Fatores associados ao controle metabólico em pacientes com diabetes melito tipo 2 não usuários de insulina

Introdução: a obtenção de um bom controle metabólico é essencial para a prevenção das complicações crônicas do Diabetes Melito (DM). O tratamento é complexo e depende da implementação efetiva das diferentes estratégias terapêuticas disponíveis. Para que isso seja possível, é necessário que o paciente entenda os princípios terapêuticos e consiga executá-los. A precária educação em diabetes é percebida como um dos obstáculos para o alcance das metas terapêuticas. Objetivo: analisar, os fatores associados ao controle metabólico, em pacientes com DM tipo 2 (DM2) não usuários de insulina. Métodos: foi realizado um estudo transversal em pacientes com DM2 não usuários de insulina, selecionados ao acaso entre aqueles que consultavam nos ambulatórios de Medicina Interna, Endocrinologia e Enfermagem do Hospital de Clínicas de Porto Alegre. Os pacientes foram submetidos à avaliação clínica, laboratorial e responderam um questionário que incluía o tipo de tratamento realizado para DM, outros medicamentos e co-morbidades, pesquisa de complicações em ano prévio e avaliação do conhecimento sobre DM. Os pacientes foram classificados em dois grupos, com bom ou mau controle glicêmico, de acordo com o valor da glico-hemoglobina de 1 ponto % acima do limite superior do método utilizado. As comparações entre variáveis contínuas, com distribuição normal, foram analisadas pelo teste t de Student para amostras não-pareadas e para as variáveis de distribuição assimétrica ou com variância heterogênea o teste U de Mann-Whitney. A comparação entre percentagem foi feita pelo teste de qui-quadrado ou exato de Fisher. Foi realizada uma análise logística múltipla para identificar os fatores mais relevantes associados ao controle metabólico (variável dependente). As variáveis independentes com um nível de significância de P < 0,1 na análise bivariada, foram incluídas no modelo. Resultados: foram avaliados 143 pacientes com DM2, idade de 59,3 ± 10,1 anos, duração conhecida do DM 7,5 ± 6,3 anos, índice de massa corporal (IMC) de 29,7 ± 5,2 kg/m².Destes, 94 pacientes (65,73%) apresentavam bom controle glicêmico. Os pacientes com mau controle glicêmico usavam mais anti-hiperglicemiantes orais como monoterapia (OR = 9,37; IC = 2,60-33,81; P=0,004) ou associados (OR = 31,08; IC = 7,42-130,15; P < 0,001). Da mesma maneira, não fizeram dieta em dias de festa (OR = 3,29; IC = 1,51-7,16; P = 0,012). A inclusão do conhecimento sobre diabetes não foi diferente entre os pacientes com bom ou mau controle glicêmico (OR = 1,08; IC = 0,97 - 1,21; P = 0,219). A análise multivariada demonstrou que a consulta com a enfermeira educadora (OR = 0,24; IC = 0,108-0,534; P = 0,003), com o endocrinologista (OR = 0,15 ; IC = 0,063-0,373; P = 0,001) e o uso de hipolipemiantes (OR = 0,10; IC = 0,016 - 0,72; P = 0,054) foram associados ao bom controle glicêmico, ajustados para a não realização de dieta em festas, uso de anti-hiperglicemiantes orais e conhecimento sobre diabetes. Conclusão: o controle metabólico em pacientes DM2 é influenciado pelas atividades de educação com enfermeira e endocrinologista. O tratamento do DM2 deve incluir atividades de educação de forma sistemática.

Curso evolutivo e fatores de progressão da nefropatia diabética em pacientes com diabete melito tipo 2

A nefropatia diabética (ND) é uma complicação microvascular freqüente, que acomete cerca de 40% dos indivíduos com diabete melito (DM). A ND associa-se a significativo aumento de morte por doença cardiovascular. É a principal causa de insuficiência renal terminal em países desenvolvidos e em desenvolvimento, representando, dessa forma, um custo elevado para o sistema de saúde. Os fatores de risco para o desenvolvimento e a progressão da ND mais definidos na literatura são a hiperglicemia e a hipertensão arterial sistêmica. Outros fatores descritos são o fumo, a dislipidemia, o tipo e a quantidade de proteína ingerida na dieta e a presença da retinopatia diabética. Alguns parâmetros de função renal também têm sido estudados como fatores de risco, tais como a excreção urinária de albumina (EUA) normal-alta e a taxa de filtração glomerular excessivamente elevada ou reduzida. Alguns genes candidatos têm sido postulados como risco, mas sem um marcador definitivo. O diagnóstico da ND é estabelecido pela presença de microalbuminúria (nefropatia incipiente: EUA 20-199 μg/min) e macroalbuminúria (nefropatia clínica: EUA ≥ 200 μg/min). À medida que progride a ND, aumenta mais a chance de o paciente morrer de cardiopatia isquêmica. Quando o paciente evolui com perda de função renal, há necessidade de terapia de substituição renal e, em diálise, a mortalidade dos pacientes com DM é muito mais significativa do que nos não-diabéticos, com predomínio das causas cardiovasculares. A progressão nos diferentes estágios da ND não é, no entanto, inexorável. Há estudos de intervenção que demonstram a possibilidade de prevenção e de retardo na evolução da ND principalmente com o uso dos inibidores da enzima conversora da angiotensina, dos bloqueadores da angiotensina II e do tratamento intensivo da hipertensão arterial. Os pacientes podem entrar em remissão, ou até mesmo regredir de estágio. A importância da detecção precoce e da compreensão do curso clínico da ND tem ganhado cada vez mais ênfase, porque a doença renal do DM é a principal causa de diálise no mundo e está associada ao progressivo aumento de morte por causas cardiovasculares.

Avaliação do retinol em parturientes com diabetes mellitus gestacional no pós parto imediato

Micronutrient deficiencies affect individuals mainly in developing countries, where vitamin A deficiency is a public health problem worldwide more worrying, especially in groups with increased physiological needs such as children and women of reproductive age. Vitamin A is supplied to the body through diet and has an important role in the visual process, cell differentiation, maintenance of epithelial tissue, reproductive and resistance to infection. The literature has demonstrated the relationship between vitamin A and diabetes, including gestational, leading to a risk to both mother and child. Gestational diabetes is any decrease in glucose tolerance of variable magnitude diagnosed each the first time during pregnancy, and may or may not persist after delivery. Insulin resistance during pregnancy is associated with placental hormones, as well as excess fat. Studies have shown that retinol transport protein produced in adipose tissue in high concentrations, this would be associated with resistance by interfering with insulin signaling. Therefore, this study aimed to evaluate the concentration of retinol in serum and colostrum from healthy and diabetic mothers in the immediate postpartum period. One hundred and nine parturient women were recruited, representing seventy-three healthy and thirty-six diabetic. Retinol was extracted and subsequently analyzed by High Performance Liquid Chromatography. Among the results highlights the mothers with gestational diabetes were older than mothers healthy, had more children and a higher prevalence of cases of cesarean section. Fetal macrosomia was present in 1.4% of healthy parturient women and in 22.2% of diabetic mothers. The maternal serum retinol showed an average of 39.7 ± 12.5 mg/dL for healthy parturients 35.12 ± 15 mg/dL for diabetic and showed no statistical difference. It was observed that in the group of diabetic had 17% vitamin A deficiency, whereas in the healthy group, only 4% of the women were deficentes. Colostrum, the concentration of retinol in healthy was 131.3 ± 56.2 mg/dL and 125.3 ± 41.9 mg/dL in diabetic did not differ statistically. This concentration of retinol found in colostrum provides approximately 656.5 mg/day for infants born to healthy mothers and 626.5 mg/day for infants of diabetic mothers, based on a daily consumption of 500 mL of breast milk and need Vitamin A 400 mg/day, thus reaching the requirement of the infant. The diabetic mothers showed significant risk factors and complications related to gestational diabetes. Although no 11 difference was found in serum retinol concentration and colostrum among women with and without gestational diabetes, the individual analysis shows that parturients women with diabetes are 4.9 times more likely to develop vitamin A deficiency than healthy parturients. However, the supply of vitamin A to the newborn was not committed in the presence of gestational diabetes

Low protein diet confers resistance to the inhibitory effects of interleukin1 beta on insulin secretion in pancreatic islets

High protein content in the diet during childhood and adolescence has been associated to the onset insulin-dependent diabetes mellitus. We investigated the effect of interleukin-1 beta (IL-I beta) on insulin secretion, glucose metabolism, and nitrite formation by islets isolated from rats fed with normal protein (NP, 17%) or low protein (LP, 6%) after weaning. Pretreatment of islets with IL-1 beta for 1 h or 34 h inhibited the insulin secretion induced by glucose in both groups, but it was less marked in LP than in NP group. Islets from LP rats exhibited a decreased IL-1 beta -induced nitric oxide (NO) production, lower inhibition of D-[(UC)-C-14]-glucose oxidation to (CO2)-C-14, and less pronounced effect of IL-1 beta on alpha -ketoisocaproic acid-induced insulin secretion than NP islets. However, when the islets were stimulated by high concentrations of K+ the inhibitory effect of IL-1 beta on insulin secretion was not different between groups. In conclusion, protein restriction protects beta -cells of the deleterious effect of IL-1 beta, apparently, by decreasing NO production. The lower NO generation in islets from protein deprived rats may be due to increased free fatty acids oxidation and consequent alteration in Ca2+ homeostasis. (C) 2001 Elsevier B.V. All rights reserved.

Cost-benefit of hospitalization compared with outpatient care for pregnant women with pregestational and gestational diabetes or with mild hyperglycemia, in Brazil

CONTEXTO E OBJETIVO: Gestações complicadas pelo diabetes estão associadas com aumento de complicações maternas e neonatais. Os custos hospitalares aumentam de acordo com a assistência prestada. O objetivo foi calcular o custo-benefício e a taxa de rentabilidade social da hospitalização comparada ao atendimento ambulatorial em gestantes com diabetes ou com hiperglicemia leve. DESENHO do ESTUDO: Estudo prospectivo, observacional, quantitativo, realizado em hospital universitário, sendo incluídas todas as gestantes com diabetes pregestacional e gestacional ou com hiperglicemia leve que não desenvolveram intercorrências clínicas na gestação e que tiveram parto no Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (HC-FMB-Unesp). MÉTODOS: Trinta gestantes tratadas com dieta foram acompanhadas em ambulatório e 20 tratadas com dieta e insulina foram abordadas com hospitalizações curtas e frequentes. Foram obtidos custos diretos (pessoal, material e exames) e indiretos (despesas gerais) a partir de dados contidos no prontuário e no sistema de custo por absorção do hospital e posteriormente calculado o custo-benefício. RESULTADOS: O sucesso do tratamento das gestantes diabéticas evitou o gasto de US$ 1.517,97 e US$ 1.127,43 para pacientes hospitalizadas e ambulatoriais, respectivamente. O custo-benefício da atenção hospitalizada foi US$ 143.719,16 e ambulatorial, US$ 253.267,22, com rentabilidade social 1,87 e 5,35 respectivamente. CONCLUSÃO: A análise árvore de decisão confirma que o sucesso dos tratamentos elimina custos no hospital. A relação custo-benefício indicou que o tratamento ambulatorial é economicamente mais vantajoso do que a hospitalização. A rentabilidade social de ambos os tratamentos foi maior que 1, indicando que ambos os tipos de atendimento à gestante diabética têm benefício positivo.

Long-term effects of insulin therapy, islet transplantation, and pancreas transplantation in the prevention of glomerular changes in kidneys of alloxan-induced diabetic rats

Groups of inbred alloxan-induced diabetic rats were treated with insulin (I), islets (IT), or pancreas transplantation (PT). Nondiabetic (N) and untreated diabetic (D) control groups were concurrently included. Each group was divided into five subgroups of 10 rats and killed after follow-up of 1, 3, 6, 9, and 12 months. Clinical and laboratory parameters were recorded, and kidney ultrastructural and morphometric analyses performed in each 12-month subgroup, namely glomerular basement membrane (GM) thickening, podocyte number, and number/extension of slit diaphragms (S). Rats from the I group showed poor metabolic control of diabetes compared with N group control rats. However, successfully transplanted rats (IT and PT) had complete restoration to normal levels for all metabolic parameters. GM thickening was significantly higher in diabetic compared with control rats. In contrast, the numbers of podocytes and slits as well as slit extensions were significantly decreased. Insulin therapy did not prevent any alterations upon comparison of diabetic vs control rats. Despite good metabolic control in IT rats, the degree of kidney lesion control never compared with that achieved in PT rats. In this group all glomerular changes were similar to the age-dependent lesions observed in control rats. We conclude that either IT or PT may be a good option for diabetes treatment, although pancreas transplantation seems to be the most effective treatment to control chronic complications.

Lipid profile of people with Diabetes mellitus type 2 and periodontal disease

The objective of this study was to evaluate improvement of lipids and periodontal disease in patients with type 2 Diabetes mellitus, by means of the relationship between blood levels of total cholesterol and its fractions, triglycerides and clinical periodontal parameters. Twenty patients, in age-range 18-70 years, were selected and divided into 2 groups: (1) conventional periodontal scaling and root planing + controlled mechanic; (2) conventional periodontal scaling and root planing + controlled mechanical + maintenance therapy. The analyses were performed on day 0, 180 and 720 days, including plaque index, gingival index, probing depth and clinical attachment level, and evaluation of total cholesterol and its fractions, and triglycerides. The 2 groups presented significant reduction in clinical periodontal parameters, however, probing depth did not diminish significantly only in Group 1. There was significant improvement in all blood parameters in both groups. It was concluded that after 720 days of the experiment, there were significant improvements in clinical and blood parameters, in general. The group that received maintenance therapy also showed a more expressive improvement in clinical periodontal parameters, in general, suggesting that this therapy is important and necessary in patients with type 2 Diabetes mellitus and periodontal disease. (C) 2011 Elsevier B.V. All rights reserved.

Effect of periodontal treatment on metabolic control, systemic inflammation and cytokines in patients with type 2 diabetes

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Temporal response pattern of biochemical analytes in experimental diabetes

The activities of the enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), lactate dehydrogenase (LD), creatine kinase (CK), amylase (AMS) and angiotensin converting enzyme (ACE) have been used to assess the toxic effects of xenobiotics that have hypoglycaemic action in hepatic, pancreatic, renal and muscle tissue. Using a validated experimental model of diabetes mellitus in rats, we ascertained whether this syndrome itself affected the serum activities of these enzymes over a 53-day period. Levels of hepatic enzymes AST, ALT and ALP were higher in the streptozotocin (STZ)diabetic rats (group D), but were controlled by insulin therapy (group DI). AMS was reduced in group D and unchanged in group DI rats. Proteinuria was detected 1 day after STZ administation and partially controlled by insulin (group DI); its early presence in group D rats, and the lack of any change in serum ACE in this group, indicates that proteinuria is the better marker for microangiopathy. Microscopic examination of liver, kidney, heart and skeletal muscles (soleus and extensor digitorum longus) revealed various alterations in group D rat tissues, which were less pronounced in group DI. The liver, pancreas and kidney tissue-damage was consistent with the altered serum levels of AST, ALT, ALP and AMS and proteinuria. We conclude that: (i) rigorous control is required when these serum-enzyme levels are used as indicators of tissue toxicity in experimental diabetes, and (ii) LD, CK and bilirubin serum levels, which are unaffected by diabetes, can be used when testing effects of xenobiotics on tissues.

Effect of combined hormonal and insulin therapy on the steroid hormone receptors and growth factors signalling in diabetic mice prostate

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Ultrastructural and proliferative features of the ventral lobe of the prostate in non-obese diabetic mice (NOD) following androgen and estrogen replacement associated to insulin therapy

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Interaction of hypercaloric diet and physical exercise on lipid profile, oxidative stress and antioxidant defenses

The present study examined the interaction of hypercaloric diet (HD) and physical exercise on lipid profile and oxidative stress in serum and liver of rats. Male Wistar rats (60-days-old) were fed with a control (C) and hypercaloric diet (H). Each of the two dietary groups (C and H) was divided into three subgroups (n = 8), sedentary (CS and HS), exercised 2 days a week (CE2 and HE2) and exercised 5 days a week (CE5 and HE5). The swimming was selected as a model for exercise performance. After 8-weeks exercised rats showed decreased lactate dehydrogenase serum activities, demonstrating the effectiveness of the swimming as an aerobic-training protocol. Exercise 5-days a week reduced the body weight gain. Triacylglycerol (TG) and very low-density lipoprotein (VLDL-C) were increased in HD-fed rats. HE5 and CE5 rats had decreased TG, VLDL-C and cholesterol. HE2 rats had enhanced high-density lipoprotein (HDL-C) in serum. No alterations were observed in lipid hydroperoxide (LH), while total antioxidant substances (TAS) were increased in serum of exercised rats. HD-fed rats had hepatic TG accumulation. Superoxide dismutase activities were increased and catalase was decreased in liver of exercised rats. The interaction of HD and physical exercise reduced TAS and enhanced LH levels in hepatic tissue. In conclusion, this study confirmed the beneficial effect of physical exercise as a dyslipidemic-lowering component. Interaction of HD and physical exercise had discrepant effects on serum and liver oxidative stress. The interaction of HID and physical exercise reduced the oxidative stress in serum. HD and physical exercise interaction had pro-oxidant effect on hepatic tissue, suggesting that more studies should be done before using physical exercise as an adjunct therapy to reduce the adverse effects of HD. (c) 2006 Elsevier Ltd. All rights reserved.

Exercise test and glucose homeostasis in rats treated with alloxan during the neonatal period or fed a high calorie diet

Background: Animal models appear well-suited for studies into the role of exercise in the prevention of non-insulin-dependent diabetes mellitus (NIDDM). The aim of the present study was to analyze glucose homeostasis and blood lactate during an exercise swimming test in rats treated with alloxan during the neonatal period and/or fed a high calorie diet from weaning onwards.Methods: Rats were injected with alloxan (200 mg/kg, i.p.) or vehicle (citrate buffer) at 6 days of age. After weaning, rats were divided into four groups and fed either a balanced diet or a high-caloric diet as follows: C, control group (vehicle + normal diet); A, alloxan-treated rats fed the normal diet; H, vehicle-treated rats fed the high-caloric diet; and HA, alloxan-treated rats fed the high-caloric diet.Results: Fasting serum glucose levels were higher in groups A and AH compared with the control group. The Homeostatic Model Assessment index varied in the groups as follows: H > A > HA = C. There were no differences in free fatty acids or blood lactate concentrations during the swim test.Conclusions: Alloxan-treated rats fed a normal or high-caloric diet have the potential to be used in studies analyzing the role physical exercise plays in the prevention of NIDDM.

Short-term stromal alterations in the rat ventral prostate following alloxan-induced diabetes and the influence of insulin replacement

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Oral manifestations of diabetes mellitus in complete denture wearers

Statement of problem. The oral mucosa has been reported to show a variety of changes in subjects with diabetes mellitus.Purpose. The purpose of this study was to compare diabetic and nondiabetic subjects wearing complete dentures with regard to salivary flow, salivary buffering capacity, denture retention, and oral mucosal lesions.Material and methods. Sixty subjects, 30 with and 30 without a diagnosis of diabetes, were matched for gender, race, and age. Salivary flow, salivary buffering capacity, glycemia, blood pressure, presence of mucosal lesions, denture retention, use of medications, and behavioral factors (controlled or uncontrolled diet, alcohol consumption, and smoking) reported by the subjects, were evaluated. For the salivary buffering capacity test, 1 mL of saliva was pipetted into a test tube containing 3 mL 0.005 N of hydrochloric acid, and the pH was measured with indicator strips. Group differences were statistically analyzed using the Student t test and the Mann-Whitney test for quantitative variables and the chi-square test for qualitative variables (alpha = .05).Results. Mean (SD) salivary flow was 1.14 (0.87) mL/min in the nondiabetic subjects and 0.95 (0.61) mL/min in the diabetic subjects. Evaluation of self-reported denture retention revealed no significant difference between groups. Denture retention was observed in 66.7% (20/30) of the control group and in 50% (15/30) of the diabetic group. The prevalence of mucosal lesions was 90% (27/30) in the control group and 83.3% (25/30) in the diabetic group. Salivary buffering capacity was 5.80 (0.85) in the control group and 5.26 (0.83) in the diabetic group (P = .017).Conclusions. Within the limitations of this study, no significant differences were observed in salivary flow, denture retention, or oral lesions in diabetic and nondiabetic subjects.