.
One possibility is that the study lacked sufficient power. However, we do not
believe that this explains the negative result; the 95% confidence interval for the
primary outcome excluded the benefit of 18% or more targeted in the trial’s
design.
Another possibility is that a sustained weight loss of more than that achieved in
the intervention group may be required to reduce the risk of cardiovascular
disease. In this regard, it is noteworthy that the differential weight loss between
the two trial groups averaged 4% over the course of the study but only 2.5% at the
end. However, our trial was planned to test the effects of an intensive lifestyle
intervention, and the weight loss achieved in the intervention group is
representative of the best that has been achieved with current lifestyle
approaches.
Third, the provision of educational sessions and the increased use of statins in
the control group, as compared with the intervention group, may have lessened
the difference between the two groups. In addition, the intensification of medical
management of cardiovascular risk factors in routine medical care in the two
study groups may have made the relative benefit of the intensive lifestyle
intervention more difficult to demonstrate. The intervention may also have had
different effects in different subgroups.
Although none of the interactions with subgroups were significant, our data
suggest that the event rate for the primary outcome was nonsignificantly lower in
the intervention group than in the control group among patients with no history of
cardiovascular disease at baseline but that it was nonsignificantly higher in the
intervention group than in the control group among those with cardiovascular
disease at baseline.
Results
The trial was stopped early on the basis of a futility
analysis when the median follow-up was 9.6 years.
Weight loss was greater in the intervention group than in
the control group throughout the study (8.6% vs. 0.7% at
1 year; 6.0% vs. 3.5% at study end). The intensive
lifestyle intervention also produced greater reductions in
glycated hemoglobin and greater initial improvements in
fitness and all cardiovascular risk factors, except for lowdensity-lipoprotein cholesterol levels. The primary
outcome occurred in 403 patients in the intervention
group and in 418 in the control group (1.83 and 1.92
events per 100 person-years, respectively; hazard ratio
in the intervention group, 0.95; 95% confidence interval,
0.83 to 1.09; P = 0.51).
Conclusions
An intensive lifestyle intervention focusing
on weight loss did not reduce the rate of
cardiovascular events in overweight or
obese adults with type 2 diabetes.
(Funded by the National Institutes of Health and others;
Look AHEAD ClinicalTrials.gov number, NCT00017953.)
Message
過体重または肥満の2型糖尿病（DM）患者
5145人を対象に、減量のための生活習慣強
化介入の効果を無作為化比較試験で検討
（Look AHEAD試験）。主要転帰（心血管死、
非致死性心筋梗塞、非致死性脳卒中、狭心
症による入院）の発生率は、介入群100人年
当たり1.83件、対照群で1.92件だった（ハ
ザード比0.95、P＝0.51）。
http://www.mindthesciencegap.org/2012/03/21/exercise-can-change-your-dna/
http://healthramblings.com/2012/03/
２型糖尿病の発症に関与する候補遺伝子（複数保有すると発症確率が増大）
Nat Genet. 2012 Sep;44(9):981-90.
PLOS Genetics | www.plosgenetics.org June 2013 | Volume 9 | Issue 6 | e1003572
Background
Epigenetic mechanisms are
implicated in gene regulation and
the development of different
diseases. The epigenome differs
between cell types and has until
now only been characterized for a
few human tissues. Environmental
factors potentially alter the
epigenome.
Methods
Here we describe the genome-wide pattern of
DNA methylation in human adipose tissue
from 23 healthy men, with a previous low level
of physical activity, before and after a six
months exercise intervention. We also
investigate the differences in adipose tissue
DNA methylation between 31 individuals with
or without a family history of type 2 diabetes.
DNA methylation was analyzed using Infinium
HumanMethylation450 BeadChip, an array
containing 485,577 probes covering 99%
RefSeq genes.
Epigenetic mechanisms such as DNA methylation are
considered to be important in phenotype transmission
and the development of different diseases [9]. The
epigenetic pattern is mainly established early in life and
thereafter maintained in differentiated cells, but agedependent alterations still have the potential to
modulate gene expression and translate environmental
factors into phenotypic traits [10–13]. In differentiated
mamma-lian cells, DNA methylation usually occurs in
the context of CG dinucleotides (CpGs) and is
associated with gene repression [14]. Changes in
epigenetic profiles are more common than genetic
mutations and may occur in response to environmental,
behavioural, psychological and pathological stimuli
1) explore genomewide levels of DNA methylation
before and after a six months exercise
intervention in adipose tissue from healthy, but
previously sedentary men;
2) investigate the differences in adipose tissue DNA
methylation between individuals with or without a
family history of T2D;
3) relate changes in DNA methylation to adipose
tissue mRNA expression and metabolic
phenotypes in vitro.
Baseline characteristics of individuals with (FH+) or without (FH-)
a family history of type 2 diabetes
A total of 31 men, 15 FH + and 16 FH-, had subcutaneous adipose tissue
biopsies taken at baseline.
False discovery rate and q-value
q-valueを計算するq-valueを定義 任意の値以上の統計量に対応づけられた最小の FDR ある値に割り当てられたq-valueは，その値を
significanceのいちきにしたときのFDRを表す先ほどの例だと，q-value=<0.05のところをとると，FDRが5%となる
p-valueとq-valuep-value p<0.05ということは False positive rateが0.05未満になるということ False positive rate = FP/(TN+FP) q-value
q<0.05ということは False discovery rateが0.05未満になるということ
http://www.slideshare.net/yuifu/fdr-kashiwar-3
http://en.wikipedia.org/wiki/False_discovery_rate#q-value
Clinical outcome and global changes in adipose tissue DNA
methylation in response to exercise
Subcutaneous adipose tissue biopsies were taken from 23 men both
before and after exercise
DNA methylation of individual CpG sites in human adipose tissue
is influenced by exercise
Figure 2. Analysis flowchart.
DNA methylation in vitro decreases reporter gene expression
DNA methylation of obesity and type 2 diabetes candidate genes
in human adipose tissue
Silencing of Hdac4 and Ncor2 in 3T3-L1 adipocytes is associated
with increased lipogenesis
Results
Global DNA methylation changed and 17,975 individual CpG sites
in 7,663 unique genes showed altered levels of DNA methylation
after the exercise intervention (q,0.05). Differential mRNA
expression was present in 1/3 of gene regions with altered DNA
methylation, including RALBP1, HDAC4 and NCOR2 (q,0.05).
Using a luciferase assay, we could show that increased DNA
methylation in vitro of the RALBP1 promoter suppressed the
transcriptional activity (p = 0.03). Moreover, 18 obesity and 21
type 2 diabetes candidate genes had CpG sites with differences in
adipose tissue DNA methylation in response to exercise (q,0.05),
including TCF7L2 (6 CpG sites) and KCNQ1 (10 CpG sites). A
simultaneous change in mRNA expression was seen for 6 of
those genes. To understand if genes that exhibit differential DNA
methylation and mRNA expression in human adipose tissue in
vivo affect adipocyte metabolism, we silenced Hdac4 and Ncor2
respectively in 3T3-L1 adipocytes, which resulted in increased
lipogenesis both in the basal and insulin stimulated state.
Conclusion
In conclusion, exercise induces
genome-wide changes in DNA
methylation in human adipose
tissue, potentially affecting
adipocyte metabolism.
Message
運動すると遺伝子自体が変化するといわれ
ているが、筋肉以外にも脂肪細胞について
も調べ、２型糖尿病発症に関係する遺伝子
もかなり影響されていることが分かったと
いうことになる。
同じ遺伝子でも、環境（運動）により影響
をうけることになる。