Eliete Leao da Silva Clemente

Obesidade na adolescência: fator de risco para complicações clínico-metabólicas

Sixty six adolescents, 36 obese (25F/13M) and 28 non-obese (23F/5M), matched for sex, age, race, education level and Tanner stage of sexual maturation were submitted to a demographical inquire, clinical evaluation and laboratory analysis. The waist-to-hip ratio (0.86±0.08 vs. 0.74±0.04; p< 0.01) and systolic and diastolic blood pressures (120.2±12.1 vs. 105.4±9.1 mmHg; p< 0.01 and 74.3±7.7 vs. 65.5±9.4mmHg; p< 0.01), were higher in the obese group as compared to the non-obese group. Acanthosis nigricans predominated in the obese group (n= 24; 63.5%). levels of HDL-cholesterol were lower in obese adolescents (36.5±10.5 vs. 43.0±9.2 mg/dl; p< 0.05), whereas levels of triglycerides and uric acid were higher (124.6±80.0 vs. 74.2±31.4mg/dl; p< 0.01 and 5.8±1,4 vs, 4.5±1.0mg/dl; p< 0,01), respectively. No differences were found in cholesterol, LDL-cholesterol and basal glucose between the two groups, Obese adolescents sought for treatment because of concern about their health (n= 15, 39.5%). Most of them had already used antiobesity drugs in the past. We conclude that obesity in adolescence seems to be associated with a clinical and metabolic profile of insulin resistance with acanthosis nigricans and higher levels of systolic and diastolic blood pressure, trygliceride and uric acid as well as low levels of HDL-cholesterol.

Avaliação de dislipidemia e de índices antropométricos em pacientes com Diabetes Mellitus tipo 1

Intensive insulin therapy in patients with type 1 diabetes is resulting in a better clinic and metabolic control. On the other hand, an increase in overweight and obesity prevalence, which could contribute to a higher risk of cardiovascular disease, has been observed. The aim of our study is to analyze the demographics, clinical and laboratorial factors associated to the presence of dyslipidemia in a group of patients with type 1 diabetes compared to a non-diabetic population. We have studied 72 type 1 diabetics: 52.8% female, aged 22.7 +/- 9.6 years old, with a body mass index (BMI) of 21.1 +/- 3.1 Kg/m2 and 66 non-diabetic patients: 60.6% female, aged 23.1 +/- 10.9 years old and a BMI of 22.12 +/- 3.7 Kg/m2. The group included 13 children (6 with type 1 diabetes), 47 adolescents (23 with type 1 diabetes) and 78 adults (43 with type 1 diabetes). We have found in the adult population with type 1 diabetes a lower overweight prevalence and lower levels of apoB (p< 0.01) and a higher apoA/apoB ratio (p< 0.01) when compared to the non-diabetic population. We have not found difference in the lipid profile in adult groups. Diabetic children and adolescents had higher frequency of total cholesterol (p= 0.02 and p< 0.01, respectively) and LDL-cholesterol (p= 0.02 and p= 0.01 respectively) above the upper limit when compared to the non-diabetic group. We concluded that the conventional methods for detecting lipids alterations in outpatients with type 1 diabetes under routine care are not sufficient to identify the lipid alterations, which could be related to the higher risk of cardiovascular disease in adult population.

Influência da gordura corporal no controle clínico e metabólico de pacientes com diabetes mellitus tipo 2

We evaluate the relationship between body adiposity (BA) by bioelectrical impedance, body mass index (BMI) and waist circumference (WC) in some clinical and laboratorial parameters in 43 patients with type 2 diabetes (DM2), 26F/17M, matched for age, with a DM duration of 13.6±9.1 years. Women had greater BMI: 30.3±5.4 vs. 26.9±3.0kg/m2 (p= 0.04), BA: 35.4±6.2 vs. 19.6±6.2% (p= 0,000), cholesterol: 235± 41 vs. 204±39mg/dL (p= 0,017), triglycerides (TG): 146±61 vs. 116± 57mg/dL (p= 0.06) and HbA1c (HPLC): 7.1±1.7 vs. 6.9±1.4% (p= 0,02) than men, but HDL and LDL cholesterol were not different. When correlated to BA, the following variables were statistically significant: TG, HbA1c, diastolic blood pressure (DBP) and WC. In the stepwise multiple regression analysis using BA, WC and BMI as independent variables and TG (r= 0.34; r2= 0.11; p= 0.02) and DBP (r= 0.39; r2= 0.15; p= 0.008) as the dependent ones, BA was found to be statistically significant. By using the same model having HbA1c as the dependent variable, BA (r= 0.31; r2= 0.10; p= 0.037) and BMI (r= 0.43; r2= 0.19; p= 0.01) became significant. In conclusion, elevated BA in patients with DM2 is an important risk factor to worse metabolic control and blood pressure levels. Women, by virtue of their greater BA and worst plasma lipid profile must need more aggressive intervention to reduce body fat.

Marcadores de inflamação em pacientes com Diabetes Mellitus tipo 1

Para avaliar a resposta inflamatoria, representada pelas proteinas de fase aguda, estudamos 48 pacientes com diabetes tipo 1 (DM1) sem complicacoes [23F:25M; 19,9±9,8 anos e 5 (1-21) anos de duracao da doenca& e 66 individuos sem DM, pareados quanto ao sexo, idade e estadiamento puberal (criterios de Tanner). Foram dosadas proteina C reativa (PCR), a1-glicoproteina acida (a-1GPA) e fibrinogenio, por imuno-turbidimetria. A taxa de excrecao de albumina (EUA) foi determinada por RIE, em amostra de urina de 10h, definindo-se normoalbuminuria como duas taxas de EUA <20µg/min. Pacientes com DM1 foram avaliados quanto a presenca de retinopatia por oftalmoscopia indireta. No DM1 os niveis de PCR [0,23 (0,01-2,90) vs. 0,14 (0,01-2,41) mg/dl, p= 0,0172& e de a1-GPA [53,5 (37-115) vs. 40 (19-78) mg/dl, p< 0,0001& foram maiores quando comparados aos sem DM. Nao houve diferenca em relacao ao fibrinogenio. Na regressao linear multipla em stepwise, tendo a a1-GPA como variavel dependente, as variaveis independentes associadas e preditoras foram a HbA1c (r2= 0,26; p< 0,05) e a glicemia (r2= 0,26; p< 0,05); tendo a PCR e o fibrinogenio como variaveis dependentes, nenhuma variavel independente foi significativa. Na correlacao de Pearson, a PCR correlacionou-se com HbA1c (r= 0,18; p= 0,05). Concluimos que a PCR e a1-GPA estao aumentadas no DM1, independente da presenca da microalbuminuria, retinopatia e doenca macrovascular clinica. Estudo prospectivo sera necessario para estabelecermos o valor preditivo destes marcadores na evolucao para complicacoes cronicas micro e macrovasculares.

Predictors of cardiovascular autonomic neuropathy in patients with type 1 diabetes.

Cardiovascular disease (CVD) is the leading cause of mortality in patients with type 1 diabetes (T1D). The cardiovascular autonomic neuropathy (CAN), although considered as an independent risk factor for CVD, remains underdiagnosed. The aim of this paper was to determine the prevalence, predictors of CAN in patients with T1D and its association with other chronic complications of diabetes. Patients with T1D underwent a clinical-epidemiological survey, had blood and urinary samples collected, performed ophthalmoscopic and clinical neurological examination and cardiovascular reflex tests. One hundred and fifty one patients with T1D, 53.6% female, 45.7% Caucasian, mean age of 33.4 ± 13 years, diabetes duration of 16.3 ± 9.5 years, and glycated hemoglobin levels of 9.1 ± 2% were evaluated. The prevalence of CAN in the studied population was 30.5%. CAN was associated with age (p = 0.01), diabetes duration (p = 0.036), hypertension (p = 0.001), resting heart rate (HR) (p = 0.000), HbA1c (p = 0.048), urea (p = 0.000), creatinine (p = 0.008), glomerular filtration rate (p = 0.000), urinary albumin concentration (p = 0.000), LDL (p = 0.048), free T4 (p = 0.023), hemoglobin (p = 0.01) and presence of retinopathy (p = 0.000), nephropathy (p = 0.000) and diabetic neuropathy (p = 0.000), the following symptoms syncope (p = 0.000), post prandial nausea (p = 0.042), early satiety (p = 0.031), sexual dysfunction (p = 0.049), and gustatory sweating (p = 0.018). In logistic regression model, it was observed that only resting HR, diabetic neuropathy, and retinopathy were independent associated with CAN. In conclusion, CAN is a common chronic complication of T1D affecting about 30% of the studied population and is associated with the presence of other chronic complications. Indicators of CAN included age, diabetes duration, hypertension, resting HR, diabetic neuropathy and retinopathy, and symptoms suggestive of autonomic neuropathy. This study confirms the importance of systematic and early screening for CAN.

Reliability of the classification of nutritional status obtained through the BMI and three different methods of body fat percentage in patients with type 1 diabetes mellitus

OBJECTIVE To assess the reliability of classification of nutritional status (NS) obtained through the body mass index (BMI) and three different methods of body composition (BC) in individuals type 1 diabetics (T1D) and non-diabetic subjects. METHODS 84 patients with T1D and 37 controls were evaluated. Anthropometric data was collected to calculate BMI and assessment of BC was performed through the methods of skinfold thickness (SF), bipolar (BI) and tetrapolar (TT) bioelectrical impedance. The agreement between the scores of each method was determined by Kappa (K) coefficient. RESULTS Considering all the patients, only 48 (57.1%) presented classification of BMI that agreed with the SF method, 58 (69%) with the BI and 45 (53.5%) with the TT. The K results for individuals with T1D was DC = 0.261, BI = 0.320 and TT = 0.174. The controls had higher values (DC = 0.605, BI = 0.360 and TT = 0.400). However, all values were considered low. CONCLUSIONS The method of BMI showed little sensitivity to BC changes in patients with T1D. Appropriated methods for the assessment of BC should be used to classify the NS of this population.

Crescimento de crianças diabéticas em controle ambulatorial em hospital universitário

The aim of this study was to evaluate the growth of patients with type 1 diabetes mellitus (DM1), under 18 years of age, followed at the outpatient Diabetes Unit of the Pedro Ernesto University Hospital - State of Rio de Janeiro University. The cross sectional study included a total of 34 patients, 19 male, chronologic age of 12±3.7y (mean±SD), age at diagnosis of DM 7.8±4.1y and duration of DM 4.2±3.1y. The median (range) of standard deviation score (SDS) of height for age (SDS H/A) was -0.05 (-1.8 to 1.1). Only 8.8% and 20.6% of the patients had SDS H/A 5y (SG2) of duration of DM, respectively: 0.26 (-1.47 to 1.10) vs. -0.77 (-1.88 to 0.73); p=0.03. Patients of the SG1 had a higher age on diagnosis of DM than patients of the SG2, respectively: 9.2+3.9 vs. 5.2±3.3y; p=0.01. The SDS H/A correlated with duration of DM1 (r=-0.47; p<0.01). Patients with appropriate control (glycated hemoglobin index - GHI <1.33) and non appropriate control (GHI ³1.33) had SDS H/A significantly different, respectively: 0.29 (-1.69 to 0.85) vs. -0.43 (-1.88 to 1.10); p=0.02. The median of SDS of weight for age (SDS W/A) of this sudy was 0.04 (-1.64 to 1.53). Only two patients had BMI on the 85 percentile. In conclusion, the greater duration of DM1 the lesser was SDS H/A of patients with conventional treatment. Patients with appropriate control had better growth.

Avaliação da suscetibilidade do LDL de pacientes com diabetes mellitus tipo 1 à oxidação in vitro e sua relação com o controle glicêmico

In 38 patients with type 1 diabetes (DM 1) and 24 non-diabetics we investigated LDL susceptibility to in vitro oxidation. Fast and post-prandial glycaemia (PPG), glycated hemoglobin (HbA1c) and lipid profile were determined, together with an spectrophotometric analysis of LDL oxidation before and 1, 3, 6 and 24 hours after addition of the oxidant substance - copper sulphate (CuSO4). The LDL oxidation coefficient in the two groups presented similar basal values; however 3 hours after CuSO4, LDL was more oxidized in patients with DM1. There was a negative correlation with PPG (r= -0.2511; p<0.05) and HbA1c (r= -0.2541; p<0.05). We conclude that in our sample of DM patients LDL was oxidized earlier than in the non-diabetics and that the glycemic control is important in this event.

Inter-relação de variáveis demográficas, terapêutica insulínica e controle glicêmico em pacientes com diabetes mellitus do tipo 1 atendidos em um hospital universitário

To evaluate the relationship between demographic variables, insulin therapy and glycemic control in type 1 diabetes mellitus (DM1), we studied 86 patients (44 F/ 42 M), aged 21.7±10 years: 10 (l 1.6%) pre-pubertal, 22 (25.6%) pubertal and 54 (62.8%) adults, with DM duration of 8.6+7.1 y and age at diagnosis of 13.2±8.5y. The number of clinic visits was 3.6±2.2 per year, with no association with gender, race and Tanner stage. Total insulin dose was 0.9±0.4 U/kg/day: 72 (83.7%) of the patients were using two daily injections; 39 (45.3%) were on fastacting insulin with 36 (92.3%) of them combined with a morning dose of intermediate- acting insulin. Multiple regression analysis showed that only HbA1C had influenced the insulin dose (r=0.45; r2=0.21; p<0.001). HbA1C was 8.4±1.9%, with higher leveis in stage 4 as compared to stages 1, 2, 3 and 5, respectively (10.5±2.4 vs 7.6±1.4 vs 8.9±2.1 vs. 8.3±2.4 vs 8.2±1.8%; p= 0.02). Pubertal females had higher HbAlc and BMI than males: 10.5±2.5 vs 8.3±2.0%; p= 0.02) and 19.4±1.9 vs 18.3±2.2 kg/m2 (p= 0.04), respectively. Glycemic control was considered good in 43 (50%) and poor in 27 (31.4%) patients. In conclusion, glycemic control in this study sample had worsened at the end of puberty, independent of the number of clinic visits and of all demographic variables analysed.The high number of patients with poor control must also be considered.

Variabilidade intra-individual do controle glicêmico em pacientes com diabetes tipo 1

OBJETIVO: Avaliar a variabilidade do controle glicemico em pacientes com diabetes tipo1 (DM1) em acompanhamento ambulatorial. PACIENTES E METODOS: Foram estudados 100 pacientes com DM1 (55 do sexo feminino), com idade de 18,6±9 anos, idade de diagnostico de 12 anos (1-35) e duracao do diabetes de 5 anos (0,09-40), com tempo de seguimento de 4,3 anos (2-8,5). A HbA1c foi determinada por cromatografia de troca ionica (valor de referencia: 2,4-6,2%). RESULTADOS: Foram analisados os dados de 94 pacientes. A HbA1c inicial e final foi de 7,6±1,8% e 8,7±2,1, com aumento absoluto de 1,1% (-7; 7,2) e anual de 0,22% (-3,5; 3,6). A HbA1c permaneceu inalterada em 2 pacientes (2,1%), aumentou em 64 (68,1%) e diminuiu em 28 (29,8%). Do grupo geral, 48 pacientes (51,1%) tiveram deterioracao, 12 (12,8%) melhora, 21 (22,3%) permaneceram com controle bom ou excelente e 13 (13,8%) com controle glicemico regular ou pessimo. O numero de HbA1c realizadas no acompanhamento foi de 6 (3-10) por paciente. Houve diferenca significativa quanto ao numero de HbA1c realizadas entre o grupo que apresentou piora no controle glicemico (7,2±2,1) e o que manteve controle regular ou pessimo (4,7±1) (p=0,003). A diferenca intra-individual entre a maior e a menor HbA1c foi de 3,1% (0,3-9,5). O coeficiente de variacao e o desvio padrao da HbA1c foi de 15,5±8,1 e 1,2±0,7%, respectivamente, sendo menor nos pacientes que mantiveram controle excelente ou bom. A correlacao entre a HbA1c final e a inicial foi de r= 0,37 (p=0,000) e entre a HbA1c media durante o estudo e a inicial foi r= 0,71 (p=0,000). CONCLUSAO: A maioria dos pacientes desta amostra apresentou piora do controle glicemico durante acompanhamento ambulatorial de rotina havendo tambem grande variabilidade intra-individual do controle glicemico. A HbA1c inicial do paciente mostrou-se um importante preditor do controle glicemico.