Marcelo M. Pinheiro

Sarcopenia associada ao envelhecimento: aspectos etiológicos e opções terapêuticas

A prevalencia de incapacidade e dependencia funcional e maior em idosos e esta intimamente associada a reducao da massa muscular, que ocorre, ate mesmo, em individuos saudaveis. A sarcopenia parece decorrer da interacao complexa de disturbios da inervacao, diminuicao de hormonios, aumento de mediadores inflamatorios e alteracoes da ingestao proteico-calorica que ocorrem durante o envelhecimento. A perda de massa e forca muscular e responsavel pela reducao de mobilidade e aumento da incapacidade funcional e dependencia. Quando associada a fragilidade, esta perda gera custos economicos e sociais. Neste artigo, pretende-se avaliar aspectos relacionados a genese da sarcopenia, bem como analisar possiveis opcoes terapeuticas e de prevencao.The high prevalence of inability and functional dependence is an important problem in elderly people. It is closely related with aging decrease of lean muscle mass that occurs even in healthy subjects. Skeletal muscle mass deficiency, or sarcopenia, results from complex interactions between innervations disturbances, hormones deficiency, inflammatory cytokines and restriction in caloric-proteic ingestion. Loss of skeletal muscle mass and strength results in disability and functional dependency that are associated to frailty in many elderly people. These conditions represent enormous economic and social budget. In this article, we evaluate pathogenesis of sarcopenia and discuss potential therapies.

Therapeutic monoclonal antibodies in ophthalmology.

Monoclonal antibodies (mAbs) can be used therapeutically by binding to molecular targets with high specificity. Therefore, they have excellent therapeutic applications in ophthalmology. This manuscript presents four aspects of the therapeutic use of mAbs in ophthalmology: the scientific rationale, the unique characteristics of selected mAbs, the current state-of-the-art application, and relevant therapeutic mAbs for future applications in ophthalmology. We identified in the literature various single-agent therapies that inhibit the following targets: tumor necrosis factor (TNF), epithelial growth factor receptor, vascular endothelial growth factor (VEGF) receptor, basic fibroblast growth factor receptor, platelet-derived growth factor, and cluster of differentiation antigens. The roles of all biochemical targets in ocular diseases were evaluated. Current and future mAbs against various cytokines were assessed for the treatment of ocular diseases. The medical literature showed the clinical benefits of mAbs for treating angiogenic and inflammatory ocular diseases. Two anti-VEGF mAbs, bevacizumab and ranibizumab, and three anti-TNF agents, infliximab, etanercept, and adalimumab, control ocular neovascularization and intraocular inflammation. Other mAbs such as rituximab, daclizumab, efalizumab, and alemtuzumab showed positive results in animal and early clinical studies and may represent useful adjuvant therapies for ocular lymphoma or ocular inflammation. Ranibizumab is the only FDA-approved therapy; for other mAbs the so-called off-label application remains the standard. Intravenous administration of mAbs has demonstrated acceptable toxicity profiles, while intraocular injection may decrease the chances of systemic complications and increase the amount of drug available to the retina and choroid. In conclusion, effective clinical use of mAbs in ophthalmology is more commonly seen in the field of angiogenic vitreoretinal and autoimmune inflammatory diseases. The challenge for the future is combining biologic therapies to improve the quality and duration of responses while diminishing side effects. The role of mAbs within ophthalmic treatments will be defined according to future clinical experience and the results of randomized clinical trials.

Nutrient intakes related to osteoporotic fractures in men and women – The Brazilian Osteoporosis Study (BRAZOS)

BackgroundAdequate nutrition plays an important role in bone mass accrual and maintenance and has been demonstrated as a significant tool for the prevention of fractures in individuals with osteoporosis.ObjectiveThe aim of the present study was to evaluate bone health-related nutrients intake and its association with osteoporotic fractures in a representative sample of 2344 individuals aged 40 years or older in Brazil.MethodsIn a transversal population-based study, a total of 2420 individuals over 40 years old were evaluated from March to April 2006. Participants were men and women from all socio-economic classes and education levels living around the Brazilian territory Individuals responded a questionnaire including self reported fractures as well a 24-hour food recall. Nutrient intakes were evaluated by Nutrition Data System for Research software (NDSR, University of Minnesota, 2007). Low trauma fracture was defined as that resulting of a fall from standing height or less. Nutrient intakes adequacies were performed by using the DRIs proposed values. Statistical analysis comprises Oneway ANCOVA adjusted by age and use of nutritional supplements and multiple logistic regression. SAS software was used for statistical analysis.ResultsFractures was reported by 13% of men and 15% of women. Women with fractures presented significantly higher calcium, phosphorus and magnesium intakes. However, in all regions and socio-economical levels mean intakes of bone related nutrients were below the recommended levels. It was demonstrated that for every 100 mg/phosphorus increase the risk of fractures by 9% (OR 1.09; IC95% 1.05–1.13, p < 0.001).ConclusionThe results demonstrated inadequacies in bone related nutrients in our population as well that an increase in phosphorus intake is related to bone fractures.

Bone mineral density and body composition in postmenopausal women with psoriasis and psoriatic arthritis

IntroductionThe aim of the present study was to compare bone mineral density (BMD) and body composition (BC) measurements as well as identify risk factors for low BMD and osteoporotic fractures in postmenopausal women with psoriasis (Ps) and psoriatic arthritis (PsA).MethodsA cross-sectional study was carried out in 45 PsA women, 52 Ps women and 98 healthy female controls (HC). Clinical risk factors for low bone density and osteoporotic fracture were evaluated by a specific questionnaire. An X-ray absorptiometry (DXA) at the lumbar spine, total femur and total body was performed on all patients. Skin and joint outcomes were measured by specific tools (PASI, HAQ and DAS28). Morphometric vertebral fractures were evaluated by lumbar and thoracic spine X-ray, according to Genants method.ResultsThere were no significant differences in age, body mass index (BMI), total lean mass and bone mineral density among the groups. However, the PsA group had a significantly higher body fat percentage (BF%) than the Ps and HC groups. Osteoporotic fractures were more frequently observed in PsA and Ps groups than in the HC group (P = 0.01). Recurrent falls and a longer duration of disease increased the risk of fracture (odds ratio (OR) = 18.3 and 1.08, respectively) in the PsA group (P = 0.02). Disability was the main factor related to osteoporotic fracture in the Ps group (odds ratio (OR) = 11.1) (P = 0.02).ConclusionsPs and PsA patients did not present lower BMD. However, they had a higher prevalence of osteoporotic fractures and higher risk of metabolic syndrome. Patients with a longer duration of disease, disability and recurrent falls need preventive measures.

Risk factors for osteoporotic fractures and low bone density in pre and postmenopausal women

OBJECTIVE To estimate the prevalence and analyze risk factors associated to osteoporosis and low-trauma fracture in women. METHODS Cross-sectional study including a total of 4,332 women older than 40 attending primary care services in the Greater São Paulo, Southeastern Brazil, between 2004 and 2007. Anthropometrical and gynecological data and information about lifestyle habits, previous fracture, medical history, food intake and physical activity were obtained through individual quantitative interviews. Low-trauma fracture was defined as that resulting from a fall from standing height or less in individuals 50 years or older. Multiple logistic regression models were designed having osteoporotic fracture and bone mineral density (BMD) as the dependent variables and all other parameters as the independent ones. The significance level was set at p<0.05. RESULTS The prevalence of osteoporosis and osteoporotic fractures was 33% and 11.5%, respectively. The main risk factors associated with low bone mass were age (OR=1.07; 95% CI: 1.06;1.08), time since menopause (OR=2.16; 95% CI: 1.49;3.14), previous fracture (OR=2.62; 95% CI: 2.08;3.29) and current smoking (OR=1.45; 95% CI: 1.13;1.85). BMI (OR=0.88; 95% CI: 0.86;0.89), regular physical activity (OR=0.78; 95% CI: 0.65;0.94) and hormone replacement therapy (OR=0.43; 95% CI: 0.33;0.56) had a protective effect on bone mass. Risk factors significantly associated with osteoporotic fractures were age (OR=1.05; 95% CI: 1.04;1.06), time since menopause (OR=4.12; 95% CI: 1.79;9.48), familial history of hip fracture (OR=3.59; 95% CI: 2.88;4.47) and low BMD (OR=2.28; 95% CI: 1.85;2.82). CONCLUSIONS Advanced age, menopause, low-trauma fracture and current smoking are major risk factors associated with low BMD and osteoporotic fracture. The clinical use of these parameters to identify women at higher risk for fractures might be a reasonable strategy to improve the management of osteoporosis.OBJETIVO: Estimar a prevalencia e analisar os fatores de risco associados com osteoporose e fratura por baixo impacto entre mulheres. METODOS: Estudo transversal realizado com 4.332 mulheres acima de 40 anos de idade provenientes de atendimento primario de saude na area metropolitana da Grande Sao Paulo, SP, entre 2004 e 2007. Dados antropometricos e ginecologicos e relativos a habitos de vida, fratura previa, antecedentes pessoais, ingestao alimentar e atividade fisica foram avaliados por meio de entrevista individual e quantitativa. Fratura por baixo impacto foi definida como decorrente de queda da propria altura ou menos em individuos com mais de 50 anos de idade. Modelos de regressao multivariada e logistica analisaram, respectivamente, a densidade ossea e a fratura por osteoporose como variaveis dependentes e todas as outras como independentes. O nivel de significância estatistica estabelecido foi p < 0,05. RESULTADOS: A prevalencia de osteoporose e de fraturas por fragilidade ossea foi de 33% e 11,5%, respectivamente. Os principais fatores de risco associados com baixa densidade ossea foram idade (OR = 1,07; IC 95%: 1,06;1,08), menopausa (OR = 2,16; IC 95%: 1,49;3,14), fratura previa (OR = 2,62; IC 95%: 2,08;3,29) e tabagismo atual (OR = 1,45; IC 95%: 1,13;1,85). Por outro lado, elevado IMC (OR = 0,88; IC 95%: 0,86;0,89), atividade fisica regular (OR = 0,78; IC 95%: 0,65;0,94) e terapia hormonal atual (OR = 0,43; IC 95%: 0,33;0,56) desempenharam papel protetor. Os fatores de risco significativamente relacionados com fratura por osteoporose foram idade (OR = 1,05; IC 95%: 1,04;1,06), menopausa (OR = 4,12; IC 95%: 1,79;9,48), historia familiar de fratura de quadril (OR = 3,59; IC 95%: 2,88;4,47) e baixa densidade ossea (OR = 2,28; IC 95%: 1,85;2,82). CONCLUSOES: Idade avancada, menopausa, fratura previa por baixo impacto e tabagismo atual sao os principais fatores de risco associados com baixa densidade ossea, a qual se associa com as fraturas por fragilidade ossea. O uso clinico desses parâmetros para identificar mulheres de maior risco para fraturas pode ser uma estrategia interessante para melhorar a abordagem da osteoporose.

Risk factors for recurrent falls among Brazilian women and men: the Brazilian Osteoporosis Study (BRAZOS)

The objective of the study was to estimate the frequency of recurrent falls and identify the main associated risk factors. The BRAZOS is the first epidemiological study performed on a representative sample of the Brazilian population. Anthropometric data, living habits, previous fractures, falls, dietary intake, physical activity and quality of life were evaluated in 2,420 individuals aged 40 and older. Recurrent falls were reported by 15.5% of men and 25.6% of women. Among women, the risk factors significantly associated to recurrent falls were age, previous fracture, sedentary lifestyle, poor quality of life, diabetes mellitus and current use of benzodiazepine. In men, the risk factors were age, poor quality of life, intake of alcoholic beverages, diabetes mellitus, previous fracture and use of benzodiazepine. A greater intake of vitamin D had a protector effect on the risk of recurrent falls. These findings demonstrated the high prevalence of recurrent falls and emphasize that a multidisciplinary approach is necessary to minimize recurrent falls and their consequences, including osteoporotic fractures.

The burden of osteoporosis in Brazil: regional data from fractures in adult men and women - The Brazilian Osteoporosis Study (BRAZOS)

INTRODUCAO/OBJETIVOS: O BRAZOS (The Brazilian Osteoporosis Study) e um estudo epidemiologico, de base populacional, realizado em amostra representativa de mulheres e homens brasileiros, de idade superior a 40 anos, com o objetivo de identificar os principais fatores clinicos de risco associados com fratura por baixo impacto. Nesse artigo sao apresentados os principais resultados do estudo, de acordo com cada regiao do pais. PACIENTES E METODOS: Um total de 2.420 individuos, provenientes das cinco regioes do pais e de todas as classes socioeconomicas foram incluidos no estudo. Foram avaliados dados antropometricos, bem como aspectos relacionados aos habitos de vida, fraturas, ingestao alimentar, atividade fisica, quedas e qualidade de vida por meio de entrevista individual e quantitativa. Fratura por baixo impacto foi definida como aquela decorrente de queda da propria altura ou menos. Valor de P < 0,05 foi considerado como estatisticamente significante. RESULTADOS: Nao houve diferenca estatisticamente significativa da prevalencia de fratura nas cinco regioes do Brasil, de acordo com o sexo ou classe social. No entanto, nas mulheres, houve maior ocorrencia de fraturas na regiao metropolitana do que nos municipios do interior dos estados e tendencia a maior frequencia de fraturas em homens da regiao nordeste. Nao foi verificada diferenca estatisticamente significativa de fraturas se os homens eram provenientes das capitais ou do interior dos estados. CONCLUSOES: De acordo com os nossos resultados, nao foi observada diferenca significativa da prevalencia de fraturas por baixo impacto nem da frequencia ou relevância de fatores de risco entre as cinco regioes do Brasil.OBJECTIVES The BRAZOS (The Brazilian Osteoporosis Study) study is the first epidemiological and population-based study carried out in a representative sample of Brazilian men and women, 40 years or older, with the objective of identifying the prevalence and main clinical risk factors (CRF) associated with low-impact fractures. This report shows the main results according to each region of the country. PATIENTS AND METHODS A total of 2,420 subjects (70% women) from 150 different cities in five geographic regions in Brazil, and from all different socio-economical classes were included in this study. Anthropometrical data, as well life style, previous fractures, nutritional status, physical activity, falls, and quality of life were evaluated by a quantitative individual survey. Low-impact fracture was defined as that resulting from a fall no greater than standing height of an individual. A P < 0.05 was considered significant. RESULTS Statistically significant differences in the prevalence of fractures among the five Brazilian regions according to gender or social class were not observed. However, in women, a higher incidence of fractures was observed in metropolitan areas than in rural areas, and a tendency for a higher frequency of fractures was observed in men from Northeastern states. Statistically significant differences among men from metropolitan areas or rural areas were not observed. CONCLUSIONS Significant differences in the prevalence of low-impact fractures among the five different regions of Brazil were not observed, as well as its frequency or relevance of risk factors.

Body composition and nutritional profile of male adolescent tennis players

Abstract In this cross-sectional study, we evaluated the body composition and dietary intake of 44 adolescent tennis players. After being divided into two groups (age 10–13 years and age 14–18), the players had their weight, height, and sexual maturation assessed. Dual-energy X-ray absorptiometry was used to assess body composition. Food intake was obtained from a non-consecutive 4-day food record. The data were analysed using the Virtual Nutri v.1.0 software and compared with the present recommendations for adolescent athletes or dietary reference intakes. Body mass index and body fat for tennis practice were adequate for 89% and 71% of the tennis players respectively, regardless of age group. A calorie deficit greater than 10% of energy expenditure was observed in 32% of the sample. Fifty percent of the athletes consumed carbohydrates in accordance with recommended values. Protein and lipid intakes were above recommended values, while fibre, calcium, potassium, magnesium, and folic acid intakes were below recommendation for 98%, 80%, 100%, 100%, and 98% of the tennis players respectively. The observed nutritional deficiencies represent an additional barrier for adolescents engaged in competitive sports to achieve an optimum nutrition to maintain growth, health, and performance.

Cálcio dietético: estratégias para otimizar o consumo

RESUMO O calcio e um nutriente essencial necessario em diversas funcoes biologicas. Estudos tem demonstrado a associacao entre o baixo consumo de calcio e doencas cronicas, entre elas osteoporose, câncer de colon, hipertensao arterial e obesidade. Entretanto, grande parte da populacao brasileira apresenta consumo de calcio abaixo do recomendado. Este artigo objetiva revisar os fatores endogenos (idade e estado hormonal) e exogenos (fitatos, oxalatos, sodio, compostos bioativos e vitamina D) que influenciam a absorcao do calcio, bem como as principais metodologias utilizadas para avaliar a absorcao e biodisponibilidade desse nutriente. discorre-se sobre os possiveis fatores para o baixo consumo de calcio: 1) Habito alimentar – substituicao de leite por bebidas com baixo teor de calcio como o refrigerante, refeicoes realizadas fora de casa e a nao realizacao de refeicoes como o cafe da manha; 2) Alto custo dos alimentos fontes de calcio. Alem disso, este artigo discute as estrategias para otimizar o consumo do calcio, que incluem: 1) Aumentar o conhecimento sobre a importância do consumo de calcio para a saude e as principais fontes alimentares desse nutriente; 2) Aumentar a disponibilidade de alimentos fortificados com calcio; 3) Uso de suplementos em grupos especificos – quando e como administrar os sais de calcio. Palavras-chave: calcio, absorcao, biodisponibilidade, consumo, sais de calcio.

Posições oficiais 2008 da Sociedade Brasileira de Densitometria Clínica (SBDens)

With the evolution of bone densitometry, differences in technologies, acquisition techniques, reference databases, reporting methods, diagnostic criteria and terminology have developed and the International Society for Clinical Densitometry (ISCD) periodically holds Position Development Conferences, the latest in 2007. The Brazilian Society for Clinical Densitometry (SBDens), with support from many Brazilian societies interested in bone health, gathered numerous specialists to discuss the ISCD proposals and to evaluate the validity of the extension of those norms to Brazilian population. The SBDens reunion of consensus made a very utile document to help the understanding and interpretation of bone densitometry and other methods of bone assessment.