Health-related quality of life in patients with type 1 diabetes mellitus in the different geographical regions of Brazil: data from the Brazilian Type 1 Diabetes Study Group.

BACKGROUND: In type 1 diabetes mellitus (T1DM) management, enhancing health-related quality of life (HRQoL) is as important as good metabolic control and prevention of secondary complications. This study aims to evaluate possible regional differences in HRQoL, demographic features and clinical characteristics of patients with T1DM in Brazil, a country of continental proportions, as well as investigate which variables could influence the HRQoL of these individuals and contribute to these regional disparities. METHODS: This was a retrospective, cross-sectional, multicenter study performed by the Brazilian Type 1 Diabetes Study Group (BrazDiab1SG), by analyzing EuroQol scores from 3005 participants with T1DM, in 28 public clinics, among all geographical regions of Brazil. Data on demography, economic status, chronic complications, glycemic control and lipid profile were also collected. RESULTS: We have found that the North-Northeast region presents a higher index in the assessment of the overall health status (EQ-VAS) compared to the Southeast (74.6 ± 30 and 70.4 ± 19, respectively; p < 0.05). In addition, North-Northeast presented a lower frequency of self-reported anxiety-depression compared to all regions of the country (North-Northeast: 1.53 ± 0.6; Southeast: 1.65 ± 0.7; South: 1.72 ± 0.7; Midwest: 1.67 ± 0.7; p < 0.05). These findings could not be entirely explained by the HbA1c levels or the other variables examined. CONCLUSIONS: Our study points to the existence of additional factors not yet evaluated that could be determinant in the HRQoL of people with T1DM and contribute to these regional disparities.

Determinants of intensive insulin therapeutic regimens in patients with type 1 diabetes: data from a nationwide multicenter survey in Brazil.

BACKGROUND: To evaluate the determinants of intensive insulin regimens (ITs) in patients with type 1 diabetes (T1D). METHODS: This multicenter study was conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. Data were obtained from 3,591 patients (56.0% female, 57.1% Caucasian). Insulin regimens were classified as follows: group 1, conventional therapy (CT) (intermediate human insulin, one to two injections daily); group 2 (three or more insulin injections of intermediate plus regular human insulin); group 3 (three or more insulin injections of intermediate human insulin plus short-acting insulin analogues); group 4, basal-bolus (one or two insulin injections of long-acting plus short-acting insulin analogues or regular insulin); and group 5, basal-bolus with continuous subcutaneous insulin infusion (CSII). Groups 2 to 5 were considered IT groups. RESULTS: We obtained complete data from 2,961 patients. Combined intermediate plus regular human insulin was the most used therapeutic regimen. CSII was used by 37 (1.2%) patients and IT by 2,669 (90.2%) patients. More patients on IT performed self-monitoring of blood glucose and were treated at the tertiary care level compared to CT patients (p < 0.001). The majority of patients from all groups had HbA1c levels above the target. Overweight or obesity was not associated with insulin regimen. Logistic regression analysis showed that economic status, age, ethnicity, and level of care were associated with IT (p < 0.001). CONCLUSIONS: Given the prevalence of intensive treatment for T1D in Brazil, more effective therapeutic strategies are needed for long term-health benefits.

Relationship between adherence to diet, glycemic control and cardiovascular risk factors in patients with type 1 diabetes: a nationwide survey in Brazil.

BACKGROUND: To determine the relationship between adherence to the diet reported by patients with type 1 diabetes under routine clinical care in Brazil, and demographic, socioeconomic status, glycemic control and cardiovascular risk factors. METHODS: This was a cross-sectional, multicenter study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. The data was obtained from 3,180 patients, aged 22 ± 11.8 years (56.3% females, 57.4% Caucasians and 43.6% non-Caucasians). The mean time since diabetes diagnosis was 11.7 ± 8.1 years. RESULTS: Overall, 1,722 (54.2%) of the patients reported to be adherent to the diet without difference in gender, duration of diabetes and socioeconomic status. Patients who reported adherence to the diet had lower BMI, HbA1c, triglycerides, LDL-cholesterol, non HDL-cholesterol and diastolic blood pressure and had more HbA1c at goal, performed more frequently self-monitoring of blood glucose (p < 0.001), and reported less difficulties to follow specific schedules of diet plans (p < 0.001). Less patients who reported to be adherent were obese or overweight (p = 0.005). The quantity of food and time schedule of the meals were the most frequent complaints. Logistic regression analysis showed that ethnicity, (Caucasians, (OR 1.26 [1.09-1.47]), number of medical clinical visits in the last year (OR 1.10 [1.06-1.15]), carbohydrate counting, (OR 2.22 [1.49-3.30]) and diets recommended by diabetes societies', (OR 1.57 [1.02-2.41]) were related to greater patients' adherence (p < 0.05) and age, [adolescents (OR 0.60 [0.50-0.72]), high BMI (OR 0.58 [0.94-0.98]) and smoking (OR 0.58 [0.41-0.84]) with poor patients' adherence (p < 0.01). CONCLUSIONS: Our results suggest that it is necessary to rethink medical nutrition therapy in order to help patients to overcome barriers that impair an optimized adherence to the diet.

Impaired antioxidant action of high density lipoprotein in patients with type 1 diabetes with normoalbuminuria and microalbuminuria.

AIMS: Patients with type 1 diabetes, in the absence of chronic complications, have serum concentrations of high density lipoprotein cholesterol (HDL-C) similar to the general population. However, their HDL particles may be dysfunctional. We aimed to evaluate the antioxidant effect of HDL2 and HDL3 obtained from Caucasian males with type 1 diabetes with normoalbuminuria and microalbuminuria. METHODS: Twenty Caucasian men with type 1 diabetes (10 with normoalbuminuria and 10 with microalbuminuria) and 10 healthy Caucasian men participated in the study. Lipoproteins were obtained by density gradient ultracentrifugation. The antioxidant effect of HDL was assessed by measuring lipid hydroperoxide (LOOH) concentration after 3h of pooled LDL oxidation catalyzed by 5µM CuSO4 in the absence or presence of HDL2 or HDL3. RESULTS: The control, normoalbuminuria, and microalbuminuria groups had similar HDL-C concentration and estimated glomerular filtration rate. Glycemic control was similar between diabetes groups (HbA1c 8.1±0.9% and 8.3±0.7%, P=0.70), but estimated glucose disposal rate was lower in patients with microalbuminuria (8.0±0.6 and 4.5±1.1mg/kg/min, P<0.01). The relative antioxidant effect of HDL2 from control, normoalbuminuria, and microalbuminuria groups were 92.8±2.4%, 85.4±1.7%, and 74.2±4.6%, respectively (P<0.01), and the HDL3 effect were 95.0±2.2%, 86.4±4.4%, and 75.3±4.2%, respectively (P<0.01). CONCLUSION: Both HDL2 and HDL3 inhibited LOOH formation in copper-catalyzed oxidation of LDL in vitro. Overall, this antioxidant effect was lower in Caucasian men with type 1 diabetes, and was further compounded in those with microalbuminuria.

Regional differences in clinical care among patients with type 1 diabetes in Brazil: Brazilian Type 1 Diabetes Study Group.

BACKGROUND: To determine the characteristics of clinical care offered to type 1 diabetic patients across the four distinct regions of Brazil, with geographic and contrasting socioeconomic differences. Glycemic control, prevalence of cardiovascular risk factors, screening for chronic complications and the frequency that the recommended treatment goals were met using the American Diabetes Association guidelines were evaluated. METHODS: This was a cross-sectional, multicenter study conducted from December 2008 to December 2010 in 28 secondary and tertiary care public clinics in 20 Brazilian cities in north/northeast, mid-west, southeast and south regions. The data were obtained from 3,591 patients (56.0% females and 57.1% Caucasians) aged 21.2 ± 11.7 years with a disease duration of 9.6 ± 8.1 years (<1 to 50 years). RESULTS: Overall, 18.4% patients had HbA1c levels <7.0%, and 47.5% patients had HbA1c levels ≥ 9%. HbA1c levels were associated with lower economic status, female gender, age and the daily frequency of self-blood glucose monitoring (SBGM) but not with insulin regimen and geographic region. Hypertension was more frequent in the mid-west (32%) and north/northeast (25%) than in the southeast (19%) and south (17%) regions (p<0.001). More patients from the southeast region achieved LDL cholesterol goals and were treated with statins (p<0.001). Fewer patients from the north/northeast and mid-west regions were screened for retinopathy and nephropathy, compared with patients from the south and southeast. Patients from the south/southeast regions had more intensive insulin regimens than patients from the north/northeast and mid-west regions (p<0.001). The most common insulin therapy combination was intermediate-acting with regular human insulin, mainly in the north/northeast region (p<0.001). The combination of insulin glargine with lispro and glulisine was more frequently used in the mid-west region (p<0.001). Patients from the north/northeast region were younger, non-Caucasian, from lower economic status, used less continuous subcutaneous insulin infusion, performed less SBGM and were less overweight/obese (p<0.001). CONCLUSIONS: A majority of patients, mainly in the north/northeast and mid-west regions, did not meet metabolic control goals and were not screened for diabetes-related chronic complications. These results should guide governmental health policy decisions, specific to each geographic region, to improve diabetes care and decrease the negative impact diabetes has on the public health system.

Assessing albuminuria in spot morning samples from diabetic patients / Avaliação de albuminúria em amostra matinal em pacientes diabéticos

Microalbuminuria assessment is essential for diagnosing incipient nephropathy in diabetic patients. The present study aim to evaluate whether urinary albumin concentration (UAC) and urinary albumin-to-creatinine ratio (UACR) agree with 24 h urine collection in screening for albuminuria > 30 mg/24 h in type 1 and 2 diabetics. In this cross-sectional study were evaluated 293 diabetic patients (117 type 1 and 176 type 2). Albuminuria was determinated by turbidimetric immunoassay. The best discriminator value was 22 mg/l (sensitivity 82.5 percent, specificity 74.0 percent) for UAC and 27.3 mg/g creatinine (sensitivity 83.3 percent, specificity 80.9 percent) for UACR. Areas under ROC curves were 0.868 and 0.878, respectively (p = 0.53). Lower discriminators as 10 mg/l (sensitivity 94.2 percent, specificity 48.6 percent) and 10 mg/g creatinine (sensitivity 96.7 percent, specificity 49.1 percent) attained high sensitivities. UAC and UACR from spot morning urine had similar accuracy in screening microalbuminuria. The simplicity and lower cost of UAC justifies its preferential clinical use.

Pesquisar microalbuminúria é essencial para o diagnóstico de nefropatia incipiente diabética. Este estudo objetiva avaliar concordância entre concentração de albumina urinária (CAU) e relação albuminúria-creatinúria (RAC) com coleta urinária de 24 h para pesquisa de albuminúria > 30 mg/24 h em diabéticos tipos 1 e 2. Estudou-se transversalmente 293 pacientes diabéticos (117 tipo 1 e 176 tipo 2). A albuminúria foi determinada por imunoensaio turbidimétrico. O melhor discriminador para CAU foi 22 mg/l (sensibilidade 82,5 por cento, especificidade 74 por cento) e para RAC 27,3 mg/g de creatinina (sensibilidade 83,3 por cento, especificidade 80,9 por cento). Áreas sob as curvas ROC foram 0,868 e 0,878, respectivamente (p = 0,53). Menores discriminadores como 10 mg/l (sensibilidade 94,2 por cento, especificidade 48,6 por cento) e 10 mg/g de creatinina (sensibilidade 96,7 por cento, especificidade 49,1 por cento) resultaram sensibilidades maiores. CAU e RAC de amostras urinárias isoladas matinais apresentaram acurácia semelhante para pesquisa de microalbuminúria. Simplicidade e baixo custo da CAU justificam seu uso clínico preferencial.

Assessing albuminuria in spot morning samples from diabetic patients.

Microalbuminuria assessment is essential for diagnosing incipient nephropathy in diabetic patients. The present study aim to evaluate whether urinary albumin concentration (UAC) and urinary albumin-to-creatinine ratio (UACR) agree with 24 h urine collection in screening for albuminuria > 30 mg/24 h in type 1 and 2 diabetics. In this cross-sectional study were evaluated 293 diabetic patients (117 type 1 and 176 type 2). Albuminuria was determined by turbidimetric immunoassay. The best discriminator value was 22 mg/l (sensitivity 82.5%, specificity 74.0%) for UAC and 27.3 mg/g creatinine (sensitivity 83.3%, specificity 80.9%) for UACR. Areas under ROC curves were 0.868 and 0.878, respectively (p = 0.53). Lower discriminators as 10 mg/l (sensitivity 94.2%, specificity 48.6%) and 10 mg/g creatinine (sensitivity 96.7%, specificity 49.1%) attained high sensitivities. UAC and UACR from spot morning urine had similar accuracy in screening microalbuminuria. The simplicity and lower cost of UAC justifies its preferential clinical use.

[Nephropathy and retinopathy in type 1 diabetics assisted by a universitary multiprofessional program]. / Nefropatia e retinopatia em diabéticos do tipo 1 de um programa de atendimento multiprofissional universitário.

Type 1 diabetes mellitus (DM) is linked to micro and macrovascular long-term complications. We proposed to study the association between diabetic nephropathy (DN) and retinopathy (DR), and of these complications with clinical-laboratory variables in type 1 DM patients followed in a universitary center. It was a transversal study through medical registry analysis. We studied 81 patients; prevalence of DR was 21.0% and of DN was 35.8%, there was association between the complications. Carriers of DN and DR have greater DM duration, greater hypertension prevalence, worse glycemic control and greater LDL cholesterol. It was found reduced glomerular filtration rate (GFR) in patients with microvascular complications, mainly in the ones with advanced lesions. In our study there was association between DR, ND and GFR, DM duration and hypertension were independently associated variables.

Nefropatia e retinopatia em diabéticos do tipo 1 de um programa de atendimento multiprofissional universitário / Nephropathy and retinopathy in type 1 diabetics assisted by a universitary multiprofessional program

O diabetes mellitus (DM) tipo 1 é associado a complicações crônicas micro e macrovasculares. Propusemo-nos a estudar a associação entre nefropatia (ND) e retinopatia diabéticas (RD), e destas com variáveis clínico-laboratoriais em portadores de DM tipo 1 acompanhados em um centro universitário. Realizou-se um estudo transversal através de análise de prontuários. Foram estudados 81 pacientes; a prevalência de RD foi 21,0 por cento e de ND, 35,8 por cento; houve associação entre ambas. Os portadores de ND e RD possuíam maior tempo de DM, maior prevalência de hipertensão, pior controle glicêmico e LDL colesterol mais elevado. A taxa de filtração glomerular (TFG) foi associada ao tempo de DM, hipertensão e albuminúria. Identificou-se menor TFG nos portadores de complicações microvasculares, principalmente naqueles com lesões avançadas. Concluímos que, em nosso estudo com portadores de DM tipo 1, houve associação entre RD, ND e TFG, sendo tempo de DM e hipertensão variáveis associadas de forma independente.

Type 1 diabetes mellitus (DM) is linked to micro and macrovascular long-term complications. We proposed to study the association between diabetic nephropathy (DN) and retinopathy (DR), and of these complications with clinical-laboratory variables in type 1 DM patients followed in a universitary center. It was a transversal study through medical registry analysis. We studied 81 patients; prevalence of DR was 21.0 percent and of DN was 35.8 percent, there was association between the complications. Carriers of DN and DR have greater DM duration, greater hypertension prevalence, worse glycemic control and greater LDL cholesterol. It was found reduced glomerular filtration rate (GFR) in patients with microvascular complications, mainly in the ones with advanced lesions. In our study there was association between DR, ND and GFR, DM duration and hypertension were independently associated variables.