Carbohydrate counting as a strategy to optimize glycemic control in type 1 diabetes mellitus

ABSTRACT Objective: The objective of this study was to verify the impact of carbohydrate counting (CC) on glycemic control and body weight variation (primary and secondary outcomes, respectively) between consultations in patients with diabetes mellitus (T1D) followed at a tertiary hospital in southern Brazil in a public health system environment. We also sought to investigate CC adherence. Materials and methods: This retrospective cohort study included 232 patients with T1D who underwent nutritional monitoring at a referral hospital for diabetes care between 2014 and 2018. To assess primary and secondary outcomes, data from 229 patients, 49 of whom underwent CC during this period and 180 individuals who used fixed doses of insulin, were analyzed. The impact of CC on glycemic control was assessed with the mean glycated hemoglobin (HbA1c) level at all consultations during the follow-up period. Results: In the model adjusted for the most confounders (except pregnancy), the mean HbA1c was better in the CC group (8.66 ± 0.4% vs. 9.36 ± 0.39%; p = 0.016), and body weight variation was lower (0.13 ± 0.28 kg vs. 0.53 ± 0.24 kg; p = 0.024). Adherence to CC was reported in 69.2% of consultations. Conclusion: CC optimized the glycemic control of individuals with T1D, resulting in less weight variation than in the fixed insulin dose group, which indicates that CC is an important care strategy for these patients.

Body adiposity markers and insulin resistance in patients with type 1 diabetes

ABSTRACT Objectives: Body composition changes are associated with adverse effects such as increased insulin resistance (IR) in individuals with diabetes mellitus. This study aims to evaluate the association between different body adiposity markers and IR in adults with type 1 diabetes (T1D). Subjects and methods: The cross-sectional study included outpatient adults with T1D from a university public hospital in southern Brazil. The body adiposity markers studied were waist circumference (WC), waist-height ratio (WHtR), body mass index (BMI), conicity index (CI), lipid accumulation product (LAP) and body adiposity index (BAI). IR was calculated using an Estimated Glucose Disposal Rate (EGDR) equation (analyzed in tertiles), considering an inverse relation between EGDR and IR. Poisson regression models were used to estimate the odds ratio (OR) and 95% CIs of association of adiposity markers with IR. Results: A total of 128 patients were enrolled (51% women), with a median EGDR of 7.2 (4.4-8.7) mg.kg−1.min−1. EGDR was negatively correlated with WC (r = −0.36, p < 0.01), WHtR (r = −0.39, p < 0.01), CI (r = −0.44, p < 0.01), LAP (r = −0.41, p < 0.01) and BMI (r = −0.24, p < 0.01). After regression analyses, WC (OR = 2.07; CIs: 1.12-3.337; p = 0.003), WHtR (OR = 2.77; CIs: 1.59-4.79; p < 0.001), CI (OR = 2.59; CIs: 1.43-4.66; p = 0.002), LAP (OR = 2.27; CIs: 1.25-4.11; p = 0.007) and BMI (OR = 1.78; CIs: 1.09-2.91; p = 0.019) remained associated with IR. Conclusions: The authors suggest using the studied adiposity markers as a routine since they were shown to be suitable parameters in association with IR.

Association between fixed night work and obesity: a systematic literature review

This systematic review aimed to evaluate the association between fixed night work and overweight or weight gain. PubMed and EMBASE were searched until October 2021 for studies evaluating the association between fixed night work patterns and the risk of overweight or obesity (for cross-sectional designs) or weight gain (for longitudinal designs). The outcomes extracted were mean body mass index (BMI), mean BMI difference, overweight %, obesity %, odds ratio, relative risk, and prevalence ratio. The quality of the report was evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. The protocol was registered at PROSPERO (# 42017080515). In total, 25 studies met the inclusion criteria. All studies were observational, 16 were cross-sectional, three were cohorts (two also had baseline cross-sectional data), and the other eight were cross-sectional at baseline and had longitudinal follow-up studies (six prospective cohorts, one retrospective, one interventional). Most had good reporting quality. The fixed night work definition and weight outcomes varied according to the different studies. Most of them found an association between fixed night work and overweight, obesity, or weight gain. This systematic review reinforces the evidence that fixed night work is associated with overweight or obesity, and prolonged night work exposure leads to weight gain. Future research should be conducted with more accurate measures and a prospective design. Fixed night workers should be monitored and advised, especially those with prolonged exposure.

Psychiatric illness, emotional distress, glycemic control and chronic complications in type 1 diabetes subjects

ABSTRACT Objectives: To assess the prevalence of psychiatric disorders in patients with type 1 diabetes mellitus (T1D) and to compare patients with and without psychiatric disorder. Materials and methods: We made a cross-sectional study including patients with T1D assisted in the outpatient clinics of the Brazilian National Health System. To assess depression and anxiety, we used the PHQ-9 questionnaire and the DSM-5th edition criteria, respectively. B-PAID evaluated the level of emotional distress associated with diabetes; EAT-26, eating disorders; SCI-R, adherence to the proposed clinical treatment. Results: We analyzed 166 patients aged 33 (22-45.2) years, 53.6% female. The prevalence of depression and anxiety was 20.5% and 40.4%, respectively. HbA1c was worse in the depressed (9.0% vs. 8.4%, p = 0.008), in the anxious ones (9.0% vs. 8.3%, p = 0.012) and in the patients with high levels of B-PAID (8.8 % vs. 8.3 %, p = 0.009). There was no difference in the prevalence of complications related to diabetes. Conclusions: The prevalence of psychiatric disorders and emotional distress related to diabetes was high in our population of T1D patients, and depression and high levels of B-PAID were associated with the worse glycemic control.

Multifactorial intervention for diabetes control among older users of insulin

ABSTRACT OBJECTIVE: To evaluate if the closer follow-up with the supply of insulin pens and the measurement of capillary blood glucose improve the management of older patients with type 2 diabetes without adequate glycemic control despite extensive therapy. METHODS: This is a prospective, non-randomized, quasi-experimental study. We have included 45 patients over 60 years old, from both sexes, with glycated hemoglobin (HbA1c) > 8.5% using oral hypoglycemic agents and insulin. The intervention consisted of monthly medical visits, with the provision of insulin pens and strips for blood glucose measurement. All patients received insulin pen, refills of Neutral Protamine Hagedorn and regular insulin, needles for the pen, blood glucose meter, and capillary blood glucose tests (three tests/day). Treatment was adjusted with the same endocrinologist monthly for six months. Glycated hemoglobin was measured at baseline and 12 and 24 weeks after intervention. RESULTS: Glycated hemoglobin at baseline was 10.34% (SE = 0.22%) and 8.54% (SE = 0.24%, p < 0.001) and 8.09% (SE = 0.21%, p < 0.001) at 12 and 24 weeks after intervention, respectively, with a significant reduction from baseline. CONCLUSIONS: More frequent medical visits, with treatment inputs including the use of insulin pens and self-monitoring, have improved glycemic control (reduction of 2.25% in HbA1C, on average, at 24 weeks of follow-up). Our data support a change in the management and medical behavior of older patients with chronically decompensated diabetes.

Physical activity level and hypoglycemia in type 1 diabetes patients

Introduction: The recommended management for individuals with type 1 diabetes (T1D) includes an intensive treatment with insulin therapy and the practice of regular exercise. However, this association is related with hypoglycemia episodes. Objective: The aim of this study was to perform a cross-sectional evaluation of the association between the physical activity (PA) level and hypoglycemia episodes reported in patients with T1D. Methods: Adult outpatients with T1D had their PA level assessed by the International Physical Activity Questionnaire (long form), considering the intensity of the physical activity (vigorous, moderate and/or walks) in daily activities, such as at work, means of transport, domestic activities and at leisure, and answered questions about self-care and hypoglycemia episodes. Results: The study included 126 patients who presented the following characteristics: mean age of 35 (28-47) years old and 16 (11-24) years of diabetes duration, 55% women, HbA1c=9.3 ± 2.1%, and body mass index = 25.0 ± 4.2 kg/m2 . Very active patients had lower values of glucose and LDL-cholesterol when compared with the less active group. A greater proportion of active (48.1%) and very active patients (66.7%) reported practicing exercise regularly when compared with the less active subjects (13.3%; P=0.003). Less active patients had a three-fold chance of reporting hypoglycemia episodes when compared with very active patients (OR=3.49; CI 95%: 1.26-9.70; P=0.016). Conclusions: Less active adults with T1D presented more hypoglycemia, probably due to the practice of informal moderate and/or vigorous activities without specific self-care.

Dietary fatty acids and cardiovascular disease: a review

Fatty acids (FAs) can be classified into saturated (SFA), unsaturated (poly- or monounsaturated) and trans FA. Recent studies have found that both the quantity and quality of dietary FAs may influence their role in metabolic pathways. Due to their chemical composition, some FAs play a major role in the development and progression of cardiovascular disease. This is especially true for SFA and n-3 polyunsaturated fatty acids, which include marine eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The proinflammatory effects of high SFA intake may increase the risk of atherosclerosis. On the other hand, dietary n-3 intake may reduce the risk of cardiovascular disease by decreasing atherosclerosis, inflammation, and thrombotic processes. The goal of this study was to review the current literature on the role of FA intake in the prevention and risk of cardiovascular disease...

Nível de atividade física e exercício físico em pacientes com diabetes mellitus / Physical activity level and exercise in patients with diabetes mellitus

OBJETIVO: Comparar nível de atividade física (NAF) e cuidados relacionados ao exercício físico (EF) em pacientes com diabetes mellitus (DM). MÉTODOS: Pacientes com DM ambulatoriais (adultos e usuários de insulina) foram avaliados conforme NAF (questionário internacional; atividades moderadas, intensas e caminhadas realizadas em uma semana típica), questionados sobre prática formal de EF, autocuidado e episódios de hipoglicemia relacionados ao EF e motivos para não praticá-lo. RESULTADOS: Foram avaliados 225 pacientes: 107 (47,6%) com diabetes mellitus tipo 2 (DM2) e 118 (52,4%) com diabetes mellitus tipo 1 (DM1), sendo maior o número de pacientes com DM2 classificados como pouco ativos [33 (30,7%) vs. 12 (10,3%)] e menor a proporção dos muito ativos [9 (8,7%) vs. 29 (25%)], quando comparados com pacientes com DM1. Não praticantes de EF (n = 140) o faziam por motivos diferentes: pacientes com DM2 por "desconforto", "restrição médica" e "não gostarem"; pacientes com DM1 por "falta de tempo", "preguiça" e "hipoglicemia". Apenas 85 pacientes praticavam EF regularmente, independente do NAF, e 38,8% realizavam autocuidados como alimentação, alongamento, monitoramento da glicemia capilar. Pacientes com DM2 [5 (14,3%)] relataram menos episódios de hipoglicemia relacionada ao EF do que aqueles com DM1 [17 (34%)]. CONCLUSÃO: Pacientes com DM2 possuem NAF e comportamento relacionado à prática de EF diferentes de pacientes com DM1.

OBJECTIVE: To compare physical activity level (PAL) and care related to exercise in patients with diabetes mellitus (DM). METHODS: DM outpatients (adult, insulin-user patients) were assessed for PAL (international questionnaire; moderate- and high-level activities, as well as walking, over a typical week) and questioned about formal exercise practice, self-care, and hypoglycemic episodes related to exercise or reasons for not exercising. RESULTS: Two hundred twenty five patients were assessed: 107 (47.6%) had type 2 diabetes mellitus (DM2) and 118 (52.4%) had type 1 diabetes mellitus (DM1), with a larger percentage of patients with DM2 being classified as poorly active [33 (30.7%) versus 12 (10.3%)] and a lower percentage being classified as highly active [9 (8.7%) versus 29 (25%)], compared with patients having DM1. Patients who do not exercise (n = 140) gave different reasons for not doing so: patients with DM2 claimed that they "felt uncomfortable", "presented medical restrictions", and "did not like it"; DM1 patients claimed that they "had no time to exercise", "were lazy", and "had hypoglycemic episodes". Only 85 patients exercised regularly, regardless of the PAL, and 38.8% performed self-care, such as eating, stretching, and capillary glucose monitoring. Patients with DM2 [5 (14.3%)] reported a lower number of hypoglycemic episodes related to exercise than those with DM1 [17 (34%)]. CONCLUSION: Patients with DM2 have different PAL and behavior related to exercise than those seen in DM1 patients.

Infecções no paciente com diabetes melito / Infection in patient with diabetes mellitus

É conhecido que o paciente com diabetes é mais susceptível a infecções. Entretanto, apesar de frequentes, determinados tipos de infecções cutâneas nem sempre são familiares ao médico que presta o atendimento a este paciente. O objetivo deste artigo foi revisar as infecções mais comuns nos pacientes com diabetes, através de uma abordagem simplificada do quadro clinico, diagnóstico e primeiro atendimento.

It is well-known that patients with diabetes are more susceptible to infections. Although frequent, specific types of skin infection are not always familiar to the physician providing care to this patient. The aim of this paper was to review the most common infections in patients with diabetes, using a simplified approach to clinical, diagnosis and first initial treatment.

Avaliação da tolerência à glicose em crianças e adolescentes com fibrose cística / Glucose tolerance evaluation in children and adolescents with cystic fibrosis

Introdução: Cerca de 20% dos adolescentes com fibrose cística têm diabetes melito (DM) relacionado à fibrose cística (FC). O teste oral de tolerância à glicose (TOTG) tem sido utilizado para identificar alterações no metabolismo da glicose. Objetivo: O objetivo deste estudo foi identificar as alterações no metabolismo da glicose em crianças e adolescentes com FC e descrever as características clínicas e laboratoriais relacionadas à tolerância diminuída à glicose (TDG) e DM nesse grupo de pacientes. Pacientes e métodos: Foi realizado um estudo transversal envolvendo crianças e adolescentes com diagnóstico de FC em atendimento no Hospital de Clínicas de Porto Alegre. TOTG com glicose na dose de 1,75 g/kg de peso com dose máxima de 75 g foi realizado. Resultados: No total foram avaliados 58 pacientes (1,9-16,9 anos). TDG foi encontrada em 6 pacientes e presença de DM em 1, todos acima de dez anos de idade. Estes 7 pacientes foram comparados com os outros 29 pacientes de mesma faixa etária com TOTG normal. Os pacientes com o TOTG alterado eram mais velhos (14±1,2 vs. 10,6±4 anos, P<0,001), apresentaram maior tempo de duração da FC (13±2,6 vs. 9±4 anos, P<0,0006) e apresentaram maior número de internações (6 [5-16] vs. 3 [1,5-8,5], P<0,029). Conclusão: Neste estudo foi observada uma prevalência de alteração da tolerância à glicose de 12% em crianças e adolescentes com FC.

Background: About 20% of adolescents with cystic fibrosis (CF) present diabetes related to this condition. The oral glucose tolerance test (OGTT) has been used to identify alterations in glucose metabolism in these patients. Aim: The aim of this study was to identify changes in glucose metabolism in children and adolescents with CF and to describe the clinical and laboratory characteristics related to impaired glucose tolerance (IGT) and diabetes. Patients and methods: This was a cross-sectional study involving children and adolescents with cystic fibrosis (CF). An OGTT with 1.75 g glucose/kg - max 75 g was performed. Results: Fifty-eight individuals (1.9-16.9 years) were evaluated. IGT was found in six and diabetes in one; all were older than 10 years. These 7 patients were compared to the 29 with normal OGTT with the same age. The patients with altered OGTT were older (14±1.2 vs 10.6±4years, P<0.001), had longer FC duration (13±2.6 vs. 9±4 years, P<0.006), and had a higher number of hospitalizations (6 [5-16] vs 3[1.5- 8.5], P<0.029). Conclusion: In this study the prevalence of impaired glucose tolerance was 12% in children and adolescents with CF.

Diabetes melito e acromegalia: interações entre hormônio de crescimento e insulina / Diabetes mellitus and acromegaly: interactions between growth hormone and insulin

Introdução: o hormônio de crescimento humano (GH) possui um importante papel na fisiologia do metabolismo glicêmico, lipídico e protéico. O excesso deste hormônio, como encontrado na acromegalia, induz a um estado de resistência insulínica que pode estar associado à presença de diabetes melito (DM). Objetivo: descrever a frequência de DM e as características dos indivíduos com acromegalia e DM em acompanhamento no Hospital de Clínicas de Porto Alegre (HCPA). Métodos: estudo transversal avaliando o perfil clínico e laboratorial de uma coorte de pacientes com acromegalia. Os critérios utilizados para cura da doença foram os sugeridos pelo consenso de 2000 e, para considerar-se sob remissão, a presença de IGF-1 normal para sexo e idade em uso de medicação para controle da acromegalia. As dosagens de IGF-1 foram realizadas pelo método imunoradiométrico e as de GH por quimioluminescência. Resultados: cinquenta e nove pacientes com acromegalia foram analisados. Desses, 24% preencheram critérios de cura e 25% estavam em remissão da doença, os restantes apresentavam doença ativa. Trinta e sete por cento dos pacientes apresentavam DM, com HbA1c média de 7,3±2,2%. Entre os pacientes com DM, 86% não preencheram critérios de cura e mais frequentemente eram hipertensos [16/22 (73%) vs. 17/37 (46%), P=0,04] e faziam mais uso de estatina [14/22 (64%) vs. 8/37 (21%), P=0,004] em relação aos pacientes sem DM. Após análise de regressão logística múltipla, a presença de DM foi associada à presença de acromegalia ativa [razão de chances: 17,4 (IC 95%: 1,08-28,0), P=0,04] e essa associação foi independente do ajuste para idade, níveis de IGF-1 ou GH, hipertensão arterial e níveis séricos de triglicerídeos. Conclusões: O DM foi frequente entre os pacientes com acromegalia e significativamente relacionado ao controle da doença.

Background: human growth hormone (GH) plays an important role in the physiology of glucose, lipid and protein metabolism. The excess of this hormone, such as in cases of acromegaly, leads to a state of insulin resistance that can be associated with diabetes. Aim: to describe the frequency of diabetes in the sample of patients with acromegaly followed up at Hospital de Clínicas de Porto Alegre (HCPA). Methods: cross-sectional study assessing the metabolic profile of a cohort of acromegalic patients. The criteria used for cure of the disease were those suggested in the 2000 consensus, and the remission criteria were presence of normal IGF-1 levels for age and gender. IGF-1 was measured using the immunoradiometric assay and GH levels were measured using chemiluminescence. Results: fifty-nine acromegalic patients were analyzed. Only 24% met criteria for cure and 25% were in remission, the remaining had active disease. Thirty-seven percent of patients had diabetes, with a mean HbA1c of 7.3±2.2%. Among patients with diabetes, 86% did not meet criteria for cure and they were more often hypertensive [16/22 (73%) vs. 17/37 (46%), P=0.04] and were on statins [14/22 (64%) vs. 8/37 (21%), P=0.004] compared with patients without diabetes. After the multiple regression analysis, the presence of diabetes was associated with the presence of active acromegaly [odds ratio: 17.4 (95% CI: 1.08-28.0), P=0.04], and this association was independent from adjustment for age, IGF-1 levels or GH levels, hypertension, and triglycerides levels. Conclusions: diabetes was frequent among patients with acromegaly and it was closely related to the control of the underlying disease.

Prevalência de síndrome metabólica em uma população de pacientes com excesso de peso (funcionários de um hospital de referência) / Prevalence of metabolic syndrome in a population of overweight workers at a reference hospital

Objetivo: Avaliar a prevalência da síndrome metabólica (SM) em uma população de pacientes com excesso de peso. Métodos: Estudo transversal realizado com 290 pacientes atendidos no ambulatório de medicina interna do Serviço de Medicina Ocupacional do Hospital de Clínicas de Porto Alegre, que consultaram por queixa de excesso de peso. Os critérios de inclusão foram idade acima de 18 anos, índice de massa corporal igual ou superior a 25 kg/m2 e ausência de diabetes melito. A SM foi definida segundo os critérios do National Cholesterol Education Program Adult Treatment Panel III. Resultados: A prevalência geral da SM neste grupo de indivíduos foi de 20,0%. Quando avaliamos apenas os pacientes com obesidade, a prevalência foi de 24,6%. Conclusões: A prevalência da SM foi semelhante à da população em geral, mesmo no grupo de obesos – um grupo teoricamente com maior risco de desenvolvimento da síndrome

Objective: To evaluate the prevalence of metabolic syndrome (MS) in a population of overweight patients. Methods: A crosssectional study was conducted in 290 patients, regularly receiving care at the internal medicine ambulatory of the Division of Occupational Medicine at Hospital de Clínicas de Porto Alegre, who had complaints of overweight. Inclusion criteria were age over 18 years, body mass index equal or higher than 25 kg/m2 and absence of diabetes mellitus. MS was defined according to criteria by the National Cholesterol Education Program Adult Treatment Panel III. Results: Prevalence of MS in this group of individuals was 20.0%. When only patients with obesity were assessed, prevalence was 24.6%. Conclusions: Prevalence of MS was similar to that of the general population, even in the group of obese patients, a group that theoretically has higher risk of developing MS

Prevalência de doenças orgânicas em pacientes deprimidos / Prevalence of organic diseases in depressed patients

Com o objetivo de se determinar a prevalência de distúrbios orgânicos em pacientes deprimidos, observar qual o tipo de distúrbio orgânico mais freqüente e verificar o início do episódio depressivo em relaçäo ao aparecimento da doença orgânica realizou-se um estudo prospectivo, transversal de uma amostra de 45 pacientes que freqüentaram o Ambulatório de Distúrbios Afetivos do Hospital Universitário de Santa Maria - Unidade Psiquiátrica, durante o período de janeiro/96 a janeiro/97. O critério de inclusäo destes pacientes na pesquisa foi o diagnóstico de Episódio Depresivo Maior, feito através do DSM-IV. Os pacientes foram entrevistados individualmente através de um questionário padronizado e pré-codificado e os dados coletados foram submetidos a testes de consistência estatística, segundo o programa da OMS, EPI-INFO 5.0. Dos 45 pacientes entrevistados, 30 (66,7 por cento) eram do sexo feminino, 16 (35,6 por cento) tinham entre 36 e 44 anos, 44 (97,8 por cento) eram da raça branca, 22 (48,9 por cento) eram casados e 12 (26,7 por cento) tinham entre 1 e 5 anos de estudo. Dentre os sinais e sintomas depressivos referidos, os mais freqüentes foram perda de energia/interesse em 91 por cento, alteraçöes no sono em 88,9 por cento, tristeza/choro em 86,7 por cento e pensamentos de morte/suicídio em 80 por cento dos pacientes. Quanto à presença de história familiar de distúrbios psiquiátricos tivemos que 21 (46,7 por cento) pacientes referiram pelo menos um distúrbio, sendo o abuso de álcool (42,8 por cento) o mais citado. Do total de entrevistados, 31 (68,9 por cento) referiram algum acontecimento estressante de vida no mesmo período do episódio depressivo, sendo difuculdades financeiras (16,2 por cento) o mais citado. A prevalência de doenças orgânicas foi de 48,9 por cento, sendo a hipertensäo arterial sistêmica referida por 29 por cento dos pacientes. Sintomas orgânicos foram referidos por 68,9 por cento dos pacientes, sendo a cefaléia (13,75 por cento) o mais prevalente. Referiram ter tido o episódio depressivo após o aparecimento de doença e/ou sintomatologia orgânica 63,2 por cento dos pacientes. Em virtude da elevada prevalência de doenças e sintomas orgânicos em pacientes deprimidos está justificada a investigaçäo de outros diagnósticos, alem da depressäo, que possam interferir com a evoluçäo, sintomatologia e prognóstico da mesma

Leiomiossarcoma em divertículo de Meckel: relato de caso / Leiomyosarcoma of Meckel's diverticulum: case report

Apresentamos um caso de Leiomissarcoma em Divertículo de Meckel, em paciente masculino, 65 anos, que após uma complicação de Ressecção Transuretral foi submetido à laparotomia. Durante a revisão da cavidade abdominal, encontrou-se uma tumoração distando 90 cm da válvula íleoceccal. A tumoração ressecada e o anatomopatológico revelou Leiomiossarcoma em Divertículo de Meckel.