The causes of the excess coronary heart disease (CHD) risk in South Asian migrants from the Indian subcontinent remain unclear. Comparisons of CHD risk factors amongst South Asian migrants living in Britain with those of the general UK population provide only a partial explanation. We compared Gujaratis in Britain with similar, non-migrant Gujaratis in India, to test the hypothesis that differences in CHD risk factors associated with migration would be more informative. Randomly sampled Gujaratis aged 25-79 years living in Sandwell (n = 242) were compared with age-, gender- and caste-matched contemporaries remaining in their villages of origin in Navsari, India (n = 295). Lifestyle indices, food intake and physical activity, were assessed with standardised questionnaires and energy expenditure and metabolic parameters measured.British Gujaratis had higher, mean body mass indices by 6 (4.5-7.4) kg/m(2) mean (95% CI), and greater dietary energy intake, fat intake, blood pressure, fasting serum cholesterol, apolipoprotein B, triglycerides, non-esterified fatty acid (NEFA) and C-reative protein concentrations than Gujaratis in India. Dietary folate and serum folate and Vitamin B-12 were lower and plasma homocysteine was higher in India. Smoking was less prevalent and high-density lipoprotein cholesterol tended to be higher in Britain. Diabetes prevalence was high in both populations and impaired fasting or 2 It post-glucose challenge plasma glucose was even more prevalent in Gujarat. In India, however, where insulin secretion and NEFA were lower diabetes and impaired glucose tolerance were less frequently accompanied by excess metabolic CVD risk factors.In conclusion, exposure to increased fat intake and obesity related to migration is likely to explain the disproportionate combination of established and emerging CHD risk factors prevalent in Gujaratis in Britain. Strategies to improve nutrition and to identify and treat cardiovascular risk factors such as dyslipidaemia and hypertension are urgently required. (c) 2005 Elsevier Ireland Ltd. All rights reserved.

Objective. To investigate the paraoxonase-2 (PON2)-C/S310 polymorphism and its relationship to the presence of diabetic complications and glycaemic control.Design. Case-control study.Setting. One study centre at University hospital.Materials and methods. The subjects were people with type 2 diabetes (n = 252), type 1 diabetes (n = 152) and healthy controls (n = 282). The PON2-C/S310 polymorphism was measured by restriction fragment length polymorphism analysis. Lipids and lipoproteins were measured by standard clinical chemistry methods. Diabetes and diabetic complications were defined by World Health Organization criteria.Results. There was an over-representation of the C/C310 genotype in those with diabetes and microvascular complications (type 2 diabetes P = 0.043, type 1 diabetes P = 0.052, both populations combined P = 0.014). The PON2-C/S310 polymorphism was also associated with glycaemic control. C310/C310 homozygotes had the highest HbA(1c) concentration (P = 0.020 type 2 diabetes, P = 0.065 type 1 diabetes, P = 0.035 both populations combined). There was no association between the PON2-310 polymorphism and lipid and lipoprotein concentrations.Conclusions. PON2 could be directly involved in protecting critical enzymes or organelles against oxidative damage; PON2 may thus predispose to the development of microvascular complications.

BACKGROUND Serum paraoxonase (PON1) provides protection against organophosphate induced toxicity. Recently we reported that the frequency of paraoxonase polymorphisms in sheep dippers with self-reported chronic ill-health differed from that in dippers with a similar dipping history but no ill-health. As these analyses may have included subjects with conditions unrelated to organophosphate exposure, the aim of this study was to examine whether the risk associated with PON1 polymorphisms varied using a more homogenous case and referent population. METHODS Each subject completed a detailed symptom questionnaire and their general practitioner was asked whether there was any history of neurological disease that could be confused with the effects of organophosphate poisoning. Subjects were then excluded both on clinical grounds and where identified as atypical on discriminant analysis. RESULTS Risk associated with the PON1 192 and 55 genotypes altered little with these changes in the population. CONCLUSIONS These findings are consistent with the hypothesis that organophosphates contribute to the self-reported ill-health of sheep dippers.

Small-dense low-density lipoprotein (SD-LDL) is associated with coronary heart disease risk. Current methods for its quantification are expensive, complex and time-consuming. Plasma was adjusted to a density (D) of 1.044 g/ml in a volume of 0.18 ml and centrifuged in a Beckman Airfuge at 160 000 x g for 3 h 7 min and apolipoprotein B (apoB) then determined in the infranatant. Results were compared with centrifugation of 5 ml of plasma at D = 1.044 g/ml at 144 000 x g for 18 h in a preparative ultracentrifuge (UC). We obtained blood samples from healthy subjects (n = 73) and from dyslipidaemic patients (n = 112). SD-LDL apoB levels as determined using the UC method ranged from 0.01-0.43 g/l and there was a good correlation with Airfuge results (r = 0.925; p < 0.0001; n = 185). There was a mean difference of 0.0125 g/l between methods. SD-LDL apoB levels as determined using the Airfuge showed a reasonable agreement with results obtained using density gradient ultracentrifugation (r = 0.773; p < 0.01; n = 12). Airfuge results correlated directly with triglyceride concentration, in both healthy men (r = 0.296; p < 0.05) and dyslipidaemic men (r = 0.520; p < 0.001) and also in dyslipidaemic women (r = 0.463; p < 0.005). Airfuge results correlated inversely with high-density lipoprotein-cholesterol (HDL-C) concentration, in both healthy men (r = -0.237; p < 0.05) and dyslipidaemic men (r = -0.293; p < 0.005). Using a micro-method, we obtained results which establish that the Airfuge provides a more rapid and less expensive method for quantification of SD-LDL.

AIM:To describe baseline characteristics of patients in the Collaborative AtoRvastatin Diabetes Study (CARDS), a randomized, placebo-controlled trial of lipid lowering with atorvastatin 10 mg daily for the primary prevention of major cardiovascular events in patients with Type 2 diabetes. METHODS:The main eligibility criteria were Type 2 diabetes, age 40-75 years, no previous history of coronary heart disease, stroke or other major cardiovascular events, a documented history of at least one of retinopathy, micro- or macroalbuminuria, hypertension or current smoking, LDL-cholesterol < or = 4.14 mmol/l and triglycerides < or = 6.78 mmol/l. RESULTS:Randomization of 2838 persons (909 women) into CARDS was completed in June 2001. At entry, mean age was 62 years, 12% were over 70 years old and median duration of diabetes was 6 years. Median fasting lipid levels were total cholesterol 5.4 mmol/l, LDL-cholesterol 3.1 mmol/l, HDL-cholesterol 1.4 mmol/l and triglyceride 1.7 mmol/l. There was a documented history of retinopathy in 30% of patients, micro/macroalbuminuria in 11% (additionally 17% had micro/macroalbuminuria based on two elevated pretreatment measurements of albumin-creatinine ratios), hypertension in 79% and 23% were current smokers. CONCLUSION:CARDS will contribute importantly to the evidence for the macrovascular and microvascular benefits of lipid lowering with atorvastatin in patients with Type 2 diabetes. The results are likely to have important implications for the management of patients.

BACKGROUND:Type 2 diabetes is associated with a substantially increased risk of cardiovascular disease, but the role of lipid-lowering therapy with statins for the primary prevention of cardiovascular disease in diabetes is inadequately defined. We aimed to assess the effectiveness of atorvastatin 10 mg daily for primary prevention of major cardiovascular events in patients with type 2 diabetes without high concentrations of LDL-cholesterol.METHODS:2838 patients aged 40-75 years in 132 centres in the UK and Ireland were randomised to placebo (n=1410) or atorvastatin 10 mg daily (n=1428). Study entrants had no documented previous history of cardiovascular disease, an LDL-cholesterol concentration of 4.14 mmol/L or lower, a fasting triglyceride amount of 6.78 mmol/L or less, and at least one of the following: retinopathy, albuminuria, current smoking, or hypertension. The primary endpoint was time to first occurrence of the following: acute coronary heart disease events, coronary revascularisation, or stroke. Analysis was by intention to treat.FINDINGS:The trial was terminated 2 years earlier than expected because the prespecified early stopping rule for efficacy had been met. Median duration of follow-up was 3.9 years (IQR 3.0-4.7). 127 patients allocated placebo (2.46 per 100 person-years at risk) and 83 allocated atorvastatin (1.54 per 100 person-years at risk) had at least one major cardiovascular event (rate reduction 37% [95% CI -52 to -17], p=0.001). Treatment would be expected to prevent at least 37 major vascular events per 1000 such people treated for 4 years. Assessed separately, acute coronary heart disease events were reduced by 36% (-55 to -9), coronary revascularisations by 31% (-59 to 16), and rate of stroke by 48% (-69 to -11). Atorvastatin reduced the death rate by 27% (-48 to 1, p=0.059). No excess of adverse events was noted in the atorvastatin group.INTERPRETATION:Atorvastatin 10 mg daily is safe and efficacious in reducing the risk of first cardiovascular disease events, including stroke, in patients with type 2 diabetes without high LDL-cholesterol. No justification is available for having a particular threshold level of LDL-cholesterol as the sole arbiter of which patients with type 2 diabetes should receive statins. The debate about whether all people with this disorder warrant statin treatment should now focus on whether any patients are at sufficiently low risk for this treatment to be withheld.

OBJECTIVE:Medroxyprogesterone (MP) was used as the progestogen in randomized clinical trials of postmenopausal hormone replacement on cardiovascular risk. To attempt to understand the lack of benefit in these trials, we have examined the effects of MP and two other progestogens, the less androgenic desogestrel (DG) and the more androgenic norethisterone (NE), on cardiovascular risk factors against a background of oestrogen therapy. DESIGN AND MEASUREMENTS:Thirty-four women were treated with conjugated equine oestrogens (CEE) 0.625 mg daily alone for 12 weeks, followed in random order by each of the three progestogens (DG 75 microg, MP 10 mg and NE 1 mg daily) given sequentially for three 12-week cycles while maintaining the same CEE treatment. We measured serum lipoproteins, paraoxonase activity, C-reactive protein (CRP), fibrinogen, fasting glucose and insulin levels at baseline, at the end of the oestrogen-only phase and at the end of each of the combined oestrogen and progestogen phases. RESULTS:The addition of progestogens to CEE maintained the oestrogen-induced reduction in apolipoprotein B (apo B) and lipoprotein (a) [Lp(a)], and further lowered total cholesterol (P < 0.01) and fibrinogen (P < 0.001). CEE raised serum triglyceride (P < 0.001) and CRP (P < 0.01) concentrations, which reverted towards pre-oestrogen levels with progestogens. Progestogens significantly reduced high density lipoprotein (HDL) cholesterol (P < 0.05). NE was associated with the greatest reduction in HDL cholesterol and apo A1, but was most effective in preserving paraoxonase activity and reducing the potentially unfavourable oestrogen-induced increases in triglycerides and CRP. CONCLUSION:Preconceptions that more androgenic progestogens necessarily have more unfavourable effects on cardiovascular risk factors may require revision.

BACKGROUND:Existing methods for detecting small-dense low-density lipoprotein (SD-LDL) are either semiquantitative (e.g., gradient gel electrophoresis) or require specialised laboratory methods (e.g., density-gradient ultracentrifugation, DGU). METHODS:We report a method in which plasma was adjusted to a density (D) of 1.044 and 1.060 g/ml, respectively, in two tubes, both of which underwent ultracentrifugation (UC). A measure of SD-LDL apolipoprotein B (apo B) was obtained by subtraction of the apo B concentration in D>1.060 g/ml lipoproteins from that in D>1.044 g/ml lipoproteins to correct for apo B associated with lipoprotein (a) [Lp(a)]. This procedure was evaluated in paired plasma samples in healthy men (n=62) and in age-matched healthy women (n=74) and in age-matched primary dyslipidaemic men (n=72) and women (n=29) and compared with an established density-gradient ultracentrifugation (DGU) method. RESULTS:The dyslipidaemic patients had either decreased high-density lipoprotein cholesterol (HDL-C) and/or increased triglycerides. In dyslipidaemic men, SD-LDL apo B level (23 [5-77] mg/dl) was significantly higher than in healthy men (P<0.001). In dyslipidaemic women, the SD-LDL apo B levels (11 [4-71] mg/dl) were significantly higher than in healthy women (7 [1-45] mg/dl; P<0.005). The concentration of SD-LDL apo B correlated inversely with HDL-C in both women (r=-0.280: P<0.005) and men (r=-0.464; P<0.0001) and positively with triglyceride concentration in both women (r=0.213; P<0.05) and men (r=0.592: P<0.0001). Correction for apo B in Lp(a) increased the analytical variation, which was 12% for apo B at D=1.044-1.060 g/ml and 9% for apo B measured at D>1.044 g/ml. Although the correlation between the new method and DGU results was high (r=0.830; P<0.0001, n=43), the concentration of apo B at D>1.044 g/ml correlated strongly with both corrected results (r=0.978; P<0.0001; n=237) and also with SD-LDL isolated using the DGU method (r=0.832; P<0.0001). Results at D>1.044 g/ml showed the expected correlations both with HDL-C (r=-0.465: P<0.0001) and triglycerides (r=0.526; P<0.0001). CONCLUSIONS:The new method gave results consistent with earlier published findings using other techniques. Further simplification of the method using a single-density spin at D>1.044 g/ml appears feasible and may provide an easier quantitative method for clinical use.

Serum paraoxonase (PON1) is a high-density lipoprotein (HDL) associated protein, which plays a critical role in the pathogenesis of atherosclerosis, although it was primarily associated with the hydrolysis of organophosphorus compounds. PON1 was initially thought to be independent from physiological or pathological states, although recently some environmental factors have been reported to modulate its activity. In this study, we have investigated the promoter (PON1 -108C/T and -909 C/G) and coding region (PON1 192Q/R and 55L/M) polymorphisms, as well as PON1 activity towards different substrates (paraoxon, phenylacetate and diazoxon) in 102 individuals with long term low dose exposure to pesticides in a plastic greenhouse setting (sprayers), who are probably the group of agricultural workers with the highest exposure to pesticides. PON1 activity towards paraoxon was nonsignificantly decreased (up to 53.5%) in the sprayers subgroup exposed to organophosphates (n = 41) compared with nonsprayers acting as controls (n = 39). None of the genotypes studied was associated significantly with the subgroup of individuals exposed to organophosphates, although differences between sprayers and nonsprayers were observed in the PON1 -909 G/C polymorphism. Among the environmental factors that significantly predicted lower rates of PON1 activity towards paraoxon are, interestingly, the exposure to organophosphates and current smoking. By contrast, the utilization of protective clothing while spraying pesticides inside the greenhouses was positively associated with PON1 activity, very likely by preventing the pesticides from being absorbed. This study suggests that chronic exposure to pesticides might decrease PON1 activity and pinpoints the potential usefulness of monitoring PON1 activity in occupational settings where exposure to organophosphates occurs.

The effect of statin therapy on subclasses of LDL, VLDL and HDL lipoproteins is unclear. We compared changes in serum lipids, apolipoproteins and nuclear magnetic resonance (NMR) spectroscopy measured lipoprotein subclass concentration and average particle size over a minimum 6 months treatment period of atorvastatin 10 mg vs. placebo in 122 men and women. All subjects had type 2 diabetes and a modest dyslipidaemia (mean LDL-cholesterol 3.2 mmol/l and median triglycerides 1.8 mmol/l) and had a previous myocardial infarction. Compared with placebo, atorvastatin therapy was associated with a greater decrease in medium VLDL (median within person change -13.4 vs. -5.9 nmol/l, P<0.001 adjusted for baseline level), small VLDL (median change -17.8 vs. -8.1 nmol/l, P=0.002), large LDL (mean within person change -167.9 vs. -48.6 nmol/l, P<0.001) and medium LDL (median within person change -101.8 vs. -22.3 nmol/l, P=0.017). Atorvastatin therapy was also associated with a greater increase in large HDL than placebo (median change 1.40 vs. 0.80 micromol/l, P=0.02) and there was little change in small HDL so that average HDL particle size increased significantly with atorvastatin (P=0.04). In addition to reducing levels of (enzymatically measured) triglyceride, LDL-cholesterol and apolipoprotein B in diabetic patients, atorvastatin significantly reduces NMR measured medium and small VLDL and large and medium LDL, and increases large HDL.

Aims: To describe the clinical features of two patients with paraproteinaemia and necrobiotic xanthogranulomatosis together with detailed immunohistochemistry of the lesions in one. Methods: The clinical history and results of biochemical investigations of the patients were retrieved from the files. Immunohistochemistry was used to investigate the expression of macrophage and mast cell markers, amyloid A and P, S-100 protein, and apolipoprotein AI and B in xanthogranulomatous skin lesions from patient 2. In addition, protein A–sepharose chromatography was used to separate serum from patient 2 and apolipoprotein B and the IgG paraprotein were measured in the fractions eluted. Results: Monocytes/macrophages comprised the major cellular component of the lesion, and unusually for xanthomata, areas of collagen necrosis were also seen. Activated mast cells were present at the margins of macrophage clusters and adjacent to areas of collagen necrosis. Serum paraprotein was bound to low density lipoproteins as judged by protein A–sepharose chromatography, and was also located within macrophagic foam cells of the lesion on immunohistochemistry. Conclusions: These observations demonstrate many features similar to atherosclerosis including collagen necrosis and mast cell activation.

Vivien Choo (July 20, p 235)1 reports WHO's recommendation for a narrower body-mass index (BMI) range (18·5–23·0 kg/m2) for Asians, based on data from body-fat percentage and BMI from ten Asian countries. We have completed a study of cardiovascular risk factors in a community of Indian migrants living in the UK (n=242) and their contemporaries in rural India (305). Using standardised methods in age-matched and sex-matched cohorts, we found that the rates of obesity were different between the two populations.

Serum paraoxonase 1 (PON1) is primarily responsible for the antioxidative activity of high-density lipoprotein (HDL). PON1 protects against the oxidative modification of low-density lipoprotein, apparently by hydrolysing lipid-peroxides. A mechanism for this process is proposed here. In the light of current knowledge, the mechanism has two fundamental requirements. Firstly, that lysolipids are safe to produce on HDL and secondly, that PON1 has two active sites. Data are also presented on the first prospective study of PON1 activity and CHD, showing low PON1 activity to be an independent risk factor for CHD, independent of all other risk factors including HDL.

Serum paraoxonase (PON1) is responsible for the metabolism of organophosphates in serum, and PON1 activity is a major determinant of their toxicity in humans. There have been reports linking lowered PON1 activity to physical symptoms after deployment to the Persian Gulf War (PGW) of 1990 to 1991. Therefore, the object of this study was to determine (1) whether PON1 activity was decreased among symptomatic PGW veterans compared with asymptomatic PGW veterans and (2) to determine whether PGW veterans as a whole had lower PON1 activity compared with other military control groups. This was a case control study nested in occupational cohort study of military personnel. Four groups of military personnel were identified from a large epidemiological study of health effects of deployment to the PGW and Bosnia: (1) symptomatic PGW veterans, n = 115; (2) healthy PGW veterans, n = 95; (3) symptomatic Bosnia peacekeeping veterans, n = 52; and (4) symptomatic nondeployed military controls, n = 85. The main outcome measures were PON1 activity and genotype for PON1-55 and -192. We found significant differences in PON1 activity among these four groups, and although the two Gulf groups did not differ in PON1 activity, those deployed to the Gulf had significantly lower PON1 activity compared with the non-PGW groups (median difference = 70.9; 95% CI: 20.2, 121.5, P = 0.012). These differences were not explained by a range of potential confounders, or differences in PON1 coding region polymorphisms. PON1 activity is reduced in PGW veterans compared with military control groups. The effect is independent of ill health in PGW veterans.

Background There are few data on the role of lipid lowering in the primary prevention of coronary heart disease (CHD) in diabetic patients. This paper describes the design of a collaborative clinical trial between Diabetes UK, the NHS Research and Development Directorate and Pfizer UK, that addresses this question.Methods The Collaborative AtoRvastatin Diabetes Study (CARDS) is a multicentre, randomized, placebo-controlled, double-blind clinical trial of primary prevention of cardiovascular disease in patients with Type 2 diabetes. The primary objective is to investigate whether treatment with the hydroxymethylglutaryl coenzyme A reductase inhibitor, atorvastatin, reduces the incidence of major cardiovascular events. At entry patients have at least one other risk factor for CHD in addition to diabetes, namely current smoking, hypertension, retinopathy, or micro- or macroalbuminuria. At randomization patients have been selected for a serum low-density lipoprotein (LDL) cholesterol concentration less than or equal to 4.14 mmol/l (160 mg/dl) and triglycerides less than or equal to 6.78 mmol/l (600 mg/dl). Randomization was completed in June 2001. Patients will be followed until 304 primary endpoints have accrued (expected date early 2005). The trial includes 2838 men and women aged 40-75 years. This report describes the design and administration of the study and reviews the evidence to date of the effectiveness of lipid-lowering therapy in Type 2 diabetes.Conclusions The case for lipid-lowering therapy for the primary prevention of CHD in diabetes has not been demonstrated. CARDS will provide essential information on the extent of any benefits and adverse effects of lipid-lowering therapy in diabetic patients without prior CHD.

BACKGROUND:The oxidation of low-density lipoprotein (LDL) is central to current theories on the initiation and progression of atherosclerosis. Type 1 diabetes is associated with an increase in oxidative stress, which may be responsible for the increased susceptibility to coronary heart disease seen in type 1 diabetes. High-density lipoprotein (HDL) associated paraoxonase (PON1) can retard the oxidation of LDL. DESIGN:Paraoxonase activity, concentration and genotype were therefore investigated in 152 people with type 1 diabetes and 282 healthy controls. These parameters were also investigated in the group with type 1 diabetes in relation to the presence of diabetic complications. RESULTS:Both PON1 activity and concentration were significantly lower by 16.7% and 19.2% (both P < 0.05) in the type 1 diabetes group. These differences were independent of the PON1 coding region polymorphisms. The distribution of PON1 activity and mass were the same in both populations, i.e. for the PON1-192 polymorphism RR > RQ > QQ and for the PON1-55 polymorphism LL > LM > MM. There were no differences in either the PON1 polymorphisms, PON1 activity and concentration in people with type 1 diabetes in the presence or absence of micro and macro vascular complications of diabetes. CONCLUSIONS:Low PON1 activity may contribute to the increased atherosclerosis found in type 1 diabetes by reducing the ability of HDL to retard LDL oxidation despite the frequently-found increased HDL in type 1 diabetes when good glycaemic control is established.

onsiderable experimental evidence suggests that lipid peroxides on LDL and their breakdown products are responsible for the physical changes in the LDL particle and the fragmentation of its apolipoprotein B, which permit it to bind to a wide range of high-affinity receptors on cells in the arterial wall, such as endothelial cells, macrophages, and smooth muscle cells, which are key players in atherosclerosis. 1 Fat-soluble antioxidant vitamins in vitro delay the oxidation of LDL, 2 suggesting that they might have the therapeutic potential to protect against coronary heart disease (CHD).3][4] The reasons for this have been reviewed, 5 but germane to the issue may be that the protection against oxidation afforded to LDL by fat-soluble antioxidants is relatively short lived, being principally in the extension of the early lag phase in lipid peroxidation (conjugated diene formation) by a matter of minutes.They act as antioxidants only when they are more susceptible to oxidation than the molecules they protect, and once oxidized, they can become pro-oxidants. 2Additionally, erosion of their potential benefit may stem from their effect in increasing cholesteryl ester heteroexchange 6,7 which is increasingly being viewed as proatherogenic. 8 -10 It could explain the amelioration by high-dose antioxidant vitamins of the regression of coronary atheroma induced by lipid-lowering drugs. 11