Nereida Kilza da Costa Lima

Prevalence of Insulin Resistance and Related Risk Factors for Cardiovascular Disease in Patients With Essential Hypertension

BACKGROUND There is evidence that the subgroup of patients with essential hypertension who are also insulin resistant is at increased risk of cardiovascular disease (CVD). We are unaware of the frequency of insulin resistance in patients with essential hypertension as well as the CVD risk in this subgroup of patients. This analysis was aimed at providing the prevalence of insulin resistance and associated CVD risk factors in treated and untreated patients with essential hypertension. METHODS The study population consisted of 126 patients with hypertension: 56 untreated and 70 in a stable treatment program. Body mass index (BMI), blood pressure, plasma glucose and insulin responses to an oral glucose challenge, lipid and lipoprotein concentrations, and steady-state plasma glucose (SSPG) concentration during the insulin suppression test were measured. Insulin resistance was defined operationally as a SSPG concentration >180 mg/dl. RESULTS Demographic characteristics and metabolic CVD risk factors were comparable in both groups, with 30-50% of both treated and untreated patients having abnormalities of all risk factors measured. Approximately 50% of patients met the criteria for insulin resistance in both groups, and the prevalence of abnormal CVD risk factors in this group was increased two to threefold as compared to the other half of the subjects. CONCLUSIONS Approximately 50% of patients with essential hypertension, both treated and untreated, appear to be insulin resistant, and CVD risk factors are greatly accentuated in this subset of patients.

Assessment of the techniques of blood pressure measurement by health professionals

OBJECTIVE To assess blood pressure measurement by health professionals of a public hospital in S o Paulo State. METHODS Semi-structured interviews and direct observation were performed with a verification list according to the criteria reported by Perloff et al. One hundred and five health professionals took part in the study. After measuring blood pressure, the level of concordance between the way the procedure was performed and the recommended one was assessed. RESULTS Nurses and nurses aides abided by 40% of the recommended procedures for adequate blood pressure measurement. The other categories of health professionals (nursing and medicine teachers, physicians, residents, and nursing students) abided by approximately 70%. CONCLUSION Permanent educational activities aiming at standardizing blood pressure measurement should be implemented among the different categories of health professionals.

Association of frailty syndrome in the elderly with higher blood pressure and other cardiovascular risk factors.

BACKGROUND Few studies have evaluated blood pressure (BP) and cardiovascular risk in older persons with frailty syndrome. The objective of the present study was to assess the cardiovascular risk factors of subjects with frailty syndrome with emphasis on BP, as compared with individuals without frailty or with prefrailty. METHODS This was a cross-sectional study in which 77 frail, prefrail, and nonfrail older subjects were selected according to the criteria of Fried et al.: self-reported weight loss, low grip strength, low energy, slow gait speed, and low physical activity. Anthropometric and BP measurements were obtained in the office, and home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM) were also performed. Fasting glucose and plasma lipids were collected. Data were analyzed by linear fixed effects model and ANOVA. RESULTS Mean age was 74.5 ± 7.5 years. There was no difference in office BP or HBPM between groups, but ABPM of frail group demonstrated higher systolic and diastolic BP values over the 24 h (135/74 mm Hg, P = 0.02 and P = 0.04) and during sleep (135/74 mm Hg, P = 0.01 and P = 0.02) than nonfrail group (122/68 mm Hg and 120/67 mm Hg, respectively). Body mass index and fasting glucose were similar among groups, although abdominal circumference was greater (P = 0.04) and high-density lipoproteins (HDL) were lower (P = 0.03) in the frail group than nonfrail one (P = 0.04). CONCLUSIONS Subjects with frailty syndrome had higher BP evaluated by ABPM and other cardiovascular risk factors such as lower HDL and more abdominal fat than nonfrailty group.

Chronic Salt Overload Increases Blood Pressure and Improves Glucose Metabolism Without Changing Insulin Sensitivity

The effect of sodium chloride salt restriction and overload on insulin sensitivity is still an open question. Some authors have shown that NaCl salt restriction increases insulin resistance, whereas others have reported the opposite. In the present study, the objective was to get some more insight on this issue by studying the influence of dietary salt content on glucose uptake in isolated adipocytes. Male Wistar rats were fed from weaning either low (0.15%) or high (7.94%) salt diets. On the 12th week of age, weight and tail-cuff blood pressure were measured, followed 10 days later by an intravenous glucose tolerance test with concomitant insulin determinations. One week later, the rats were killed by decapitation and epididymal adipocytes were obtained for glucose metabolism evaluation. No weight differences were observed between both groups of animals. Blood pressure was significantly higher (P < .001) on salt overloaded rats (146 +/- 11 mm Hg) than on salt restricted ones (115 +/- 5 mm Hg). Dietary salt content did not influence the area under the curve of plasma glucose. Area under the curve of insulin levels was lower (P = .023) on the high than on the low salt diet. A higher (P < .001) glucose uptake in the absence and in the presence of insulin was observed in adipocytes from rats on the high salt diet. The median effective concentration (EC50) from the dose-response curves of glucose uptake was the same on both groups of animals. Glucose oxidation and incorporation into lipids was also enhanced by salt overload. High salt increased insulin receptor density (P < .001). In conclusion, salt overload increased blood pressure, and high and low salt dietary content did not influence insulin sensitivity based on the unchanged EC50 from the in vitro studies. However, insulin-independent glucose uptake, oxidation, and incorporation into lipids were enhanced in adipocytes from rats on the high salt diet. The lower levels of insulin during the glucose tolerance test on salt-loaded animals may be a consequence of the higher insulin-independent glucose uptake in that group.

THE EFFECT OF DIFFERENT VOLUMES OF ACUTE RESISTANCE EXERCISE ON ELDERLY INDIVIDUALS WITH TREATED HYPERTENSION

Scher, LML, Ferriolli, E, Moriguti, JC, Scher, R, and Lima, NKC. The effect of different volumes of acute resistance exercise on elderly individuals with treated hypertension. J Strength Cond Res 25(4): 1016-1023, 2011-Acute resistance exercise can reduce the blood pressure (BP) of hypertensive subjects. The aim of this study was to evaluate the effect of different volumes of acute low-intensity resistance exercise over the magnitude and the extent of BP changes in treated hypertensive elderly individuals. Sixteen participants (7 men, 9 women), with mean age of 68 ± 5 years, performed 3 independent randomized sessions: Control (C: 40 minutes of rest), Exercise 1 (E1: 20 minutes, 1 lap in the circuit), and Exercise 2 (E2: 40 minutes, 2 laps in the circuit) with the intensity of 40% of 1 repetition maximum. Blood pressure was measured before (during 20 minutes) and after each session (every 5 minutes during 60 minutes) using both a mercury sphygmomanometer and a semiautomatic device (Omrom-HEM-431). After that, 24-hour ambulatory blood pressure monitoring was performed (Dyna-MAPA). Blood pressure decreased during the first 60 minutes (systolic: p < 0.01, diastolic: p < 0.05) after all exercise sessions. Only the highest volume session promoted a reduction of mean systolic 24-hour BP and awake BP (p < 0.05) after exercise, with higher diastolic BP during sleep (p < 0.05). Diastolic 24-hour BP and both systolic and diastolic BP during sleep were higher after E1 (p < 0.05). Concluding, acute resistive exercise sessions in a circuit with different volumes reduced BP during the first 60 minutes after exercise in elderly individuals with treated hypertension. However, only the highest volume promoted a reduction of mean 24-hour and awake systolic BP.

Under-reporting of food intake is frequent among Brazilian free-living older persons: a doubly labelled water study†

The assessment of food intake is essential for the development of dietetic interventions. Accuracy is low when intake is assessed by questionnaires, the under-reporting of food intake being frequent. Most such studies, however, were performed in developed countries and there is little data about the older population of developing nations. This study aimed to verify the total energy expenditure (TEE) of independent older Brazilians living in an urban area, through the doubly labelled water (DLW) method and to compare it with the reported energy intake obtained through the application of a food frequency questionnaire (FFQ). Initially, 100 volunteers aged from 60 to 75 years had their body composition determined by dual-energy X-ray absorptiometry (DEXA). Five volunteers of each quartile of body fat percentage had their energy expenditure determined by DLW. The mean age of the subjects included in this phase of the study was 66.4 +/- 3.5 years, and ten of the subjects were men. The mean TEE was 2565 +/- 614 and 2154 +/- 339 kcal.day(-1) for men and women, respectively. The Physical Activity Level (PAL) was 1.58 +/- 0.31 and 1.52 +/- 0.22, respectively. Under-reporting of food intake was highly prevalent, with a mean percentage of reported intake in relation to measured TEE of -17.7%. Thus, under-reporting of food intake is highly prevalent among Brazilian independent older persons. The DLW method is an important tool in nutritional studies and its use is to be recommended in developing countries.

Body composition, physical performance and muscle quality of active elderly women

Fat gain is one of the major factors aggravating physical disability in the elderly population, which presents an increase in fat mass and a decrease in lean mass compared to the young population. For this reason it is important to assess body composition and the effects of these alterations in obese elderly women. The purpose of this study was to assess body composition, physical performance and muscle quality in active elderly women. Cross-sectional study included 75 elderly women (29 eutrophic and 46 obese) 65-80 years old. Body composition was evaluated by dual energy X-ray absorptiometry (DXA) and the physical performance was determined by 6-minute walk test (6MWT), handgrip strength (HS) and knee extension strength (KES). Muscle quality was calculated as the ratio between muscle strength and lean mass. Fat free mass, lean mass, fat mass and percent body fat were significantly higher in the obese group (p<0.05). Furthermore, the obese group showed a poorer performance than the eutrophic group in the 6MWT (432.31±66.13 m and 472.07±74.03 m, respectively, p=0.01). HS and KES did not differ between groups, however, regarding muscle quality, the obese group exhibited a impaired in comparison to the eutrophic group in the upper (11.45±2.57 kg and 13.31±2.03 kg, respectively, p<0.01) and lower limb (2.91±1.16 kg and 3.44±0.97 kg, respectively, p=0.05). The increase in muscle mass detected in the obese elderly was not sufficient to maintain adequate muscle quality and physical function, showing a negative influence of the excess of body fat.

Under-reporting of food intake and body fatness in independent older people: a doubly labelled water study

BACKGROUND there are no accurate methods for the assessment of food intake in older populations, under-reporting of intake being highly prevalent. There is controversy about which dietary assessment method and what persons characteristics are associated with greater under-reporting rates. OBJECTIVE to assess the correlation between under-reporting of energy intake (EI) and different percentages of body fat in independent older people. DESIGN cross-sectional study. SETTTING area assisted by the Family Health Program of the Ribeirão Preto Medical School, University of São Paulo, Brazil. SUJECTS one hundred volunteers aged 60-70 years. METHODS all volunteers had their body composition assessed by dual-energy x-ray absorptiometry. In second phase, 41 volunteers were evaluated, representing the four quartiles of fat percentage. Total energy expenditure (TEE) was measured by the doubly labelled water method, and EI was assessed by 24-h recalls and a food frequency questionnaire (FFQ). TEE and EI values, EI-to-TEE ratios and EI-TEE values were compared. RESULTS TEE was 2,220 ± 601 kcal, while the EI was 1,919 ± 602 kcal (24-h recall) and 2,119 ± 670 kcal (FFQ). The proportion of under-reporters was 31 and 40.5%, respectively. Under-reporting was more frequent in subjects with higher percentage of body fat and in females (P < 0.05). CONCLUSION under-reporting was more frequent among older persons with higher percentage of body fat in both methods of assessment of food intake. Older persons follow the same profile of under-reporting as younger adults.

Adesão ao tratamento e controle da pressão arterial em idosos com hipertensão

FUNDAMENTO: A nao adesao ao tratamento tem sido identificada como a causa principal da Pressao Arterial (PA) nao controlada, e pode representar um risco maior em idosos. OBJETIVO: O objetivo deste estudo foi avaliar e comparar a taxa de adesao ao tratamento da hipertensao arterial por diferentes metodos, para estimar a taxa de controle da PA, e observar se ha uma associacao entre controle da pressao arterial e adesao. METODOS: A adesao ao tratamento foi avaliada em pacientes idosos com hipertensao, acompanhados pelo servico publico de saude, por meio de quatro metodos, incluindo o teste de Morisky-Green (referencia), o questionario sobre atitudes referentes a ingestao de medicacao (AMI), uma avaliacao da adesao por parte do enfermeiro em consultorio (AEC), e avaliacao domiciliar da adesao (ADA). A ingestao de sal foi estimada pela excrecao urinaria de sodio de 24 horas. O controle da pressao arterial foi avaliado pelo monitorizacao ambulatorial da pressao arterial na vigilia. RESULTADOS: A concordância entre o teste de Morisky-Green e o AMI (Kappa = 0,27) ou a AEC (Kappa = 0,05) foi pobre. Houve uma concordância moderada entre o teste de Morisky-Green e a ADA. Oitenta por cento tinham a PA controlada, incluindo 42% com efeito do jaleco branco. O grupo com menor excrecao de sal relatou evitar o consumo de sal mais vezes (p < 0,001) e tambem teve maior adesao ao medicamento (p < 0,001) do que o grupo com maior de excrecao de sal. CONCLUSAO: Os testes avaliados nao apresentaram boa concordância com o teste de Morisky-Green. A adesao ao tratamento da hipertensao foi baixa; no entanto, houve uma elevada taxa de controle da pressao arterial, quando os sujeitos com o efeito do jaleco branco foram incluidos na analise.BACKGROUND Non-adherence to treatment has been identified as the main cause of uncontrolled blood pressure (BP), and may represent a greater risk in older individuals. OBJECTIVE The aim of this study was to evaluate and compare the rate of adherence to hypertension treatment using different methods, to estimate the BP control rate, and to observe if there is an association between BP control and adherence. METHODS Treatment adherence was evaluated in older patients with hypertension, followed by the public primary health care, through four methods, including the Morisky-Green test (reference), the Attitude regarding the Medication Intake questionnaire (AMI), an evaluation of adherence by the nurse in the office (Nurse Adherence Evaluation - NAE), and at home (Home Adherence Evaluation - HAE). Salt intake was estimated by 24-hour sodium urinary excretion. BP control was assessed by the awake ambulatory blood pressure monitoring. RESULTS Concordance between the Morisky-Green test and AMI (Kappa=0.27) or NAE (Kappa=0.05) was poor. There was a moderate concordance between the Morisky-Green test and HAE. Eighty percent had controlled BP, including 42% with white-coat effect. The group with lower salt excretion informed to avoid salt intake more times (p<0.001) and had better medication adherence (p<0.001) than the higher salt excretion group. CONCLUSION The evaluated tests did not show a good concordance to the Morisky-Green test. Adherence to hypertension treatment was low; however, there was a high rate of BP control when subjects with the white-coat effect were included in the analysis.

Effect of Lifelong High- or Low-Salt Intake on Blood Pressure, Left Ventricular Mass and Plasma Insulin in Wistar Rats

Background:Salt restriction is recommended for hypertension treatment to reduce blood pressure, but its effect on some risk factors is still a matter of discussion. The aim of this study was to observe the effect of a long period of salt restriction or overload on blood pressure, left ventricular mass (LVM), kidney mass (KM), glucose tolerance, and plasma insulin. Methods:Male Wistar rats were fed from weaning with a low-salt diet (LSD) or a high-salt diet (HSD) until 72 weeks of age. After 48 weeks, the diets were changed in half of the rats: HSD until 48 weeks and then LSD (LHSD) and LSD until 48 weeks and then HSD (HLSD). Body weight, blood pressure, electrolyte excretion, creatinine clearance, plasma renin activity, LVM, KM, and intravenous glucose tolerance test with insulin determinations were evaluated. Results:Blood pressure, LVM and KM were higher on the HSD than on the LSD. Blood pressure was lower on the LHSD than on the HLSD. There were no differences in LVM and KM on the LHSD compared with the HLSD. The relationship between area under the curve (AUC) of insulin and glucose during the intravenous glucose tolerance test was higher on the LSD. No differences were detected in AUC between the two groups of rats whose diet were inverted with 48 weeks of age. Conclusions:A chronic HSD increases blood pressure, LVM, and KM and a chronic LSD increases plasma insulin in response to a glucose challenge in aging rats. The hypotensive effect of salt restriction is not modified by a previous long period on a HSD.