Maria Eliane Campos Magalhães

Metabolic syndrome, dyslipidemia, hypertension and type 2 diabetes in youth: from diagnosis to treatment

Overweight and obesity in youth is a worldwide public health problem. Overweight and obesity in childhood and adolescents have a substantial effect upon many systems, resulting in clinical conditions such as metabolic syndrome, early atherosclerosis, dyslipidemia, hypertension and type 2 diabetes (T2D). Obesity and the type of body fat distribution are still the core aspects of insulin resistance and seem to be the physiopathologic links common to metabolic syndrome, cardiovascular disease and T2D. The earlier the appearance of the clustering of risk factors and the higher the time of exposure, the greater will be the chance of developing coronary disease with a more severe endpoint. The age when the event may occur seems to be related to the presence and aggregation of risk factors throughout life.The treatment in this age-group is non pharmacological and aims at promoting changes in lifestyle. However, pharmacological treatments are indicated in special situations.The major goals in dietary treatments are not only limited to weight loss, but also to an improvement in the quality of life. Modification of risk factors associated to comorbidities, personal satisfaction of the child or adolescent and trying to establish healthy life habits from an early age are also important. There is a continuous debate on the best possible exercise to do, for children or adolescents, in order to lose weight. The prescription of physical activity to children and adolescents requires extensive integrated work among multidisciplinary teams, patients and their families, in order to reach therapeutic success.The most important conclusion drawn from this symposium was that if the growing prevalence of overweight and obesity continues at this pace, the result will be a population of children and adolescents with metabolic syndrome. This would lead to high mortality rates in young adults, changing the current increasing trend of worldwide longevity. Government actions and a better understanding of the causes of this problem must be implemented worldwide, by aiming at the prevention of obesity in children and adolescents.

National alert campaign about increased cholesterol: determination of cholesterol levels in 81,262 Brazilians

OBJECTIVE To determine the levels of total cholesterol in a significant sample of the Brazilian population. METHODS Blood cholesterol was determined in 81.262 individuals > 18 years old (51% male, 44.7 +/- 15.7 years), using Accutrend equipment, in the cities São Paulo, Campinas, Campos do Jordão, São José dos Campos, Santos, Santo André , Ribeirão Preto, Porto Alegre, Rio de Janeiro, Belo Horizonte, Curitiba, Brasília, Salvador and documented in the presence of other risk factors (RF) for coronary artery disease (CAD) (systemic hypertension, CAD in the family, smoking, and diabetes). Participants were classified according to sex, age, and the presence or absence of RF, respectively, as 0 RF, 1 RF and > 2 RF. The percentage of individuals with cholesterol > 200 mg/dL and > 240 mg/dL was evaluated. RESULTS The prevalence of individuals with 0, 1, and > 2 risk factors was 30% (n = 24,589), 36% (n =29,324), and 34% (n = 27,349) respectively, (P=0.657), and the mean total cholesterol of the population was 199.0 +/- 35.0 mg/dL. Cholesterol levels above 200 and 240 mg/dL were found, respectively, in 40% (n = 32,515) and 13% (10.942) of individuals. The greater the number of risk factors the higher the levels of cholesterol (P<0.0001) and the greater the proportion of individuals with cholesterol > 200 mg/dL (P=0.032). No difference existed in the proportion of individuals with cholesterol > 240 mg/dL (P=0.11). CONCLUSION A great percentage of individuals with cholesterol levels above those recommended to prevent coronary artery disease was found.

Early blood pressure level as a mark of familial aggregation of metabolic cardiovascular risk factors--the Rio de Janeiro Study.

Objective To investigate the familial aggregation of metabolic risk factors (RF) according to blood pressure (BP) percentile of children and adolescents. Design and methods Normal BP was established in 3906 children and adolescents in 1987. From this population two groups of target individuals were separated: group A (n = 327) with systolic and/or diastolic BP percentile > 95 and group B (n = 327) with systolic and diastolic BP percentile ≤ 50. Ten years later, familial aggregation of metabolic RF was evaluated using clinical and laboratorial data from 785 individuals, divided into two groups: group 1 with 135 target individuals (BP percentile > 95), 181 parents, 100 siblings and 16 grandparents; and group 2: 106 target individuals (BP percentile ≤ 50), 145 parents, 84 siblings and 18 grandparents. Results (1) The longitudinal study 10 years later (tracking effect) showed that 34.8% of target individuals of group 1 and 90.5% of group 2 remained at the same BP percentile. (2) Comparing the two groups of target individuals, group 1 had higher weight and body mass index (BMI), systolic BP (SBP), diastolic BP (DBP), and heart rate (HR) (P < 0.001) and lower HDL (P < 0.003). (3) Comparing target individuals’ and their relatives’ measurements together, group 1 had higher BMI, HR, SBP, DBP (P < 0.03) and lower HDL (P < 0.001). (4) SBP and DBP showed significant correlation with all metabolic variables even when BMI was controlled in a multiple regression analysis (P < 0.04). Conclusion BP level in children and adolescents was a good marker for familial aggregation of metabolic RF, suggesting an interaction of genetic and environmental factors. Primary intervention should be carried out in early stages of life.

Importance of high-density lipoprotein-cholesterol (HDL-C) levels to the incidence of cardiovascular disease (CVD) in the elderly

Studies about the impact of HDL-C levels on the incidence of cardiovascular disease (CVD) in the elderly are scarce. We decided to evaluate the relation of clinical and laboratory variables to the incidence of CVD events in the elderly stratified according to HDL-C behavior in an 8-year follow-up. We assessed 126 elderly (mean age: 70.01±7.24 years; 33.3% were men) on two occasions (assessment 1=A1, and assessment 2=A2), with a minimum of 5-year interval. They underwent clinical and laboratory evaluation and were divided into three groups as follows: (1) GN (n=52), normal HDL-C levels on A1 and A2; (2) GL (n=36), low HDL-C levels on A1 and A2; (3) GV (n=38), HDL-C levels varying from A1 to A2. The following CVD events were observed: coronary artery disease (angina pectoris=AP, myocardial infarction=MI, percutaneous/surgical coronary intervention); stroke; transient ischemic attack=TIA; carotid disease; and heart failure=HF. The groups did not differ in age or gender at A1 and A2. Triglyceride=TG mean levels were lower in GN at A1 (p=0.007) and A2 (p<0.001) than in GL. There were 14 CVD events in GN (26.9%), 23 (63.9%) in GL, and 13 (34.2%) in GV (χ2=12.825; p=0.002). In logistic regression analysis, we observed that the higher the systolic blood pressure (SBP) (odds ratio [OR]=1.0231; p=0.0338) and the lower the HDL-C (OR=0.9363; p=0.0035), the higher the incidence of CVD events. Persistently low HDL-C levels over 8 years of follow-up were a risk factor (RF) for the development of CVD events in the elderly.

Could pre-diabetes be considered a clinical condition? opinions from an endocrinologist and a cardiologist

The prevalence of pre-diabetes is increasing worldwide and may start 7 to 10 years before the clinical diagnosis of diabetes. In this stage the presence and accumulation of risk factors is common and already implies an increase in cardiovascular risk. Likewise, the onset of cardiovascular diseases (CVD), mainly coronary artery disease (CAD), peripheral vascular disease and cerebrovascular disease can also take place, all of which account for high rates of morbidity and mortality worldwide. Considering pre-diabetes as a clinical entity, non-pharmacological and pharmacological treatments are indicated with drugs which have shown clinical benefits related to reduction in morbidity and mortality. However, there is still need for new long-term studies to assess the real benefits of several new therapeutical approaches, as well as its cost-effectiveness.

Study of the intima-media thickening in carotid arteries of healthy elderly with high blood pressure and elderly with high blood pressure and dyslipidemia

Objective The objective of this study was to assess the mean intima-media thickening of carotid arteries of elderly subjects, and its relationship with age, anthropometric measurements, high systolic blood pressure and dyslipidemia. Methods In this investigation, 129 subjects were enrolled between 1995 and 1998, age ranging from 29 to 94 years. They were assigned to one of 4 groups, including 2 control groups (group I, of healthy younger subjects; group II of healthy elderly subjects). Groups III and IV included those who presented with isolated systolic hypertension (ISH), and ISH and dyslipidemia, respectively. All subjects were submitted to a medical interview, lab tests with measurement of cholesterol levels, electrocardiogram, and carotid ultrasound. The ultrasound included measurement of the intima-media thickening (IMT) of the carotid arteries, the right carotid artery (RCA) and left carotid artery (LCA), and assessment of the presence of plaques. Blood fat and glucose were measured by a standard method. The results were compared among the groups through statistical tests. The tests employed were: Chi-Square, Pearson’s and Likelihood Ratio, Student’s t, Mann-Whitney; ANOVA followed by Tukey’s test, Kruskal-Wallis nonparametric test, and test for multiple comparisons and Odds Ratio determination (OR). Results In this investigation, a positive association was observed between aging and IMT. In relation to systolic hypertension, a significant association was observed with IMT (IMT-RCA p = 0.0034; IMT-LCA p = 0.0196; IMT-RLCA p = 0.0299), and with the presence of plaques (PlaqueR p = 0.0110; PlaqueL p = 0.0294; PlaqueRL p = 0.0040). Conclusion This investigation evidenced the important role of aging in IMT, and of systolic hypertension in the IMT and presence of plaque. However, further studies are needed for a better understanding of the actual role of risk factors in aging.

Management of Metabolic Syndrome in Young Population

Metabolic syndrome is a complex disorder associated with several cardiovascular risk factors resulting in a 2.5-fold increase in cardiovascular mortality in adults. However, over the last 20 years, the same association has been demonstrated in the young population, and it is also related to a parental history of the syndrome. However, the root of the problem could be a high risk factor profile for metabolic syndrome in children and adolescents, as it has been demonstrated over the last 20 years. It has been shown that the association of obesity, alterations of glucose and lipids metabolism, and high blood pressure are responsible for early atherosclerotic lesions at autopsy as observed in young people. The prevalence of several risk factors for cardiovascular diseases has increased in the Brazilian population, as has that of obesity, a cause of great concern because of its importance as one of the metabolic syndrome components. The anthropometric patterns of the Brazilian population have changed over the last 30 years from undernourishment to weight excess, regardless of age, sex, or socioeconomic level. The identification of such individuals, followed by primary preventive measures, changes in lifestyle, and pharmacologic treatment, should be implemented, aiming at reducing the cardiovascular risk in countries undergoing economic transition, such as Brazil. The measures recommended for that age group should focus on changing lifestyle through adoption of healthy habits such as avoiding excessive intake of calories, salt, saturated fat, and cholesterol and engagement in regular physical activity without smoking.

Association between uric acid and cardiovascular risk variables in a non-hospitalized population

FUNDAMENTO: A associacao entre acido urico (AU) e as variaveis de risco cardiovascular permanece controversa em estudos epidemiologicos. OBJETIVO: Avaliar a associacao entre o AU, pressao arterial (PA), indices antropometricos e variaveis metabolicas em populacao nao hospitalar estratificada por quintis de AU. METODOS: Em estudo observacional transversal, foram avaliados 756 individuos (369M), com idade de 50,3 ± 16,12 anos, divididos em quintis de AU. Foram obtidos PA, indice de massa corporal (IMC), circunferencia abdominal (CA), AU, glicose, insulina, HOMA-IR, colesterol (CT), LDL-c, HDL-c, triglicerideos (TG), creatinina (C). Foi calculada a taxa de filtracao glomerular estimada (TFGE) e considerada hipertensao arterial (HA) quando a PA > 140x90 mmHg, sobrepeso/obesidade (S/O) quando IMC > 25 kg/m2 e sindrome metabolica (SM) de acordo com a I Diretriz Brasileira de SM. RESULTADOS: 1) Nao houve diferenca entre os grupos na distribuicao por sexo e faixa etaria; 2) Os maiores quintis de AU apresentaram maiores medias de idade (p < 0,01), IMC, CA (p < 0,01), PAS, PAD (p < 0,001), CT, LDL-c, TG (p < 0,01), C e TFGE (p < 0,001) e menor media de HDL-c (p < 0,001); 3) O grupo com maior quintil de AU mostrou maiores prevalencias de HA, S/O e SM (p < 0,001); 4) Maiores percentuais dos menores quintis de insulina (p < 0,02) e de HOMA-IR (p < 0,01) foram encontrados nos menores quintis de AU; 5) Em analise de regressao logistica, o AU e as variaveis que compoem a SM apresentaram-se associados a ocorrencia de SM (p < 0,01). CONCLUSAO: Maiores quintis de acido urico associaram-se a pior perfil de risco cardiovascular e a pior perfil de funcao renal na amostra populacional nao hospitalar estudada.BACKGROUND The association between uric acid (UA) and cardiovascular risk variables remains a controversial issue in epidemiological studies. OBJECTIVE To evaluate the association between UA, blood pressure (BP), anthropometric indices and metabolic variables in a non-hospitalized population stratified by UA quintiles. METHODS A cross-sectional observational study evaluated 756 individuals (369 males), aged 50.3 ± 16.12 years, divided in UA quintiles. BP, body mass index (BMI), abdominal circumference (AC), UA, glucose, insulin, HOMA-IR, total cholesterol (TC), LDL-c, HDL-c, triglycerides (TG) and creatinine (C) levels were obtained. The estimated glomerular filtration rate (eGFR) was calculated and arterial hypertension (AH) was considered when BP > 140x90 mmHg, overweight/obesity (OW/O) was considered when BMI > 25 kg/m² and metabolic syndrome (MS) was established according to the I Brazilian Guideline of MS. RESULTS 1) There was no difference between the groups regarding the distribution by sex and age range; 2) The highest UA quintiles presented higher mean age (p < 0.01), BMI, AC (p < 0.01), SBP, DBP (p < 0.001), TC, LDL-c, TG (p < 0.01), C and eGFR (p < 0.001) and lower mean HDL-c (p < 0.001); 3) The group with the highest UA quintile showed higher prevalence of AH, OW/O and MS (p < 0.001); 4) Higher percentages of the lowest quintiles of insulin (p < 0.02) and HOMA-IR (p < 0.01) were observed with the lowest quintiles of UA; 5) A logistic regression analysis showed that UA and the variables that compose MS were associated with the occurrence of MS (p < 0.01). CONCLUSION Higher quintiles of uric acid were associated with a worse cardiovascular risk profile and a worse kidney function profile in the non-hospitalized population sample studied.

Associação entre ácido úrico e variáveis de risco cardiovascular em uma população não hospitalar

FUNDAMENTO: A associacao entre acido urico (AU) e as variaveis de risco cardiovascular permanece controversa em estudos epidemiologicos. OBJETIVO: Avaliar a associacao entre o AU, pressao arterial (PA), indices antropometricos e variaveis metabolicas em populacao nao hospitalar estratificada por quintis de AU. METODOS: Em estudo observacional transversal, foram avaliados 756 individuos (369M), com idade de 50,3 ± 16,12 anos, divididos em quintis de AU. Foram obtidos PA, indice de massa corporal (IMC), circunferencia abdominal (CA), AU, glicose, insulina, HOMA-IR, colesterol (CT), LDL-c, HDL-c, triglicerideos (TG), creatinina (C). Foi calculada a taxa de filtracao glomerular estimada (TFGE) e considerada hipertensao arterial (HA) quando a PA > 140x90 mmHg, sobrepeso/obesidade (S/O) quando IMC > 25 kg/m2 e sindrome metabolica (SM) de acordo com a I Diretriz Brasileira de SM. RESULTADOS: 1) Nao houve diferenca entre os grupos na distribuicao por sexo e faixa etaria; 2) Os maiores quintis de AU apresentaram maiores medias de idade (p < 0,01), IMC, CA (p < 0,01), PAS, PAD (p < 0,001), CT, LDL-c, TG (p < 0,01), C e TFGE (p < 0,001) e menor media de HDL-c (p < 0,001); 3) O grupo com maior quintil de AU mostrou maiores prevalencias de HA, S/O e SM (p < 0,001); 4) Maiores percentuais dos menores quintis de insulina (p < 0,02) e de HOMA-IR (p < 0,01) foram encontrados nos menores quintis de AU; 5) Em analise de regressao logistica, o AU e as variaveis que compoem a SM apresentaram-se associados a ocorrencia de SM (p < 0,01). CONCLUSAO: Maiores quintis de acido urico associaram-se a pior perfil de risco cardiovascular e a pior perfil de funcao renal na amostra populacional nao hospitalar estudada.BACKGROUND The association between uric acid (UA) and cardiovascular risk variables remains a controversial issue in epidemiological studies. OBJECTIVE To evaluate the association between UA, blood pressure (BP), anthropometric indices and metabolic variables in a non-hospitalized population stratified by UA quintiles. METHODS A cross-sectional observational study evaluated 756 individuals (369 males), aged 50.3 ± 16.12 years, divided in UA quintiles. BP, body mass index (BMI), abdominal circumference (AC), UA, glucose, insulin, HOMA-IR, total cholesterol (TC), LDL-c, HDL-c, triglycerides (TG) and creatinine (C) levels were obtained. The estimated glomerular filtration rate (eGFR) was calculated and arterial hypertension (AH) was considered when BP > 140x90 mmHg, overweight/obesity (OW/O) was considered when BMI > 25 kg/m² and metabolic syndrome (MS) was established according to the I Brazilian Guideline of MS. RESULTS 1) There was no difference between the groups regarding the distribution by sex and age range; 2) The highest UA quintiles presented higher mean age (p < 0.01), BMI, AC (p < 0.01), SBP, DBP (p < 0.001), TC, LDL-c, TG (p < 0.01), C and eGFR (p < 0.001) and lower mean HDL-c (p < 0.001); 3) The group with the highest UA quintile showed higher prevalence of AH, OW/O and MS (p < 0.001); 4) Higher percentages of the lowest quintiles of insulin (p < 0.02) and HOMA-IR (p < 0.01) were observed with the lowest quintiles of UA; 5) A logistic regression analysis showed that UA and the variables that compose MS were associated with the occurrence of MS (p < 0.01). CONCLUSION Higher quintiles of uric acid were associated with a worse cardiovascular risk profile and a worse kidney function profile in the non-hospitalized population sample studied.

Pressão Arterial em jovens como marcador de risco cardiovascular. Estudo do Rio de Janeiro

BACKGROUND: The study of the cardiovascular risk variables in young populations is fundamental to establish primary prevention strategies. OBJECTIVE: To evaluate the blood pressure (BP), anthropometric and metabolic profile in young individuals from The Rio de Janeiro Study, followed by 17 years. METHODS: A total of 115 individuals (64 males) were evaluated at three different moments (follow-up: 212.23±16.0 months): A1 (12.97±1.48 years), A2 (21.90±1.71 years) and A3 (30.65±2.00 years) and divided in two groups: NG (n=84) with at least two normal BP measurements at the three assessments; HG (n=31) with at least two abnormal BP measurements at the three assessments. BP and body mass index (BMI) were obtained at the three assessments. Levels of glucose, triglycerides, total cholesterol and fractions were obtained at A2 and A3. Abdominal circumference (AC) was obtained only at A3. RESULTS: 1) The means of BP, BMI and AC (p<0.0001) as well as the prevalence of systemic arterial hypertension (SAH) and overweight/obesity (O/O) (p<0.003) were higher in the HG at the three assessments; 2) The means of LDL-c and glycemia (p<0.05) at A2 and the prevalence of metabolic syndrome (MS) at A3 were higher in the HG; 3) the association SAH+O/O was more prevalent in the HG, whereas the association NBP+NBMI was more prevalent in the NG (p<0.0001) at the three assessments; 4) SAH at A1 (RR=5.20 = 5.20; p<0.0007), male gender (RR=5.26 = 5.26; p<0.0019) and OO at A1 (RR=3.40 = 3.40; p<0.0278) determined an increased risk for AH at the young adult life (A3). CONCLUSION: After 17 years of follow-up, the BP of young individuals showed a significant association with the cardiovascular risk variables and the occurrence of MS at the young adult life.BACKGROUND The study of the cardiovascular risk variables in young populations is fundamental to establish primary prevention strategies. OBJECTIVE To evaluate the blood pressure (BP), anthropometric and metabolic profile in young individuals from The Rio de Janeiro Study, followed by 17 years. METHODS A total of 115 individuals (64 males) were evaluated at three different moments (follow-up: 212.23+/-16.0 months): A1 (12.97+/-1.48 years), A2 (21.90+/-1.71 years) and A3 (30.65+/-2.00 years) and divided in two groups: NG (n=84) with at least two normal BP measurements at the three assessments; HG (n=31) with at least two abnormal BP measurements at the three assessments. BP and body mass index (BMI) were obtained at the three assessments. Levels of glucose, triglycerides, total cholesterol and fractions were obtained at A2 and A3. Abdominal circumference (AC) was obtained only at A3. RESULTS 1) The means of BP, BMI and AC (p<0.0001) as well as the prevalence of systemic arterial hypertension (SAH) and overweight/obesity (O/O) (p<0.003) were higher in the HG at the three assessments; 2) The means of LDL-c and glycemia (p<0.05) at A2 and the prevalence of metabolic syndrome (MS) at A3 were higher in the HG; 3) the association SAH+O/O was more prevalent in the HG, whereas the association NBP+NBMI was more prevalent in the NG (p<0.0001) at the three assessments; 4) SAH at A1 (RR=5.20 = 5.20; p<0.0007), male gender (RR=5.26 = 5.26; p<0.0019) and OO at A1 (RR=3.40 = 3.40; p<0.0278) determined an increased risk for AH at the young adult life (A3). CONCLUSION After 17 years of follow-up, the BP of young individuals showed a significant association with the cardiovascular risk variables and the occurrence of MS at the young adult life.