Long-Term Changes in Bone Density and Bone Metabolism After Gastric Bypass Surgery: a Retrospective Cohort Study.

PURPOSE: Patients with severe obesity submitted to Roux-en-Y gastric bypass (RYGB) are at risk of developing long-term hypovitaminosis D and secondary hyperparathyroidism (SHPT) as well as osteometabolic disease. This study aimed to evaluate calcium-vitamin D-PTH axis and bone mineral density (BMD) changes from post-RYGB patients who were followed-up until a median of 5 years. MATERIALS AND METHODS: Vitamin D deficiency was defined as 25-hydroxyvitamin D <20 ng/mL and SHPT as PTH >68 pg/mL, in patients with normal serum creatinine and calcium. BMD was estimated by dual-energy X-ray absorptiometry (DXA, g/cm2). RESULTS: We included 127 post-RYGB patients (51±10.6 years, 87.4% self-declared White, 91.3% female, 52.8% postmenopausal). Vitamin D deficiency prevalence was the highest (41.5%) in the second year and the lowest (21.2%) in the third year (p<0.05). SHPT prevalence was 65.4% in the second year and increased to 83.7% in the sixth year (p<0.05). Patients with low BMD in lumbar, femoral neck, and total proximal femur were older and presented menopausal status more frequently than normal BMD group (p<0.05). Older age was a risk marker for altered BMD in femoral neck (OR=1.185; 95% CI 1.118-1.256) and in total proximal femur (OR=1.158; 95% CI 1.066-1.258), both after adjusting for follow-up and excess weight loss. CONCLUSION: After 5 years, most bariatric patients presented calcium-vitamin D-PTH axis disruption, in which SHPT was more frequent than hypovitaminosis D. Older patients and menopausal women presented higher rates of low BMD, and older age was a risk marker, especially for low BMD in femoral sites.

Dietary Fiber Intake (Supplemental or Dietary Pattern Rich in Fiber) and Diabetic Kidney Disease: A Systematic Review of Clinical Trials.

Fiber intake is associated with better glycemic control being an important nonpharmacologicaltreatment for diabetes (DM). We hypothesize that a dietary fiber intake can bringbenefits to diabetic kidney disease (DKD), improving renal outcomes. This systematic review aimedto evaluate the effect of dietary fiber (supplemental or dietary pattern rich in fiber) on DKD. Wesearched six databases to identify clinical trials that reported fiber intake and renal outcomes(albuminuria, proteinuria, estimated glomerular filtration rate (eGFR) dialysis) in patients with DM.From 1814 studies, 48 papers were fully evaluated. In the end, seven trials (161 patients, aged 58.3years, 49% females) were included. The studies were organized into three categories (vegetarian,Dietary Approaches to Stop Hypertension (DASH) diet, and fiber supplement), two evaluatedsupplements and five dietary patterns. Vegetarian diet reduced albuminuria in three trials, two inpatients with type 1 DM and one in patients with type 2 DM; and one study demonstrated a change inthe eGFR in type 1 DM. The individual quality of the studies was low/uncertain. A vegetarian dietarypattern may have a beneficial effect on these renal outcomes. However, the individual effect of theintake of fiber on DKD not was possible to be evaluated.

Dietary source of saturated fat and percentage body fat of patients with type 2 diabetes mellitus: A cross-sectional study.

BACKGROUND: The influence of dietary fat on the body fat of patients with diabetes is not well established. This cross-sectional study aimed to analyze the association between percentage body fat (PBF) and dietary sources of fat from the usual diet of patients with type 2 diabetes. METHODS: Outpatients were submitted to PBF evaluation estimated by bioelectrical impedance. The patient's usual diet was assessed by a 3-day weighed diet record (WDR), and compliance was analyzed by comparing the protein intake estimated from the WDR and that from 24-hr urinary nitrogen output. RESULTS: A total of 188 patients with type 2 diabetes (aged 62.5 ± 8.8 years; 57% female, body mass index [BMI] 29.3 ± 3.8 kg/m²) were analyzed and divided into groups with high and low PBF according to mean PBF (men: 26.6 ± 7.1%; women: 39.8 ± 5.9%). Patients with high PBF consumed an increased proportion of red meat (52.0% of total meat), processed meat (5.4%), and saturated fat from red meat (2.1% of energy) compared to low PBF individuals (42.3% [p = 0.036]; 3.0% [p = 0.010]; 1.5% of energy [p = 0.032], respectively). According to Poisson's regression, the consumption of red meat (PR = 1.008 [95% CI = 1.002-1.013]; p = 0.006) and the reuse of frying oil (PR = 1.670 [95% CI = 1.240-2.249]; p = 0.001) were associated with higher PBF. In the adjusted analysis, the upper tertile of processed meat intake was associated with higher PBF (PR = 1.522 [95% CI = 1.226-1.891]; p = 0.001) compared to the lower tertile. CONCLUSIONS: The present study suggested that a higher ingestion of dietary sources of saturated fat was associated with high PBF in patients with type 2 diabetes.

Insulin Regimens to Treat Hyperglycemia in Hospitalized Patients on Nutritional Support: Systematic Review and Meta-Analyses.

BACKGROUND: The best insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support (NS) is unclear. METHODS: We searched electronic databases to identify cohort studies or randomized clinical trials in order to evaluate the efficacy of different insulin regimens used to treat hyperglycemia in hospitalized patients on NS on diverse outcomes: mean blood glucose (MBG), hypoglycemia, length of stay in hospital, and mortality. RESULTS: Seventeen studies from a total of 5,030 were included. Enteral Group included 8 studies; 1,203 patients using rapid, glargine, NPH, or Premix insulin; MBG 108-225 mg/dL; hypoglycemia 0-13%. In indirect meta-analyses, NPH insulin ranked best for glucose control (MD 95% CI -2.50 mg/dL [2.65 to -2.35]). Parenteral Group included 4 studies; 228 patients using regular and glargine or NPH insulin; MBG 137-202 mg/dL; hypoglycemia 0-40%. In meta-analyses comparing regular insulin added to parenteral nutrition bag with glargine, MBG (MD 95% CI -3.78 mg/dL [-11.93 to 4.37]; I2 = 0%) or hypoglycemia frequency (RR 95% CI 1.37 [0.43-4.32]; I2 = 70.7%) did not differ. The description related to hospital length of stay and mortality was inconsistent between groups. CONCLUSIONS: The best insulin regimen to treat hyperglycemia in hospitalized patients on NS has not been established; best results using insulin regimens with NPH in enteral nutrition do not seem to be clinically relevant.

Dietary fat composition and cardiac events in patients with type 2 diabetes.

OBJECTIVE: To evaluate associations of dietary fat composition with the development of cardiac events in patients with type 2 diabetes, without ischemic heart disease who were followed for at least 12 months. METHODS: In this prospective cohort study the usual diet of patients was retrospectively assessed by a 3-day weighed diet record (WDR). Compliance with the WDR technique was assessed by comparing protein intake estimated from 3-day WDR and 24-h urinary nitrogen output. The following were considered cardiac events: myocardial infarction, myocardial revascularization procedures, congestive heart failure, new-onset angina pectoris, and sudden death. RESULTS: A total of 227 patients with type 2 diabetes (aged 59 ± 10 years; 46.0% male), were followed during 4.6 years. In a multivariate Cox regression analysis, the intake of polyunsaturated fatty acids had a protective effect for cardiac events (HR = 0.31, 95% CI: 0.11-0.89; P = 0.03) adjusted for age, gender, duration of diabetes, smoking, compliance with WDR, using hypolipidemic agents, and the presence of hypertension and diabetic nephropathy. When the fat intake was divided into quartiles, the highest intake of α-linolenic acid (>1.25% of energy) was negatively associated with cardiac events (HR = 0.58, 95% CI: 0.39-0.85; P = 0.006), adjusted for the same covariates.. CONCLUSION: In patients with type 2 diabetes without ischemic heart disease, a high intake of polyunsaturated fatty acids, especially alpha linolenic acid, was protective for the development of cardiac events..

Reproducibility and validity of a quantitative FFQ designed for patients with type 2 diabetes mellitus from southern Brazil.

OBJECTIVE: To evaluate the reproducibility and validity of a previously constructed FFQ to assess the usual diet of patients with type 2 diabetes mellitus (T2DM). DESIGN: Cross-sectional survey using two quantitative FFQ (1-month interval) supported by a food photograph portfolio, a 3 d weighed diet record (WDR) and urinary N output measurement (as a biomarker of protein intake). SETTING: Group of Nutrition in Endocrinology, southern Brazil. SUBJECTS: Out-patients with T2DM. RESULTS: From a total of 104 eligible T2DM patients, eighty-eight were included in the evaluation of FFQ reproducibility and seventy-two provided data for the validity study. The intakes estimated from the two FFQ did not differ (P > 0·05) and the correlation coefficients were significant (P < 0·01) for energy and nutrients, ranging from 0·451 (soluble fibre) to 0·936 (PUFA). Regarding the validity evaluation, data from the FFQ were higher than those from the WDR for total (28·3%), soluble (27·4%) and insoluble fibres (29·1%), and SFA (13·5%), MUFA (11·1 %) and total lipids (9·2%; all P < 0·05). There were significant correlation coefficients between the FFQ and WDR for most nutrients, when adjusted for energy intake and de-attenuated. Also, the Bland-Altman plots between the FFQ and WDR for energy and macronutrient intakes showed that the FFQ may be used as alternative method to the WDR. The validity coefficient (using the method of triads) for the FFQ protein intake was 0·522 (95% CI 0·414, 0·597). CONCLUSIONS: This quantitative FFQ was valid and precise to assess the usual diet of patients with T2DM, according to its validity and reproducibility.

Development of a quantitative food frequency questionnaire for Brazilian patients with type 2 diabetes.

BACKGROUND: To investigate the association between dietary components and development of chronic diabetic complications, the dietary evaluation should include a long period, months or years. The present manuscript aims to develop a quantitative food frequency questionnaire (FFQ) and a portfolio with food photos to assess the usual intake pattern of Brazilian patients with type 2 diabetes to be used in future studies. METHODS: Dietary data using 3-day weighed diet records (WDR) from 188 outpatients with type 2 diabetes were used to construct the list of usually consumed foods. Foods were initially clustered into eight groups: "cereals, tubers, roots, and derivatives"; "vegetables and legumes"; "fruits"; "beans"; "meat and eggs"; "milk and dairy products"; "oils and fats", and "sugars and sweets". The frequency of food intake and the relative contribution of each food item to the total energy and nutrient intakes were calculated. Portion sizes were determined according to the 25th, 50th, 75th, and 95th percentiles of intake for each food item. RESULTS: A total of 62 food items were selected based on the 3-day WDR and another 27 foods or how they are prepared and nine beverages were included after the expert examination. Also, a portfolio with food photos of each included food item and portion sizes was made to assist the patients in identifying the consumed portion. CONCLUSIONS: We developed a practical quantitative FFQ and portfolio with photos of 98 food items covering those most commonly consumed in the past 12 months, to assess the usual diet pattern of patients with type 2 diabetes in Southern Brazil.

Lunch energy density and the metabolic syndrome in patients with type 2 diabetes mellitus.

The aim of the present study was to investigate the possible associations between dietary energy density (ED) and the metabolic syndrome (MetS) in patients with type 2 diabetes. In the present case-control study, the dietary ED of 125 patients with type 2 diabetes (seventy-eight with (cases) the MetS and forty-seven without (controls) the MetS; mean age 62·0 (SD 9·4) years, mean diabetes duration 12·5 (SD 8·4) years and mean glycated Hb 7·2 (SD 1·3) %) was assessed by weighed diet records. The MetS was defined according to the 2009 Joint Interim Statement and ED by the amount of energy (kJ) in a given weight of food. Data are expressed as means (standard deviations) or medians (interquartile ranges). Patients with the MetS reported lower intakes of total energy and fibre, and a higher total food amount than the controls; the total ED did not differ, but the cases had a higher ED at lunch (mean 6·3 (SD 1·3) v. 5·9 (SD 0·8) kJ/g; P= 0·017). In this meal, patients with the MetS had lower intakes of beans (median 0·7 (interquartile range 0·4-1·1) v. 1·1 (interquartile range 0·6-1·6) g/kg; P= 0·020), vegetables (median 1·2 (interquartile range 0·6-1·7) v. 1·4 (interquartile range 1·0-2·0) g/kg; P= 0·046) and total meat (median 1·3 (interquartile range 1·0-1·6) v. 1·4 (interquartile range 1·2-1·8) g/kg; P= 0·034) than patients without the MetS. The associations between lunch ED (kJ/g) and food groups (g/kg) were confirmed for vegetables (r - 0·584; P< 0·001), fruits (r - 0·233; P= 0·070), beans (r - 0·189; P= 0·037) and oils (r 0·323; P< 0·001). In a multivariate logistic regression model, a high lunch ED was associated with the MetS (OR 6·89, 95 % CI 1·35, 35·15; P =0·020) after adjusting for confounders. In conclusion, a high ED at lunch increased the odds of the presence of the MetS in patients with type 2 diabetes. Beans and vegetables may be the major contributors to this association and their consumption might be considered to decrease ED.

Reference values for glomerular filtration rate in healthy Brazilian adults.

BACKGROUND: Glomerular filtration rate (GFR) is the best index of renal function, but age, gender and ethnicity can putatively affect its values. The aim of this study was to establish reference values for GFR in healthy Brazilian subjects while taking these factors into account. METHODS: In this cross-sectional study, GFR was measured by the 51Cr-EDTA single-injection method. GFR reference values were developed according to CLSI Guidelines for Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory (CLSI C28 protocol). RESULTS: The age range of the 285 healthy individuals was 19 to 70 years, 57% were females, and GFR was 106 ± 18 mL/min/1.73 m(2). There was no difference between male and female GFRs (108 ± 18 vs. 104 ± 18 mL/min/1.73 m(2) respectively, P = 0.134), and reference values were therefore developed from the pooled sample. GFR values were lower in subjects aged ≥45 years as compared with those younger than 45 years (98 ± 15 vs.112 ± 18 mL/min/1.73 m(2), P < 0.001). Based on mean ± 2 SD, GFR reference values were 76 to 148 mL/min/1.73 m(2) for subjects younger than 45 years and 68 to 128 mL/min/1.73 m(2) for individuals older than 45 years, irrespective of gender. CONCLUSION: The age-adjusted reference intervals reported may be reliably adopted to evaluate kidney function, since they are based on recommended standards.

The rs7204609 polymorphism in the fat mass and obesity-associated gene is positively associated with central obesity and microalbuminuria in patients with type 2 diabetes from Southern Brazil.

OBJECTIVE: Single nucleotide polymorphisms (SNPs) in the fat mass and obesity-associated (FTO) gene, especially the common rs9939609 (A/T) SNP, are associated with body mass index (BMI), diabetes, and metabolic syndrome (MetS). MetS is highly prevalent in patients with type 2 diabetes and has been associated with chronic diabetic complications. Therefore, the aim of this study was to evaluate possible associations of the scarcely investigated rs7204609 (C/T) polymorphism, as well as the rs9939609 (A/T) polymorphism, with MetS and chronic diabetic complications in type 2 diabetic patients from Southern Brazil. DESIGN: This was a cross-sectional study. PATIENTS AND METHODS: A total of 236 patients with type 2 diabetes (age: 60.0 ± 10.3 years; diabetes duration: 12.7 ± 8.2 years; 53.4% women) were genotyped for the FTO rs7204609 and rs9939609 polymorphisms (ABI PRISM 7000 Real-Time PCR System). Patients underwent clinical, laboratory, and nutritional evaluation. MetS was defined according to the 2009-Joint Interim Statement. RESULTS: Carriers of C allele of the rs7204609 polymorphism (CT/CC genotypes, n = 35) were at increased risk for the presence of MetS (odds ratio [OR] = 4.56; 95% CI: 1.04 to 19.9), elevated waist circumference (OR = 8.66; 95% CI: 1.12 to 66.7), BMI: ≥ 30 kg/m(2) (OR = 3.71; 95% CI: 1.71 to 8.02), and microalbuminuria (OR = 2.30; 95% CI: 1.08 to 4.88), adjusted for gender and diabetes duration (P < .05 for all models). The rs9939609 polymorphism was not associated with MetS, elevated waist circumference or BMI, or diabetic complications. Daily energy and nutrient intakes did not differ according to the presence of the polymorphisms. CONCLUSIONS: The C allele of the rs7204609 polymorphism in the FTO gene increased the chance for the presence of MetS, especially central obesity, and microalbuminuria, independently of energy and nutrient intakes in this sample of type 2 diabetic patients from Southern Brazil.

Left atrial metastases of poorly differentiated thyroid carcinoma diagnosed by echocardiography and magnetic resonance imaging--case report and review of literature.

Intracardiac metastases of thyroid carcinoma are a rare event. Their incidence is low in large autopsy series, and antemortem diagnosis is even less common. We present the case of a woman with advanced poorly differentiated thyroid carcinoma who had extensive intracardiac metastases. This case highlights the usefulness of echocardiography and magnetic resonance imaging in the diagnosis and differential diagnosis of cardiac metastases.

The role of Dietary Approaches to Stop Hypertension (DASH) diet food groups in blood pressure in type 2 diabetes.

The role of each Dietary Approaches to Stop Hypertension (DASH) diet component in blood pressure (BP) of patients with diabetes is still uncertain. The aim of the present study was to evaluate possible associations of the recommended food groups of the DASH diet eating plan with BP values in patients with type 2 diabetes. In the present cross-sectional study, 225 patients with type 2 diabetes (age 61·1 (SD 10·4) years; diabetes duration 13·1 (SD 9·1) years; males 48·4 %; BMI 28·5 (SD 4·3) kg/m(2); HbA1c 7·1 (SD 1·3) %; systolic BP 136·7 (SD 20·0) mmHg; diastolic BP 78·4 (SD 11·8) mmHg) without dietary counselling during the previous 6 months had their dietary intake assessed by 3 d weighed-diet records. Patients were divided into two groups according to BP tertiles: LOW BP (first tertile) and HIGH BP (second plus third tertiles). Multivariate logistic regression models demonstrated that the daily intake of 80 g of fruits per 4184 kJ (1000 kcal) (OR 0·781; 95 % CI 0·617, 0·987; P = 0·039) or 50 g of vegetables per 4184 kJ (1000 kcal) (OR 0·781; 95 % CI 0·618, 0·988; P = 0·040) reduced the chance of the presence of HIGH mean BP (MBP ≥ 92 mmHg) by 22 % each, adjusted for possible confounders. In conclusion, fruit and vegetables were the food groups of the DASH diet associated with reduced BP values in patients with type 2 diabetes, and their consumption might play a protective role against increased BP values.

Protein intake estimated by weighed diet records in patients with type 2 diabetes: misreporting and intra-individual variability using 24-hour nitrogen output as criterion standard.

In patients with type 2 diabetes mellitus (DM), the factors associated with under- or overreporting of protein intake in nutrition assessment tools, as well as the variability of diet records, have not been fully established. The aim of this cross-sectional study was to evaluate factors associated with under- or overreporting of protein intake and its variability in patients with type 2 DM. Protein intake was estimated in 205 patients (aged 59.8+/-9.6 years) using 3-day weighed diet records and 24-hour nitrogen output (criterion standard). Twenty-three patients repeated the 3-day weighed diet records three times. Clinical, nutrition, and lifestyle evaluations were performed. Coefficients of variation were calculated for protein intake. Factors associated with under- and overreporting were assessed using multivariate logistic regression models. Coefficients of variation for protein intake estimated by weighed diet records or nitrogen output were similar (11.9% vs 11.3%; P>0.05). Using Beaton's formula, a difference of 16.5% in protein intake between two 3-day weighed diet records was acceptable. The lowest A1c test tertile (< or =6.9%) was associated with protein intake underreporting (odds ratio [OR]=0.40; 95% confidence interval [CI]=0.16 to 0.99; P=0.046] after adjustment for sex, age, employment status, and living alone. Male sex (OR=6.66; 95% CI: 2.08 to 22.07; P=0.002), A1c test (OR=1.29; 95% CI: 1.02 to 1.64; P=0.036), and body mass index (OR=0.89; 95% CI: 0.80 to 0.994; P=0.039), adjusted for physical and employment status, education, and preparing one's own meals, were associated with overreporting. In conclusion, in patients with type 2 DM, a difference >16.5% in protein intake between two 3-day weighed diet records should be interpreted as a true discrepancy. Poor glucose control and male sex increase the chance of inaccurate 3-day weighed diet records.

Evaluation of tests for microalbuminuria screening in patients with diabetes.

BACKGROUND: The first step in the diagnosis of diabetic nephropathy is to measure albumin in a spot urine sample. The aim of this study was to assess the accuracy of urinary albumin concentration (UAC), urinary albumin-to-creatinine ratio (UACR), and the Micral-Test II in a random urine specimen (RUS) for microalbuminuria screening in diabetes mellitus. METHODS: Two hundred and seventy-eight patients collected 24 h timed urine specimens followed by RUS. Albumin (immunoturbidimetry) and creatinine were measured in protein-negative (Combur-Test) urine samples. Samples were classified as normoalbuminuric [24 h urinary albumin excretion rate (UAER) <20 microg/min; n = 189] and microalbuminuric (UAER =20-199 microg/min; n = 89). Micral-Test II readings were performed in 130 RUS. Receiver operating characteristics (ROC) curves were constructed using UAER as the reference standard. RESULTS: The areas under the ROC curves were similar for UAC (0.934+/-0.032) and UACR (0.920+/-0.035; P = 0.626), but the Micral-Test II had lower accuracy to diagnose microalbuminuria (area = 0.846+/-0.047) than UAC (P = 0.014). The first cutoff point with 100% sensitivity for UAC was 14.4 mg/l (specificity =77.2%), and 15.7 mg/g for UACR (specificity =73.0%). Concerning the Micral-Test II, sensitivity and specificity for the 20 mg/l cutoff point were 90.0 and 46.0%, respectively. The agreement between UAER and the Micral-Test II for microalbuminuria diagnosis was 55.8% (kappa = 0.22; P < 0.001). The cost of diagnosing microalbuminuria was 1.74 dollars(UAC), 2.00 dollars (UACR) and 4.09 dollars (Micral-Test II) per patient. CONCLUSIONS: Measurement of UAC in a RUS was the best choice for the diagnosis screening of microalbuminuria in diabetic patients, considering cost and accuracy.