Control glucémico y de los factores de riesgo cardiovascular en los pacientes con diabetes tipo 2 con enfermedad cardiovascular en España, y su patrón de tratamiento, en función del género: estudio CODICE / Blood glucose control and cardiovascular risk factors in type 2 diabetic patients with cardiovascular disease in Spain, and its treatment pattern, according to gender: CODICE study

INTRODUCCIÓN Y OBJETIVOS: Con la implementación de la Estrategia de Promoción de la Salud y Prevención en España, el escenario reflejado en estudios previos de infracontrol de los factores de riesgo cardiovascular (FRCV) en pacientes con diabetes tipo 2 (DM2) y enfermedad cardiovascular (ECV) puede haberse modificado, por lo que nos planteamos conocer el grado de control glucémico y de otros FRCV en los pacientes con DM2 y ECV atendidos actualmente en nuestro medio, el patrón de tratamiento antidiabético y las diferencias en función del género. MATERIALES Y MÉTODOS: Estudio epidemiológico, observacional, transversal, de ámbito nacional en pacientes de ambos géneros diagnosticados de DM2 y ECV establecida. RESULTADOS: Se incluyeron 3.143 pacientes. Edad media: 69,0±10 años. La HbA1c media fue mayor en mujeres que en varones (7,4±1,1% vs. 7,3±1,2%; p < 0,05), así como el colesterol-LDL (101,5±38,1mg/dl vs. 91,1±37,5mg/dl; p < 0,001), la presión arterial sistólica (137,0mmHg vs. 135,6mmHg; p < 0,05) y el índice de masa corporal (30,7±5,4kg/m2 vs. 29,6±4,5kg/m2; p < 0,001). Los tratamientos más utilizados fueron la metformina (68,1%) y/o inhibidores-DPP4 (53,7%), sin diferencias entre géneros. CONCLUSIONES: El grado de control glucémico de los pacientes con DM2 y ECV en España es mejorable. El perfil de tratamiento no se ajusta a las recomendaciones de las guías de práctica clínica en general. Las diferencias en el control de los FRCV son peores en mujeres para lípidos y obesidad

INTRODUCTION AND OBJECTIVES: With the implementation of the Strategy of Health Promotion and Prevention in Spain, the scenario reflected in previous studies of low control of cardiovascular risk factors (CVRF) in patients with type 2 diabetes (DM2) and cardiovascular disease (CVD) can be modified. This study intends to determine the level of blood glucose control and other CVRF in patients with DM2 and CVD currently seen in clinics in Spain, as well as the pattern of antidiabetic treatment, and differences according to gender. MATERIALS AND METHODS: An epidemiological, observational, cross-sectional, nationwide study was conducted in patients of both genders diagnosed with DM2 and established CVD. RESULTS: The study included 3,143 patients with a mean age 69.0±10 years. The mean HbA1c was 7.4±1.1% in females vs 7.3±1.2% in males (P<.05) and systolic blood pressure was 137±15.0mmHg in females vs 135.6±14.7mmHg in males (P<.05). The mean LDL-cholesterol was 101.5±38.1mg/dl in females vs 91.1±37.5mg/dl in males; P<.001) and the mean body mass index (30.7±5.4kg/m2 in females vs 29.6±4.5kg/m2 in males; P<.001). The most used treatments were metformin (68.1%) and/or DPP4 inhibitors (53.7%), with no differences between genders. CONCLUSIONS: The level of blood glucose control of DM2 patients with CVD in Spain can be improved. The treatment profile does not conform to the recommendations of clinical practice guidelines in general. The differences in the control of CVRF are worse in women for lipids and obesity

[Blood glucose control and cardiovascular risk factors in type 2 diabetic patients with cardiovascular disease in Spain, and its treatment pattern, according to gender: CODICE study]. / Control glucémico y de los factores de riesgo cardiovascular en los pacientes con diabetes tipo 2 con enfermedad cardiovascular en España, y su patrón de tratamiento, en función del género: Estudio CODICE.

INTRODUCTION AND OBJECTIVES: With the implementation of the Strategy of Health Promotion and Prevention in Spain, the scenario reflected in previous studies of low control of cardiovascular risk factors (CVRF) in patients with type 2 diabetes (DM2) and cardiovascular disease (CVD) can be modified. This study intends to determine the level of blood glucose control and other CVRF in patients with DM2 and CVD currently seen in clinics in Spain, as well as the pattern of antidiabetic treatment, and differences according to gender. MATERIALS AND METHODS: An epidemiological, observational, cross-sectional, nationwide study was conducted in patients of both genders diagnosed with DM2 and established CVD. RESULTS: The study included 3,143 patients with a mean age 69.0±10 years. The mean HbA1c was 7.4±1.1% in females vs 7.3±1.2% in males (P<.05) and systolic blood pressure was 137±15.0mmHg in females vs 135.6±14.7mmHg in males (P<.05). The mean LDL-cholesterol was 101.5±38.1mg/dl in females vs 91.1±37.5mg/dl in males; P<.001) and the mean body mass index (30.7±5.4kg/m2 in females vs 29.6±4.5kg/m2 in males; P<.001). The most used treatments were metformin (68.1%) and/or DPP4 inhibitors (53.7%), with no differences between genders. CONCLUSIONS: The level of blood glucose control of DM2 patients with CVD in Spain can be improved. The treatment profile does not conform to the recommendations of clinical practice guidelines in general. The differences in the control of CVRF are worse in women for lipids and obesity.

[Poor awareness among health care professionals about gender differences in the relationship between type 2 diabetes mellitus and cardiovascular disease]. / Escaso conocimiento entre los profesionales sanitarios sobre las diferencias de género en la asociación entre la diabetes tipo 2 y la enfermedad cardiovascular.

INTRODUCTION: Several studies have found poorer control of the cardiovascular risk factors among women with type 2 diabetes. This could be explained by the lack of awareness of their cardiovascular risk among professionals. AIMS: To determine the perception and knowledge of health care professionals involved in diabetes management on the impact of gender difference on the control of cardiovascular risk factors in patients with type 2 diabetes mellitus. METHODS: A 24-question survey related to knowledge and perceptions (grouped by topics) was sent to professionals who were interested and involved in diabetes care. A total of 998 surveys were analysed. An ANOVA model was constructed to compare the results by specialty and years of experience, as well as adjusting for the rest of the confounding factors. On having more than 12 correct answers (favourable result), a logistic regression was also performed in order to study the factors that could have an influence. RESULTS: The mean number of correct answers was 10.3, and was slightly better for specialists (range 10.7-11.8), and associated with years of experience (P=.001). Female gender and years of experience were identified as predictors of having more than 12 correct answers. CONCLUSIONS: The level of knowledge was low, but similar to the results of the other studies.

Psychometric properties of the Weight Locus of Control Scale (MWLCS): study with Spanish individuals of different anthropometric nutritional status.

INTRODUCTION: The Multidimensional Weight Locus of Control Scale (MWLCS) measures a person's beliefs regarding the locus of control or lack of locus of control over his/her body weight. PURPOSE: We aim to evaluate the factorial structure and psychometric properties of the MWLCS with Spanish normal weight, overweight and obese samples. METHODS: The research was carried out in two different studies. The first included a sample of 140 normal weight participants, selected out of a 274 sample recruited with an online survey. Study 2 was carried out in a sample of 633 participants recruited from the PREDIMED-Plus study. Out of them, 558 participants fulfilled the weight criteria and were categorized into: overweight (BMI 25 - < 29.99; N = 170), obese class I (BMI 30 - < 34.99; N = 266), and obese class II (BMI 35 - < 39.99; N = 122). Exploratory (EFA) and confirmatory (CFA) factor analyses were used to evaluate the factor structure of the MWLCS, and reliabilities and Spearman's correlations were estimated. Invariance measurement was tested across the three subgroups of weight in Study 2. RESULTS: A three-factor structure indicating weight locus of control factors (internal, chance, and powerful others) was supported, both via EFA in the normal weight sample and CFA in the overweight and obese samples. In the normal weight sample, the powerful others dimension was positively related to BMI and the dimensions of the Dutch Eating Behaviors Questionnaire. Additionally, the scale showed evidence of scalar invariance across the groups with different weight conditions. CONCLUSIONS: This scale seems to be a psychometrically appropriate instrument and its use is highly recommended when designing interventions for overweight or obese individuals. LEVEL OF EVIDENCE: Level V, descriptive study.

Fermented dairy products, diet quality, and cardio-metabolic profile of a Mediterranean cohort at high cardiovascular risk.

BACKGROUND AND AIMS: Fermented dairy products have been associated with a better diet quality and cardio-metabolic profile. However, in Mediterranean populations, these associations have not been well characterized. The aim of this study was to assess the diet quality and the associations between the consumption of total fermented dairy products and their subtypes and the prevalence of Metabolic Syndrome (MetS) components in a Mediterranean population at high cardiovascular risk. METHODS AND RESULTS: Baseline cross-sectional analyses were conducted on 6,572 men and women (mean age: 65 years) with overweight or obesity and MetS recruited into the PREDIMED-Plus cohort. A 143-item Food Frequency Questionnaire (FFQ) was used, and anthropometrical, biochemical, and blood pressure measurements were recorded. Multivariate-adjusted Cox regressions were fitted to analyze the association between quartiles of consumption of fermented dairy products and their subtypes and MetS components to estimate the relative risk (RR) and 95% confidence intervals (95% CIs). Participants who were high consumers of fermented dairy products reported a higher consumption of fruit, vegetables, fish, nuts, and whole bread and a lower consumption of white bread, alcohol, and cookies. Participants in the higher quartile showed a lower prevalence of the low HDL-cholesterol component of the MetS (RR=0.88; 95% CI: 0.78-0.98) than those in the lowest quartile of cheese consumption. Cheese consumption was inversely associated with the prevalence of hypertriglyceridemia. Total fermented dairy products, yogurt, and its types were not associated with any of the MetS components. CONCLUSIONS: Compared to nonconsumers, participants consuming fermented dairy products reported a better diet quality and, particularly, cheese consumers presented a lower prevalence of hypertriglyceridemia and low HDL-cholesterol plasma levels, which are MetS components.

Egg consumption and cardiovascular disease according to diabetic status: The PREDIMED study.

BACKGROUND: Eggs are a major source of dietary cholesterol and their consumption has been sometimes discouraged. A relationship between egg consumption and the incidence of cardiovascular disease (CVD) has been suggested to be present exclusively among patients with type2 diabetes. AIMS: To assess the association between egg consumption and CVD in a large Mediterranean cohort where approximately 50% of participants had type 2 diabetes. METHODS: We prospectively followed 7216 participants (55-80 years old) at high cardiovascular risk from the PREDIMED (PREvención con DIeta MEDiterránea) study for a mean of 5.8 years. All participants were initially free of CVD. Yearly repeated measurements of dietary information with a validated 137-item food-frequency questionnaire were used to assess egg consumption and other dietary exposures. The endpoint was the rate of major cardiovascular events (myocardial infarction, stroke or death from cardiovascular causes). RESULTS: A major cardiovascular event occurred in 342 participants. Baseline egg consumption was not significantly associated with cardiovascular events in the total population. Non-diabetic participants who ate on average >4 eggs/week had a hazard ratio (HR) of 0.96 (95% confidence interval, 0.33-2.76) in the fully adjusted multivariable model when compared with non-diabetic participants who reported the lowest egg consumption (<2 eggs/week). Among diabetic participants, the HR was 1.33 (0.72-2.46). There was no evidence of interaction by diabetic status. HRs per 500 eggs of cumulative consumption during follow-up were 0.94 (0.66-1.33) in non-diabetics and 1.18 (0.90-1.55) in diabetics. CONCLUSIONS: Low to moderated egg consumption was not associated with an increased CVD risk in diabetic or non-diabetic individuals at high cardiovascular risk. This trial was registered at controlled-trials.com as ISRCTN35739639.

Does the Mediterranean diet counteract the adverse effects of abdominal adiposity?

BACKGROUND AND AIM: We tested the hypothesis that an intervention with a Mediterranean diet (MeDiet) could mitigate the well-known harmful effects of abdominal obesity on cardiovascular health. METHODS AND RESULTS: We assessed the relationship between baseline waist-to-height ratio (WHtR) and major cardiovascular events during a median follow-up of 4.8 years in the Prevention with Mediterranean Diet (PREDIMED) randomized primary prevention trial, which tested a MeDiet against a control diet (advice on a low-fat diet). We also examined whether the MeDiet intervention was able to counteract the detrimental cardiovascular effects of an increased WHtR. The trial included 7447 participants (55-80 years old, 57% women) at high cardiovascular risk but free of cardiovascular disease (CVD) at enrollment. An increased risk of CVD events (myocardial infarction, stroke, or cardiovascular death) was apparent for the highest versus the lowest quartile of WHtR (multivariable-adjusted hazard ratio: 1.98) (95% confidence interval: 1.10-3.57; linear trend: p = 0.019) only in the control-diet group, but not in the two groups allocated to intervention with MeDiet (p for interaction = 0.034). This apparent interaction suggesting that the intervention counterbalanced the detrimental cardiovascular effects of adiposity was also significant for body mass index (BMI) (p = 0.01) and waist circumference (p = 0.043). CONCLUSIONS: The MeDiet may counteract the harmful effects of increased adiposity on the risk of CVD.

Mediterranean diet and cognitive function: the SUN project.

OBJECTIVE: Our aim was to evaluate the association between adherence to the Mediterranean Diet (MedDiet) and cognitive function in 823 participants (62 ± 6 years at baseline) from a Spanish prospective cohort (SUN project). METHOD: A validated 136-item food frequency questionnaire was used to assess the adherence to the MedDiet at baseline. The 10-point (0 to 9) MedDiet Score was used to categorize adherence to MedDiet. Cognitive function was assessed twice at follow-up with a mean follow-up time between exposure and outcome assessment of 6 and 8y using the Telephone Interview of Cognitive Status-modified (TICS-m, range 0 to 54 points). ANCOVA models were used to assess the association between adherence to the MedDiet and cognitive decline. RESULTS: In the multivariable-adjusted analysis of 2-year changes, a higher cognitive decline was observed among participants with low or moderate baseline adherence to the MedDiet than among those with better adherence (adjusted difference = -0.56 points in TICS-m, 95% CI = -0.99 to -0.13). CONCLUSION: A higher adherence to the MedDiet might be associated with better cognitive function. However, observed differences were of small magnitude and further studies are needed to confirm this finding.

Effects of total dietary polyphenols on plasma nitric oxide and blood pressure in a high cardiovascular risk cohort. The PREDIMED randomized trial.

BACKGROUND AND AIM: Hypertension is one of the main cardiovascular risk factors in the elderly. The aims of this work were to evaluate if a one-year intervention with two Mediterranean diets (Med-diet) could decrease blood pressure (BP) due to a high polyphenol consumption, and if the decrease in BP was mediated by plasma nitric oxide (NO) production. METHODS AND RESULTS: An intervention substudy of 200 participants at high cardiovascular risk was carried out within the PREDIMED trial. They were randomly assigned to a low-fat control diet or to two Med-diets, one supplemented with extra virgin olive oil (Med-EVOO) and the other with nuts (Med-nuts). Anthropometrics and clinical parameters were measured at baseline and after one year of intervention, as well as BP, plasma NO and total polyphenol excretion (TPE) in urine samples. Systolic and diastolic BP decreased significantly after a one-year dietary intervention with Med-EVOO and Med-nuts. These changes were associated with a significant increase in TPE and plasma NO. Additionally, a significant positive correlation was observed between changes in urinary TPE, a biomarker of TP intake, and in plasma NO (Beta = 4.84; 95% CI: 0.57-9.10). CONCLUSIONS: TPE in spot urine sample was positively correlated with plasma NO in Med-diets supplemented with either EVOO or nuts. The statistically significant increases in plasma NO were associated with a reduction in systolic and diastolic BP levels, adding to the growing evidence that polyphenols might protect the cardiovascular system by improving the endothelial function and enhancing endothelial synthesis of NO.

Dietary fibre intake is inversely associated with carotid intima-media thickness: a cross-sectional assessment in the PREDIMED study.

OBJECTIVE: To assess the association between the intake of dietary fibre and carotid intima-media thickness (IMT) in a Mediterranean population at high cardiovascular risk. METHODS: Baseline cross-sectional assessment of 457 men and women (average age 67 years) from two different Spanish centres of the PREDIMED trial. A previously validated food frequency questionnaire (137 food items) was administered by trained dieticians in a face-to-face interview. Mean common carotid IMT was measured using B-mode ultrasound imaging of the right and left carotid arteries by four certified sonographers who used a common protocol. Anthropometric and blood pressure measurements were performed and samples of fasting blood were obtained. Participants were categorized into four groups (roughly quartiles: < or =21; >21 to < or =25; >25 to < or =31 and >31 g/day) of energy-adjusted intake of dietary fibre. Multiple linear regression models were used to adjust for age, sex, centre, smoking, body mass index, diabetes, blood pressure, lipid levels and statin use. RESULTS: In the crude analyses, energy-adjusted fibre intake showed a significant inverse correlation with IMT (r=-0.27, P<0.001). In multivariate analyses, a modest, though statistically significant (P=0.03) inverse association between energy-adjusted fibre intake and IMT was also found. The multivariate-adjusted difference in average IMT was -0.051 mm (95% confidence interval: -0.094 to-0.009, P=0.02) for participants whose intake was >35 g/day, (n=47) when compared with those whose intake was <25 g/day (n=224). CONCLUSIONS: Our results suggest that high fibre intake is inversely associated with carotid atherosclerosis.

La presión arterial domiciliaria se asocia con la hipertrofia concéntrica del ventrículo izquierdo / Home blood pressure is associated with concentric hypertrophy of the letf ventricle

Introducción. La hipertrofia del ventrículo se relaciona con el grado de hipertensión arterial e incrementa el riesgo de sufrir eventos cardiovasculares. Hay controversia acerca de la asociación entre las cifras de presión arterial medida por los distintos métodos clínicos y domiciliarios y la morfología ecográfica del ventrículo izquierdo. El objetivo ha sido investigar posibles asociaciones entre los parámetros ecocardiográficos de hipertrofia y las presiones clínicas y por automedida domiciliaria. Material y métodos. Se realizó determinación de presión arterial clínica y ambulatoria mediante automedida domiciliaria de presión arterial y ecocardiograma a 122 pacientes hipertensos (61,5% hombres). Se dividió a los pacientes según el patrón ecográfico del ventrículo izquierdo: normal, remodelado concéntrico, hipertrofia excéntrica y concéntrica. Resultados. Solamente 51 pacientes (41,8 %) mostraron un patrón ecográfico ventricular izquierdo normal. El 25,4 % tenía remodelado concéntrico y el 32,8 % hipertrofia ventricular izquierda. Existió asociación estadísticamente significativa entre la presión arterial sistólica clínica y el índice de masa de ventrículo izquierdo ajustando por edad, sexo e índice de masa corporal (ß = 0,004; intervalo de confianza del 95% [IC 95 %]: 0,001 a 0,007 [p = 0,022]), y entre la presión de pulso de automedida y el grosor relativo de pared (ß = 0,006; IC 95 %: 0,001 a 0,010 [p = 0,013]). La presión de pulso domiciliaria fue estadísticamente superior en los pacientes con grosor relativo de la pared mayor de 0,44. Discusión. Se han encontrado evidencias que sugieren la asociación de las mediciones de presión arterial de automedida con los patrones de remodelado e hipertrofia concéntrica que predicen mayor riesgo cardiovascular, las cuales no se relacionan con las mediciones clínicas. Estos resultados apoyan la utilización de automedida domiciliaria en la evaluación de los pacientes hipertensos

Introduction. Ventricle hypertrophy is related with the degree of arterial hypertension and increases risk of suffering cardiovascular events. There is a debate on the association between the blood pressure values measured by different clinical and home methods and ultrasonographic morphology of the left ventricle. The objective has been to investigate possible associations between echocardiographic parameters of hypertrophy and clinical pressures and by home self-measurement. Material and methods. Clinical and out-patient blood pressure was measured by home blood pressure monitoring and echocardiogram in 122 hypertensive patients (61.5 % men). Patients were divided according to the ultrasonographic pattern of the left ventricle: normal, concentric remodeling, eccentric and concentric hypertrophy. Results. Only 51 patients (41.8 %) had a normal left ventricular ultrasonographic pattern. A total of 25.4 % had concentric remodeling and 32.8 % left ventricular hypertrophy. There was a statistically significant association between the clinical systolic blood pressure and the left ventricle mass index, adjusting by age, gender and body mass index [ß = 0.004; 95 % confidence interval (95 % CI): 0.001 to 0.007 (p = 0.022)], and between self-measured pulse pressure and relative wall thickness [ß = 0.006; 95 % CI: 0.001 to 0.010; (p = 0.013)]. Home pulse pressure was statistically greater in patients with relative wall thickness greater than 0.44. Discussion. Evidence has been found that suggests the association of the self-measurement blood pressure measurement with remodeling patterns and concentric hypertrophy, that predict greater cardiovascular risk, these not being related with clinical measurements. These results support the use of home self-measurement in the evaluation of hypertensive patients

[The competence and skills of the family physician in ophthalmology]. / Competencias y destrezas del médico de familia en oftalmología.

BACKGROUND: In order to facilitate interprofessional collaboration and continuing education, it is necessary to define the family doctor (FD) work profile in ophthalmology and that this profile is accepted by FD and specialized doctors. METHODS: A questionnaire with 42 activities and 18 skills, belonging to the scope of ophthalmology was sent to 20 ophthalmologists in the Health Area of Pamplona. They were asked to value each item and to express whether they thought it belonged to the FD activity scope. The answers from 16 specialized doctors are compared with the answers from 16 FD. RESULTS: 30 activities and 12 skills are considered to be a part of the FD scope by 75% of them, compared with 22 activities and 10 skills accepted by the ophthalmologists. More that 75% of these ones express their disagreement with three activities: identification of traumatic wounds in both cameras, surveillance of eye-pressure in patients at risk, surveillance of chronic glaucoma and early care of wounds in the eye globe; and in three skills: valuation of iridocorneal angle, enlargement of the eye pupil and verification of lacrimal conduct permeability. In 9 items, statistically significant differences were found (p 0.05) between both groups answers. Among them, the examinations and surveillance of retinopathies in vascular and metabolic diseases, stands out. CONCLUSIONS: Our study shows a disparity of positions, which may raise difficulties to the interprofessional collaboration between both groups. It is recommended to study the factors, which might have an influence on this disagreement. The elaborated list constitutes a progress in the definition of FD profile in ophthalmology, although it would be necessary to carry out more studies.