Sandra Roberta Gouvea Ferreira

Multifaceted Determinants for Achieving Glycemic Control: The International Diabetes Management Practice Study (IDMPS)

OBJECTIVE—The International Diabetes Mellitus Practice Study is a 5-year survey documenting changes in diabetes treatment practice in developing regions. RESEARCH DESIGN AND METHODS—Logistic regression analysis was used to identify factors for achieving A1C <7% in 11,799 patients (1,898 type 1 diabetic and 9,901 type 2 diabetic) recruited by 937 physicians from 17 countries in Eastern Europe (n = 3,519), Asia (n = 5,888), Latin America (n = 2,116), and Africa (n = 276). RESULTS—Twenty-two percent of type 1 diabetic and 36% of type 2 diabetic patients never had A1C measurements. In those with values for A1C, blood pressure, and LDL cholesterol, 7.5% of type 1 diabetic (n = 696) and 3.6% of type 2 diabetic (n = 3,896) patients attained all three recommended targets (blood pressure <130/80 mmHg, LDL cholesterol <100 mg/dl, and A1C <7%). Self-monitoring of blood glucose was the only predictor for achieving the A1C goal in type 1 diabetes (odds ratios: Asia 2.24, Latin America 3.55, and Eastern Europe 2.42). In type 2 diabetes, short disease duration (Asia 0.97, Latin America 0.97, and Eastern Europe 0.82) and treatment with few oral glucose–lowering drugs (Asia 0.64, Latin America 0.76, and Eastern Europe 0.62) were predictors. Other region-specific factors included lack of microvascular complications and old age in Latin America and Asia; health insurance coverage and specialist care in Latin America; lack of obesity and self-adjustment of insulin dosages in Asia; and training by a diabetes educator, self-monitoring of blood glucose in patients who self-adjusted insulin, and lack of macrovascular complications in Eastern Europe. CONCLUSIONS—In developing countries, factors pertinent to patients, doctors, and health care systems all impact on glycemic control.

Influência da distribuição da gordura corporal sobre a prevalência de hipertensão arterial e outros fatores de risco cardiovascular em indivíduos obesos

INTRODUCTION: Obese people are at higher cardiovascular risk than people with normal body weight. The objective of this study was to establish the relationship between obesity, body fat distribution and cardiovascular risk factors. METHODS: Body mass index (BMI), waist-hip ratio (WHR) systolic (SBP) and diastolic blood pressure (DBP), plasma cholesterol, triglycerides and glucose levels were determined in a population of 499 overweight and obese patients (432F/67M; age 39±12.9y). RESULTS: High prevalence of abnormal glucose tolerance or diabetes (21.8%), hypercholesterolenemia (49.1%), hypertri glyceridemia (21.3%) and hypertension (43.8%) were found in this population. The prevalence of hypertension increased from 23% in patients with BMI 25-29.9 kg/m2 to 67.1% (p 40kg/m2 and also from 35.7% in patients with WHR between 0.73 and 0.88 to 66.6% in those with WHR >0.97 (p 40kg/m2, (p<0.05). CONCLUSION: Our data reinforce the association between obesity and high cardiovascular risk. In addition, our findings suggested a role for body fat distribution in the development of hypertension in obese patients.

Gordura visceral e síndrome metabólica: mais que uma simples associação

ABSTRACT Visceral Fat and Metabolic Syndrome: More Than a Simple Association.Metabolic syndrome (MS) is seen nowadays as a worldwide epidemicevent associated with high cardiovascular morbi-mortality and highsocioeconomic cost. The ponderal gain is an independent predictor forthe development of MS, although not all obese individuals present it. Onthe other hand, some populations with low obesity prevalence presenthigh prevalence of MS and cardiovascular mortality. The distribution ofcorporal fat is relevant and visceral fat (VF), specifically, seems to be thelink between adipose tissue and insulin resistance (IR), a mean featureof MS. Adipose tissue is now considered a complex organ with multiplefunctions. VF presents metabolic properties, which are different from thegluteo-femoral subcutaneous fat and related to IR. Several studies showthe narrow relationship of abdominal adiposity with the glucose tole-rance, hyperinsulinemia, hypertriglyceridemia and arterial hypertension.More than a simple association, recently it is thought that the VF plays acentral part in the physiopathology of MS. Consequently, the quantifi-cation of VF plays an important role to identify individuals with larger risk

Ultrasonography for the Evaluation of Visceral Fat and Cardiovascular Risk

Visceral fat accumulation is associated with increased cardiovascular risk. Clinical evaluation of visceral fat is limited because of the lack of reliable and low-cost methods. To assess the correlation between ultrasonography and computed tomography (CT) for the evaluation of visceral fat, 101 obese women, age 50.5±7.7 years with a body mass index of 39.2±5.4 kg/m2, were submitted to ultrasonograph and CT scans. Visceral fat measured by ultrasonography, 1 cm above the umbilical knot, showed a high correlation with CT-determined visceral fat (r =0.67, P <0.0001). The ultrasonograph method showed good reproducibility with an intra-observer variation coefficient of <2%. Both ultrasonograph and CT visceral fat values were correlated with fasting insulin (r =0.29 and r =0.27, P <0.01) and plasma glucose 2 hours after oral glucose load (r =0.22 and r =0.34, P <0.05), indicating that ultrasonography is a useful method to evaluate cardiovascular risk. A significant correlation was also found between visceral fat by CT and serum sodium (r =0.18, P <0.05). A ultrasonograph-determined visceral-to-subcutaneous fat ratio of 2.50 was established as a cutoff value to define patients with abdominal visceral obesity. This value also identified patients with higher levels of plasma glucose, serum insulin and triglycerides and lower levels of HDL-cholesterol, which are metabolic abnormalities characteristic of the metabolic syndrome. Our data demonstrate that ultrasonography is a precise and reliable method for evaluation of visceral fat and identification of patients with adverse metabolic profile.

Prevalence and 7-year incidence of Type II diabetes mellitus in a Japanese-Brazilian population: an alarming public health problem

Abstract Aims/hypothesis. In 1993, the prevalence of glucose intolerance was studied in a sample of 647 first-generation and second-generation Japanese-Brazilians. Their cohort was followed until 2000, when a second survey was conducted, this included the first and second generations, aged 30 or more years. The aims were to estimate the prevalence of glucose intolerance and 7-yr incidence of Type II (non-insulin-dependent) diabetes mellitus in this population. Methods. Prevalence rates were obtained for 1330 subjects examined in 2000. The incidence of diabetes mellitus was calculated for those classified as normal glucose tolerant in 1993 (n=253). A Students t test and the Cox proportional hazard model were used in data analysis. Results. In the year 2000, higher proportions of subjects were observed in all categories of glucose intolerance than those found in 1993. The overall incidence of diabetes was 30.9 per 1000 per year. A worse profile was observed among incident cases of diabetes, characterized by higher baseline values of anthropometric and metabolic variables as compared to those who had not developed diabetes. Analysis considering the simultaneous effects of demographic, nutritional and metabolic variables and physical activity levels for the development of diabetes showed that age, sex, waist circumference, fasting and 2-h plasma glucose concentrations were independent predictors. Conclusion/interpretation. Our data point towards a worsening of glucose tolerance status among Japanese-Brazilians, who show one of the highest prevalence rates of diabetes mellitus worldwide. This could reflect their strong genetic susceptibility associated with unfavourable environmental conditions.

Excesso de peso e gordura abdominal para a síndrome metabólica em nipo-brasileiros

OBJECTIVE: Obesity, especially abdominal, has been associated with cardiovascular risk factors such as dyslipidemia, hypertension and diabetes mellitus (DM). The importance of these risk factors among Japanese-Brazilians was previously shown, although obesity is not a typical characteristic of Japanese migrants. In this study the prevalence of weight excess and central adiposity (CA) among Japanese-Brazilians and their association with metabolic disorders was evaluated. METHODS: A sample of 530 1st and 2nd generation Japanese-Brazilians (aged 40¾79 years) went through anthropometric and blood pressure measurements, lipid profile and oral glucose tolerance tests. The prevalence rate (point and confidence interval) of overweight was calculated using a cut-off value of >26.4 kg/m2. CA diagnosis was based on waist-to-hip circumference ratio (WHR): ³ 0.85 and 0.95 in women and men, respectively. RESULTS: The prevalence of weight excess was 22.4% (CI 95% 20.6¾28.1), and CA was 67.0% (95% CI 63.1¾70.9). In addition to higher prevalence of DM, hypertension and dyslipidemia, stratifying by BMI and WHR, people with weight excess and CA revealed a poorer metabolic profile: blood pressure levels were significantly higher among those with weight excess with or without CA; CA individuals had higher glucose, triglycerides, total and LDL cholesterol, and lower HDL than those without weight excess or CA; fasting insulinemia was significantly higher among subjects with weight excess (with or without CA) than among those without weight excess or CA. CONCLUSION: Comparing subgroups with and without CA supports the hypothesis that abdominal fat accumulation represents a risk factor for insulin resistance-related diseases, even among Japanese descendants. The increased prevalence of metabolic syndrome among Japanese migrants could be attributed to visceral fat deposition, which has been implicated in the genesis of insulin resistance.

Subclinical thyroid dysfunctions are independent risk factors for mortality in a 7.5-year follow-up: the Japanese-Brazilian thyroid study.

OBJECTIVE The currently available data concerning the influence of subclinical thyroid disease (STD) on morbidity and mortality are conflicting. Our objective was to investigate the relationships between STD and cardiometabolic profile and cardiovascular disease at baseline, as well as with all-cause and cardiovascular mortality in a 7.5-year follow-up. DESIGN Prospective, observational study. METHODS An overall of 1110 Japanese-Brazilians aged above 30 years, free of thyroid disease, and not taking thyroid medication at baseline were studied. In a cross-sectional analysis, we investigated the prevalence of STD and its relationship with cardiometabolic profile and cardiovascular disease. All-cause and cardiovascular mortality rates were assessed for participants followed for up to 7.5 years. Association between STD and mortality was drawn using multivariate analysis, adjusting for potential confounders. RESULTS A total of 913 (82.3%) participants had euthyroidism, 99 (8.7%) had subclinical hypothyroidism, and 69 (6.2%) had subclinical hyperthyroidism. At baseline, no association was found between STD and cardiometabolic profile or cardiovascular disease. Multivariate-adjusted hazard ratios (HRs (95% confidence interval)) for all-cause mortality were significantly higher for individuals with both subclinical hyperthyroidism (HR, 3.0 (1.5-5.9); n=14) and subclinical hypothyroidism (HR, 2.3 (1.2-4.4); n=13) than for euthyroid subjects. Cardiovascular mortality was significantly associated with subclinical hyperthyroidism (HR, 3.3 (1.4-7.5); n=8), but not with subclinical hypothyroidism (HR, 1.6 (0.6-4.2); n=5). CONCLUSION In the Japanese-Brazilian population, subclinical hyperthyroidism is an independent risk factor for all-cause and cardiovascular mortality, while subclinical hypothyroidism is associated with all-cause mortality.

Estimativa de consumo de sódio pela população brasileira, 2002-2003

OBJETIVO: Estimar a magnitude e a distribuicao regional e socioeconomica do consumo de sodio no Brasil e identificar as fontes alimentares que mais contribuem para esse consumo. METODOS: As estimativas foram baseadas nos dados da Pesquisa de Orcamentos Familiares, realizada no Brasil entre julho de 2002 e junho de 2003. Foram analisados 969.989 registros de aquisicao de alimentos efetuados por uma amostra probabilistica de 48.470 domicilios localizados em 3.984 setores censitarios do Pais. Realizou-se conversao dos registros das aquisicoes de alimentos em nutrientes por meio de tabelas de composicao de alimentos. Foram calculadas a disponibilidade media de sodio por pessoa e por dia e a disponibilidade media ajustada para um consumo energetico equivalente a 2.000 kcal. Calculou-se a contribuicao de grupos de alimentos selecionados para o total de sodio disponivel para consumo no domicilio. As estimativas sao apresentadas segundo regioes, situacao urbana ou rural do domicilio, e estratos de renda. RESULTADOS: A quantidade diaria de sodio disponivel para consumo nos domicilios brasileiros foi de 4,5 g por pessoa (ou 4,7 g para uma ingestao diaria de 2.000 Kcal), excedendo, assim, em mais de duas vezes o limite recomendado de ingestao desse nutriente. Embora a maior parte do sodio disponivel para consumo em todas classes de renda provenha do sal de cozinha e de condimentos a base desse sal (76,2%), a fracao proveniente de alimentos processados com adicao de sal aumenta linear e intensamente com o poder aquisitivo domiciliar, representando 9,7% do total de sodio no quinto inferior da distribuicao da renda per capita e 25,0% no quinto superior. CONCLUSOES: Os resultados indicam que o consumo de sodio no Brasil excede largamente a recomendacao maxima para esse nutriente em todas as macrorregioes brasileiras e em todas as classes de renda.OBJECTIVE To estimate the magnitude and distribution of sodium intake in Brazil and to identify major dietary sources contributing to this intake. METHODS Estimates were based on data from a Brazilian household budget survey carried between July 2002 and June 2003. A total of 969,989 food purchase records from a probabilistic sample of 48,470 households located in 3,984 census tracts across the country were analyzed. Purchase records were converted into nutrients using food composition charts. Mean sodium availability per person per day and mean adjusted availability considering a 2,000 kcal daily energy intake were calculated, as well as the contribution of selected food groups to total household sodium availability. Estimates are presented according to geographical region, urban or rural status of the household, and income stratum. RESULTS Mean daily sodium availability in Brazilian households was 4.5 g per person (or 4.7 g considering a daily calorie intake of 2,000 kcal), thus exceeding by more than two times the recommended levels of intake for this nutrient. Although most of the sodium available for intake across all income strata was derived from kitchen salt or salt-based condiments (76.2%), the fraction derived from processed foods with added salt showed a strong linear increase as household purchasing power increased, representing 9.7% of total sodium intake in the lower quintile of the per capita income distribution and 25.0% in the upper quintile. CONCLUSIONS Results indicate that sodium intake in Brazil widely exceeds the maximum recommended intake level for this nutrient in all of the countrys macro regions and across all income strata.

The New Adipose Tissue and Adipocytokines

Obesity is a well-known risk factor for the development of insulin resistance, type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease. Rather than the total amount of fat, central distribution of adipose tissue is very important in the pathophysiology of this constellation of abnormalities termed metabolic syndrome. Adipose tissue, regarded only as an energy storage organ until the last decade, is now known as the biggest endocrine organ of the human body. This tissue secretes a number of substances--adipocytokines--with multiple functions in metabolic profile and immunological process. Therefore, excessive fat mass may trigger metabolic and hemostatic disturbances as well as CVD. Adipocytokines may act locally or distally as inflammatory, immune or hormonal signalers. In this review we discuss visceral obesity, the potential mechanisms by which it would be related to insulin resistance, methods for its assessment and focus on the main adipocytokines expressed and secreted by the adipose tissue. Particularly, we review the role of adiponectin, leptin, resistin, angiotensinogen, TNF-alpha, and PAI-1, describing their impact on insulin resistance and cardiovascular risk, based on more recent findings in this area.

Freqüência de hipertensão arterial e fatores associados: Brasil, 2006

OBJECTIVE To analyze the frequency of self-reported systemic arterial hypertension and associated factors. METHODS Study based on data provided by the system of Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (VIGITEL--Telephone-based surveillance of risk and protective factors for chronic diseases), collected in 2006 in Brazils capitals and Federal District. The frequency of systemic arterial hypertension was estimated in 54,369 adults, stratified by sex, geographic region, sociodemographic and behavioral variables and self-reported morbidities. Crude odds ratios of hypertension were calculated, as well as odds ratios adjusted for the studys variables. RESULTS The frequency of self-reported hypertension was 21.6%. It was higher among women (24.4% versus 18.4%), lower in the North and Central-West regions and higher in the Southeast region. The frequency of hypertension increased with age, decreased with level of schooling, was higher among blacks and widowed subjects, and lower among singles. The chance of hypertension, adjusted for confounding variables, was higher in subjects with overweight, diabetes, dyslipidemia and cardiovascular events. CONCLUSIONS Around one fifth of the population reported suffering from systemic arterial hypertension. The high frequencies of modifiable risk factors indicate the population segments on which intervention should be targeted, aiming to prevent and control hypertension.OBJETIVO: Analisar a frequencia de hipertensao arterial sistemica auto-referida e fatores associados. METODOS: Estudo baseado em dados do sistema de Vigilância de Fatores de Risco e Protecao para Doencas Cronicas por Inquerito Telefonico (VIGITEL), coletados em 2006 nas capitais brasileiras e Distrito Federal. Estimou-se a frequencia de hipertensao arterial sistemica entre 54.369 adultos, estratificada por sexo, regiao geografica, variaveis sociodemograficas e comportamentais e morbidades auto-referidas. Foram calculadas os odds ratios brutos de hipertensao e ajustados para variaveis do estudo. RESULTADOS: A frequencia de hipertensao auto-referida foi de 21,6%, maior entre mulheres (24,4% versus 18,4%), menor nas regioes Norte e Centro-Oeste e maior na Sudeste. A frequencia de hipertensao aumentou com a idade, diminuiu com a escolaridade, foi maior entre negros e viuvos e menor entre solteiros. A chance de hipertensao, ajustada para variaveis de confusao, foi maior para os individuos com excesso de peso, diabetes, dislipidemia e de eventos cardiovasculares. CONCLUSOES: Cerca de um quinto da populacao referiu ser portadora de hipertensao arterial sistemica. As altas frequencias de fatores de risco modificaveis indicam os segmentos populacionais alvos de intervencao, visando a prevencao e controle da hipertensao.