RESUMO
The segment of the world population showing permanent or temporary lactose intolerance is quite significant. Because milk is a widely consumed food with an high nutritional value, technological alternatives have been sought to overcome this dilemma. Microfiltration combined with pasteurization can not only extend the shelf life of milk but can also maintain the sensory, functional, and nutritional properties of the product. This studied developed a pasteurized, microfiltered, lactose hydrolyzed (delactosed) skim milk (PMLHSM). Hydrolysis was performed using ß-galactosidase at a concentration of 0.4mL/L and incubation for approximately 21h at 10±1°C. During these procedures, the degree of hydrolysis obtained (>90%) was accompanied by evaluation of freezing point depression, and the remaining quantity of lactose was confirmed by HPLC. Milk was processed using a microfiltration pilot unit equipped with uniform transmembrane pressure (UTP) ceramic membranes with a mean pore size of 1.4 µm and UTP of 60 kPa. The product was submitted to physicochemical, microbiological, and sensory evaluations, and its shelf life was estimated. Microfiltration reduced the aerobic mesophilic count by more than 4 log cycles. We were able to produce high-quality PMLHSM with a shelf life of 21 to 27d when stored at 5±1°C in terms of sensory analysis and proteolysis index and a shelf life of 50d in regard to total aerobic mesophile count and titratable acidity.
Assuntos
Filtração , Lactose/análise , Leite/química , Pasteurização , Animais , Cerâmica , Fenômenos Químicos , Temperatura Baixa , Contagem de Colônia Microbiana , Enterobacteriaceae/isolamento & purificação , Contaminação de Alimentos/análise , Microbiologia de Alimentos , Armazenamento de Alimentos , Hidrólise , Leite/microbiologia , Pressão , Salmonella/isolamento & purificação , Staphylococcus/isolamento & purificação , Paladar , beta-Galactosidase/metabolismoRESUMO
BACKGROUND: Although hypoglycemia is the most common complication of intensive diabetes therapy, there is little information about risk factors for hypoglycemia in patients with type 2 diabetes mellitus. OBJECTIVE: To determine the prevalence and predisposing factors for hypoglycemia in patients with type 2 diabetes. METHODS: Retrospective, cross-sectional analysis set in an outpatient specialty diabetes clinic. We included those patients who had baseline and follow-up visits from April 1 through October 31, 1999. Hypoglycemia was defined as typical symptoms relieved by eating, and/or blood glucose level of less than 60 mg/dL (<3.3 mmol/L). Univariate and multivariate logistic regression were used to determine the contributions to hypoglycemia of age, sex, diabetes duration, body mass index (calculated as weight in kilograms divided by the square of height in meters), fasting plasma glucose level, glycosylated hemoglobin (HbA(1c)) level, type of therapy, and previous episodes at the follow-up visit. RESULTS: We studied 1055 patients. Prevalence of hypoglycemic symptoms was 12% (9/76) for patients treated with diet alone, 16% (56/346) for those using oral agents alone, and 30% (193/633) for those using any insulin (P<.001). Severe hypoglycemia occurred in only 5 patients (0.5%), all using insulin. Multiple logistic regression analysis demonstrated that insulin therapy, lower HbA(1c) level at follow-up, younger age, and report of hypoglycemia at the baseline visit were independently associated with increased prevalence of hypoglycemia. There were no significant predictors of severe hypoglycemia. CONCLUSIONS: Mild hypoglycemia is common in patients with type 2 diabetes undergoing aggressive diabetes management, but severe hypoglycemia is rare. Concerns about hypoglycemia should not deter efforts to achieve tight glycemic control in most patients with type 2 diabetes.
Assuntos
Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/terapia , Dieta para Diabéticos , Hipoglicemia/etiologia , Hipoglicemiantes/efeitos adversos , Glicemia , Índice de Massa Corporal , Estudos Transversais , Feminino , Georgia/epidemiologia , Hemoglobinas Glicadas , Humanos , Hipoglicemia/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: It is commonly believed that good glycemic control is hard to achieve in patients with diabetes mellitus and concurrent chronic illnesses. OBJECTIVE: To determine the impact of comorbidity on glycemic control at presentation and subsequent follow-up in patients with type 2 diabetes. METHODS: We studied 654 consecutive patients who presented to a diabetes clinic in 1997. Comorbidity was rated using the Chronic Disease Score (CDS) index, which is a validated, weighted score that takes into account the patient's age, sex, and classes of medications. Univariate and multivariate linear regressions were used to determine the contribution of age, body mass index (calculated as weight in kilograms divided by the square of height in meters), diabetes duration, type of therapy, and CDS to initial hemoglobin A(1c) (HbA(1c)) level. A similar analysis was performed for the 169 patients with follow-up HbA(1c) levels 6 months after presentation. RESULTS: Patients were 90% African American, and 66% female, with average age of 53 years. Average diabetes duration was 5 years; body mass index, 33; HbA(1c) level, 8.8%; and CDS, 1121 (range, 232-7953). At presentation, patients with higher CDSs tended to be older and to have a lower HbA(1c) level, but multivariate linear regression showed that receiving pharmacological therapy, younger age, and having a lower C-peptide level were the only significant contributors to HbA(1c) level. In the 169 follow-up patients, presenting characteristics were not significantly different from those of the full cohort: average initial HbA(1c) level was 8.8%; CDS, 1073. Their HbA(1c) level at 6 months averaged 7.5% and the CDS had no significant impact on their follow-up HbA(1c) level. CONCLUSION: Comorbidity does not appear to limit achievement of good glycemic control in patients with type 2 diabetes.
Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/epidemiologia , Hemoglobinas Glicadas/análise , Hipoglicemiantes/uso terapêutico , Distribuição por Idade , Glicemia/análise , Doenças Cardiovasculares/epidemiologia , Doença Crônica , Comorbidade , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/metabolismo , Angiopatias Diabéticas/epidemiologia , Neuropatias Diabéticas/epidemiologia , Feminino , Seguimentos , Gastroenteropatias/epidemiologia , Humanos , Infecções/epidemiologia , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Obesidade/epidemiologia , Prevalência , Medição de Risco , Sensibilidade e Especificidade , Distribuição por Sexo , Estatísticas não ParamétricasRESUMO
OBJECTIVE: To determine whether health care providers appropriately identify patients with poor glycemic control and to investigate reasons why providers may fail to intensify therapy in these patients. RESEARCH DESIGN AND METHODS: Our management protocol calls for providers to advance diabetes therapy in patients with fasting plasma glucose levels > 7.8 mmol/l or random plasma glucose levels > 10.0 mmol/l. During a 3-month period, providers completed a questionnaire at the end of individual patient visits by asking whether the patient was well controlled and whether therapy was advanced. If therapy was not advanced in patients perceived to have poor control, providers were asked to provide a justification. RESULTS: Providers appropriately identified 88% of well-controlled patients and 94% of patients with poor glycemic control. Out of 1,144 patient visits, control was reported to be good in 508 and poor in 636. In these 636 visits, therapy was advanced in 490 but not in 146 visits. The dominant reasons for failure to intensify therapy were the perception by the provider that control was improving (34%) or the belief that the patient was not compliant with diet or medications (25%). Less common reasons included acute illness, patient refusal, and recurrent hypoglycemia. Based on fasting glucose levels, protocol adherence was 55% before the questionnaire, 64% during the questionnaire (P = 0.006), and 63% afterwards. CONCLUSIONS: Providers in a specialty diabetes clinic appropriately classified patients according to glycemic control and tended to intensify therapy when indicated in most poorly controlled patients. Provider self-survey of behavior and decision making may be an effective strategy to improve adherence to management protocols.
Assuntos
Negro ou Afro-Americano , Glicemia/metabolismo , Diabetes Mellitus/sangue , Diabetes Mellitus/terapia , Relações Médico-Paciente , População Urbana/estatística & dados numéricos , População Negra , Diabetes Mellitus/psicologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/terapia , Dieta para Diabéticos , Jejum , Feminino , Georgia , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Recusa do Paciente ao TratamentoRESUMO
OBJECTIVE: African-Americans with diabetes have an increased risk of endstage renal disease, but underlying mechanisms are poorly understood. We undertook this study to evaluate prevalence and risk factors for renal disease in an African-American population with diabetes. RESEARCH DESIGN AND METHODS: We measured urine albumin excretion in 578 consecutive patients presenting for the first time to the Grady Memorial Hospital Diabetes Unit in Atlanta, GA. The unit serves an urban population that is predominantly African-American; 85% of patients have non-insulin-dependent diabetes mellitus (NIDDM). Subjects provided 24-h and/or approximately 3-h urine collections for measurement of albumin and creatinine. RESULTS: Correlation of the albumin/creatinine ratio (micrograms/mg) with the 24-h albumin excretion rate was 0.89 (P < 0.001, n = 123). Although the median duration of diabetes was only 1 year, among all subjects, the estimated prevalence of microalbuminuria (30-300 mg albumin/24 h) was 25% and that of nephropathy ( > 300 mg albumin/24 h) was 11%. Among African-Americans with NIDDM (n = 466), the estimated prevalence of microalbuminuria was 24% and that of nephropathy was 12%; prevalence remained high (25 and 5%, respectively) among 219 patients with < 1 year known duration of diabetes. Metabolic control was not associated with disease. However, among all subjects with NIDDM, the odds ratio for nephropathy among subjects with disease duration > 5 years compared with those with disease duration < 1 year was 4.65 (95% confidence interval [CI] 2.24-9.79), and the odds ratio for nephropathy among subjects with hypertension compared with those without hypertension was 2.64 (CI 1.42-4.93). Odds ratios were comparable among African-Americans with NIDDM. Trends were similar but less significant for subjects with microalbuminuria. CONCLUSIONS: Albuminuria can be identified reliably and conveniently by the albumin/creatinine ratio in brief urine collections. In our patients, clinically significant albuminuria occurred in 36% of persons at first presentation. Since increased risk was associated with hypertension and control of hypertension can slow progression of renal disease, screening for albuminuria and treatment of hypertension should be aggressive in urban populations of African-Americans with diabetes.
Assuntos
Albuminúria/epidemiologia , População Negra , Diabetes Mellitus Tipo 1/fisiopatologia , Diabetes Mellitus Tipo 2/fisiopatologia , Nefropatias Diabéticas/epidemiologia , População Urbana/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Creatinina/urina , Diabetes Mellitus Tipo 1/urina , Diabetes Mellitus Tipo 2/urina , Angiopatias Diabéticas/fisiopatologia , Angiopatias Diabéticas/urina , Feminino , Georgia/epidemiologia , Humanos , Hipertensão/fisiopatologia , Hipertensão/urina , Masculino , Pessoa de Meia-Idade , Prevalência , Reprodutibilidade dos Testes , Fatores de Risco , Caracteres SexuaisRESUMO
OBJECTIVE: African-Americans have an increased prevalence of both diabetes and diabetes complications, creating an imperative for improved metabolic control. Because American Diabetes Association guidelines recommend that action be taken when HbA1c is > 8.0%, but access to rapid-turnaround HbA1c assays remains limited, we tested the utility of fasting and random plasma glucose cutoffs as indicators of HbA1c > 8.0%. RESEARCH DESIGN AND METHODS: Using receiver operating characteristics (ROC) analysis, we evaluated the sensitivity, specificity, and predictive value of fasting and random plasma glucose measurements in identifying an HbA1c > 8.0% (fasting n = 974, random n = 552). The population studied was predominantly African-American, middle-aged, and non-insulin-dependent. RESULTS: Fasting plasma glucose was a significant indicator of HbA1c > 8.0%, both in the whole group and in subgroups for diet, sulfonylureas, and insulin; the corresponding areas under the ROC curve were 0.87, 0.90, 0.87, and 0.84, respectively (all P < 0.0001). A fasting plasma glucose cutoff of > 9.2 mmol/l (165 mg/dl) provided a sensitivity of 80% and a specificity of 83% for the whole group and a 77% positive predictive value. Random plasma glucose was also a good indicator of HbA1c > 8.0%, both in the whole group and in subgroups for diet, sulfonylureas, and insulin; the corresponding areas under the ROC curve were 0.85, 0.91, 0.85, and 0.77, respectively (all P < 0.0001). A cutoff > 9.8 mmol/l (177 mg/dl) provided a sensitivity of 78% and a specificity of 77% for the whole group and a 78% positive predictive value. Overall, a plasma glucose > 11.1 mmol/l (200 mg/dl) identified an HbA1c > 8.0% with a predictive value of approximately 90% if done while fasting and a predictive value of approximately 80-85% if random. The utility of both fasting and random plasma glucose cutoffs was subsequently confirmed in a prospective study of another 2,309 and 1,396 patients, respectively. CONCLUSIONS: Although glucose levels cannot replace HbA1c determinations, measurement of fasting or random plasma glucose may be used during a clinic visit to identify poorly controlled type 2 patients with reasonable certainty and allow timely patient education and therapeutic intervention.
Assuntos
Negro ou Afro-Americano , Glicemia/metabolismo , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 2/sangue , Jejum , Hemoglobinas Glicadas/análise , Cooperação do Paciente , Saúde da População Urbana , População Negra , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Distribuição Aleatória , Estudos Retrospectivos , População UrbanaRESUMO
OBJECTIVE: HbA1c levels can be reduced in populations of diabetic patients, but some individuals may exhibit little improvement. To search for reasons underlying differences in HbA1c outcome, we analyzed patients managed in an outpatient diabetes clinic. RESEARCH DESIGN AND METHODS: African-Americans with type 2 diabetes were categorized as responders, intermediate responders or poor responders according to their HbA1c level after 1 year of care. Logistical regression was used to determine baseline characteristics that distinguished poor responders from responders. Therapeutic strategies were examined for each of the response categories. RESULTS: The 447 patients had a mean age and disease duration of 58 and 5 years, respectively, and BMI of 32 kg/m2. Overall, the mean HbA1c level fell from 9.6 to 8.1% after 12 months. Mean HbA1c levels improved from 8.8 to 6.2% in responders, and from 9.5 to 7.9% in intermediate responders. In poor responders, the average HbA1c level was 10.8% on presentation and 10.9% at 1 year. The odds of being a poor responder were significantly increased with longer disease duration, higher initial HbA1c level, and greater BMI. Although doses of oral agents and insulin were significantly higher among poor responders at most visits, the acceleration of insulin therapy did not occur until late in the follow-up period. CONCLUSIONS: Clinical diabetes programs need to devise methods to identify patients who are at risk for persistent hyperglycemia. Whereas patient characteristics explain some heterogeneity of HbA1c outcome (and may aid in earlier identification of patients who potentially may not respond to conventional treatment), insufficient intensification of therapy may also be a component underlying the failure to achieve glycemic goals.
Assuntos
Assistência Ambulatorial , População Negra , Diabetes Mellitus Tipo 2/terapia , Resultado do Tratamento , População Urbana , Adulto , Idoso , Pressão Sanguínea , Índice de Massa Corporal , Peptídeo C/sangue , Colesterol/sangue , Diabetes Mellitus Tipo 2/sangue , Dieta , Feminino , Hemoglobinas Glicadas/análise , Humanos , Hipoglicemiantes/administração & dosagem , Hipoglicemiantes/uso terapêutico , Insulina/administração & dosagem , Insulina/uso terapêutico , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Compostos de Sulfonilureia/uso terapêutico , Triglicerídeos/sangueRESUMO
OBJECTIVE: To develop a prediction rule that will identify patients who will require pharmacological therapy within 6 months of first presentation to a diabetes clinic. RESEARCH DESIGN AND METHODS: Among the patients who came to the Grady Diabetes Clinic between 1991 and 1997, we randomized 557 frequent attenders to a development group and 520 frequent attenders to a validation group. Using multiple logistical regression, we derived a prediction rule in the development group to project whether patients would require pharmacological intervention to achieve HbA1c levels <7% after 6 months. The utility of the prediction rule was then confirmed in the validation group and tested prospectively on an additional group of 93 patients who presented from 1997 to 1998. Performance of the prediction rule was assessed using receiver operating characteristic (ROC) curves. RESULTS: The rule (-4.469 + 1.932 x sulfonylurea Rx + 1.334 x insulin Rx + 0.196 x duration + 0.468 x fasting glucose, where "Rx" indicates a prescription) predicted the need for pharmacological intervention in the development group (P < 0.0001). Use of insulin or sulfonylurea therapy at presentation, duration of diabetes, and fasting glucose levels were significant predictors of the future need for pharmacological management. The prediction rule also performed well in the validation group (positive predictive value 90%, correlation between predicted and observed need for medical management 0.99). ROC curves confirmed the value of the prediction rule (area under the curves was 0.91 for the development group, 0.85 for the validation group, and 0.81 for the prospective group). CONCLUSIONS: Early identification of individuals who will require pharmacological intervention to achieve national standards for glycemic control can be achieved with high probability, thus allowing for more efficient management of diabetes.
Assuntos
Negro ou Afro-Americano , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , População Urbana/estatística & dados numéricos , População Negra , Georgia/epidemiologia , Humanos , Insulina/uso terapêutico , Pessoa de Meia-Idade , Razão de Chances , Probabilidade , Prognóstico , Curva ROC , Reprodutibilidade dos Testes , Compostos de Sulfonilureia/uso terapêutico , Fatores de TempoRESUMO
OBJECTIVE: Staged diabetes management should permit glycemic goals to be attained in a timely manner, but the success of such an approach requires conformity by health care providers. To test performance, we analyzed the adherence of practitioners to a protocol for staged management of NIDDM patients. RESEARCH DESIGN AND METHODS: Records of patients treated at the Grady Memorial Hospital Diabetes Clinic were reviewed retrospectively over a 3-year period. For each patient, intensification of therapy was indicated if fasting plasma glucose was > 7.8 mmol/l and a prior HbA1c was > 7.0%. Protocols dictated a progression from dietary therapy alone to increasing dosages of sulfonylureas to increasing dosages of insulin. Patients were seen at bimonthly intervals. RESULTS: During the 3-year period, 1,051 patient visits met protocol criteria for intensification. Adherence to the protocol improved significantly in the 3rd year compared with the first 2 years (30, 31, and 47% adherence in the 1st, 2nd, and 3rd years, respectively). Patients treated with diet alone were significantly less likely to have their therapy intensified than patients on sulfonylureas or insulin (intensification rates 25, 41, and 47%, respectively). In the management of patients treated with diet alone, practitioners were reluctant to intensify therapy at early visits, but were more likely to do so later, 19% of patients beyond goal range at the 2-month visit were started on pharmacological therapy vs. 28% at the 4-month visit, and 39% at the 6-month visit (P < 0.01). In contrast, there was no significant difference in the frequency of therapy intensification between early and late visits for patients on sulfonylureas or insulin. Practitioners appeared to base the decision to intensify on the fasting plasma glucose level more than on the most recent HbA1c. Age did not appear to be a significant factor in the decision to intensify. CONCLUSIONS: Although staged management protocols constitute critical tools to achieve glycemic goals, the adherence of health care providers may be suboptimal. Special efforts may be needed to assure compliance.
Assuntos
Negro ou Afro-Americano , Diabetes Mellitus Tipo 2/psicologia , Diabetes Mellitus Tipo 2/terapia , Cooperação do Paciente , População Urbana , Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Dieta para Diabéticos , Etnicidade , Feminino , Georgia , Hemoglobinas Glicadas/análise , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Compostos de Sulfonilureia/uso terapêutico , População BrancaRESUMO
OBJECTIVE: To assess the impact of rapid-turnaround HbA1c results on providers' clinical decision-making and on follow-up HbA1c levels. RESEARCH DESIGN AND METHODS: The research design was a randomized clinical trial in which rapid HbA1c results were made available to providers on even days of the month (rapid, n = 575), but delayed by 24 h on odd days (conventional, n = 563). Adjustment of therapy for patients with type 2 diabetes was considered appropriate if therapy was intensified for HbA1c values >7% or not intensified for HbA1c values < or =7%. A post-hoc analysis was also performed using patients (n = 574) who returned for follow-up 2-7 months later to ascertain the effect of rapid HbA1c availability on subsequent glycemic control. RESULTS: Rapid HbA1c availability resulted in more appropriate management compared with conventional HbA1c availability (79 vs. 71%, P = 0.003). This difference was due mainly to less frequent intensification when HbA1c levels were < or =7% (10 vs. 22%, P < 0.0001) and slightly to more frequent intensification for patients with HbA1c values >7% (67 vs. 63%, P = 0.33). For both groups, intensification was greatest for patients on insulin (51%) compared with patients on oral agents (35%) and diet alone (14%) (P < 0.0001). Regression analysis confirmed that providers receiving conventional HbA1c results were more likely to intensify therapy in patients who already had HbA1c levels < or =7%. Over 2-7 months of follow-up, HbA1c rose more in patients with conventional HbA1c results compared with rapid results (0.8 vs. 0.4%, P = 0.02). In patients with initial HbA1c >7%, rapid HbA1c results had a favorable impact on follow-up HbA1c independent of the decision to intensify therapy (P = 0.03). CONCLUSIONS: Availability of rapid HbA1c determinations appears to facilitate diabetes management. The more favorable follow-up HbA1c profile in the rapid HbA1c group occurs independently of the decision to intensify therapy, suggesting the involvement of other factors such as enhanced provider and/or patient motivation.
Assuntos
População Negra/genética , Tomada de Decisões , Diabetes Mellitus Tipo 2/diagnóstico , Hemoglobinas Glicadas/metabolismo , Diabetes Mellitus Tipo 2/fisiopatologia , Diabetes Mellitus Tipo 2/terapia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Fatores de Tempo , Saúde da População UrbanaRESUMO
OBJECTIVE: Diabetes care can be limited by clinical inertia-failure of the provider to intensify therapy when glucose levels are high. Although disease management programs have been proposed as a means to improve diabetes care, there are few studies examining their effectiveness in patient populations that have traditionally been underserved. We examined the impact of our management program in the Grady Diabetes Unit, which provides care primarily to urban African-American patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: We assessed glycemic outcomes in patients with type 2 diabetes who had an intake evaluation between 1992 and 1996 and who were identified on the basis of compliance with keeping the recommended number of return visits. For 698 patients, we analyzed changes in HbA1c values between baseline and follow-up visits at 6 and 12 months, and the proportion of patients achieving a target value of < or =7.0% at 12 months. Since a greater emphasis on therapeutic intensification began in 1995, we also compared HbA1c values and clinical management in 1995-1996 with that of 1992-1994. RESULTS: HbA1c averaged 9.3% on presentation. After 12 months of care, HbA1c values averaged 8.2, 8.4, 8.5, 7.7, and 7.3% for the 1992-1996 cohorts, respectively, and were significantly lower compared with values on presentation (P < 0.0025); the average fall in HbA1c was 1.4%. The percentage of patients achieving a target HbA1c < or =7.0% improved progressively from 1993 to 1996, with 57% of the patients attaining this goal in 1996. Mean HbA1c after 12 months was 7.6% in 1995-1996, significantly improved over the level of 8.4% in 1992-1994 (P < 0.0001). HbA1c levels after 12 months of care were lower in 1995-1996 versus 1992-1994, whether patients were managed with diet alone, oral agents, or insulin (P < 0.02). Improved HbA1c in 1995-1996 versus 1992-1994 was associated with increased use of pharmacologic therapy CONCLUSIONS: Structured programs can improve glycemic control in urban African-Americans with diabetes. Self-examination of performance focused on overcoming clinical inertia is essential to progressive upgrading of care.
Assuntos
População Negra/genética , Glicemia/metabolismo , Diabetes Mellitus Tipo 2/terapia , Índice de Massa Corporal , Diabetes Mellitus Tipo 2/genética , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Resultado do Tratamento , Saúde da População UrbanaRESUMO
OBJECTIVE: To analyze lipid profiles from a large sample of African-American patients with type 2 diabetes who receive care at an urban outpatient diabetes clinic. RESEARCH DESIGN AND METHODS: Fasting serum lipid profiles of 4,014 African-Americans and 328 Caucasians with type 2 diabetes were retrieved from a computerized registry. American Diabetes Association criteria were applied to classify LDL cholesterol, HDL cholesterol, and triglyceride (TG) levels into risk categories. The proportion of patients who had none, one, two, and three lipoprotein concentrations outside of recommended clinical targets was examined. Multiple logistical regression analyses were performed to determine the influence of sex and race on the probability of having a lipid level outside of the recommended target. RESULTS: The percentages of African-Americans with high-, borderline-, and low-risk LDL cholesterol concentrations were 58, 26, and 16%, respectively, and the percentages for Caucasians were 54, 29, and 16%, respectively (P = 0.51). For HDL cholesterol, 41, 33, and 26% of African-Americans were in the high-, borderline-, and low-risk categories, respectively, compared with 73, 18, and 9% of Caucasians, respectively (P < 0.0001). Nearly 81% of African-Americans had TG concentrations that were in the low-risk category compared with only 50% of Caucasians. More women than men had high-risk LDL and HDL cholesterol profiles. The most common pattern of dyslipidemia was an LDL cholesterol level above target combined with an HDL cholesterol level below target, which was detected in nearly 50% of African-Americans and 42% of Caucasians. African-Americans had lower odds of having an HDL cholesterol or TG level outside of target. African-American women, compared to men, had greater probabilities of having abnormal levels of LDL and HDL, but a lower likelihood of having a TG level above goal. CONCLUSIONS: In a large sample of urban type 2 diabetic patients receiving care at a diabetes treatment program, race and sex differences in serum lipid profiles were present. Because hypertriglyceridemia was rare among African-American subjects, interventions will need to focus primarily on improving their LDL and HDL cholesterol levels. Further studies are required regarding how to best adapt these observed differences into more effective strategies to optimize lipid levels for this population of diabetic patients and to determine whether similar patterns of dyslipidemia occur in other clinical settings.
Assuntos
População Negra , Diabetes Mellitus Tipo 2/complicações , Hiperlipidemias/complicações , Hiperlipidemias/epidemiologia , Negro ou Afro-Americano , Glicemia/análise , Colesterol/sangue , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Comparação Transcultural , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Georgia/epidemiologia , Hemoglobinas Glicadas/análise , Humanos , Hiperlipidemias/sangue , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais , Triglicerídeos/sangue , População Urbana , População BrancaRESUMO
Control, low-protein, low-calorie, and low-protein-plus-low-calorie diets were fed to 37, 14, 8, and 16 infant squirrel monkeys, respectively, from ages 2-8 wk. The deficient diets were planned to prevent growth and were designed to examine the short- and long-term effects of defined nutritional restrictions on body weight, food intake, hematocrit, plasma albumin, growth hormone, and cortisol concentrations. During the restriction period, plasma albumin levels were significantly decreased in both groups with a protein restriction component: plasma cortisol levels were significantly increased only in the low protein and low calorie groups. No significant group differences were observed for hematocrit or plasma growth hormone. Results of this study indicate that 1) energy restriction did not seem to modify the protein requirement for weight maintenance and 2) animals fed low-protein diets, even in the face of growth failure, have a mechanism for wasting energy.
Assuntos
Ingestão de Energia , Transtornos do Crescimento/etiologia , Desnutrição Proteico-Calórica/complicações , Fatores Etários , Animais , Peso Corporal , Proteínas Alimentares/administração & dosagem , Modelos Animais de Doenças , Ingestão de Alimentos , Feminino , Transtornos do Crescimento/sangue , Hormônio do Crescimento/sangue , Hematócrito , Hidrocortisona/sangue , Masculino , Desnutrição Proteico-Calórica/sangue , SaimiriRESUMO
The responses of albumin and transferrin to selective nutritional interventions were assessed in 31 infant monkeys. Diets were restricted in protein, calories, or both from age 2 to 8 wk (study A) or protein alone from age 4 to 24 wk (study B)--in both cases to prevent growth. Transferrin levels in study A were significantly lower than control in all three restricted groups whereas albumin levels were decreased only in both low-protein groups. In study B albumin and transferrin concentrations were significantly decreased during the first 12 wk of intervention. A sharp recovery in the transferrin concentrations, however, was observed when a minimal increase in protein intake was allowed in the latter portion of the study. It appears that the response of albumin is linked to amino acid availability whereas the response of transferrin is influenced by variables such as acute dietary manipulation and rate of growth, among others. The value of these indices as single predictors of nutritional status is questioned.
Assuntos
Desnutrição Proteico-Calórica/sangue , Albumina Sérica/metabolismo , Transferrina/metabolismo , Fatores Etários , Animais , Peso Corporal , Proteínas Alimentares/administração & dosagem , Ingestão de Energia , Feminino , Hematócrito , Masculino , SaimiriRESUMO
Infant squirrel monkeys fed low protein diets using an isolated soy protein develop an acute anemia. To investigate this syndrome, four groups of animals fed diets containing adequate or restricted amounts of casein or soy protein were studied from 1 through 16 weeks of age. The low protein groups, in which growth was prevented by adjustment of the protein content between 2 through 8 weeks, showed no difference in caloric intake or plasma albumin concentrations. However, the low soy group developed a severe anemia (hemoglobin 4 to 7 g/dl) after 4 to 6 weeks of dietary treatment. The anemia was characterized as normocytic, normochromic, and was associated with reduced reticulocyte concentrations. Bone marrow specimens showed an increased myeloid/erythroid ratio due primarily to an absolute erythroid hypoplasia. Juvenile animals fed similar low soy diets did not become anemic. The selective effect of this isolated soy protein, demonstrable only during the transitional period of early infancy, was attributed to the interaction of the malnourished animal with a component of the isolated soy protein per se. The potential role of soy glycoproteins is discussed.
Assuntos
Anemia/etiologia , Doenças da Medula Óssea/etiologia , Glycine max/efeitos adversos , Proteínas de Vegetais Comestíveis/efeitos adversos , Deficiência de Proteína/metabolismo , Envelhecimento , Anemia/sangue , Animais , Células Sanguíneas , Caseínas/administração & dosagem , Contagem de Células , Proteínas Alimentares/efeitos adversos , Glicoproteínas/efeitos adversos , Haplorrinos , Hematopoese , Hemoglobinas/metabolismo , Reticulócitos , Saimiri , Albumina Sérica/metabolismoRESUMO
The efficiency of protein utilization was assessed in three groups of infant squirrel monkeys fed diets containing restricted amounts of lactalbumin, casein, and soy protein isolate as the sole nitrogen source for 3-week periods. Lactalbumin was fed in similar conditions to a group of macaques for comparison. The regression of weight gain on protein intake was calculated for each dietary protein yielding an estimate of protein needs for weight maintenance and an estimate of the efficiency of utilization of protein for growth (slope X percentage protein in tissue). Mean requirements for weight maintenance of infant squirrel monkeys for lactalbumin, casein and soy protein isolate were 3.43, 3.63, and 7.96 g/kg per day and growth was accomplished with an efficiency of 27.8, 32.1, and 22.2%, respectively. In contrast, the macaques utilized lactalbumin with an efficiency of 65%, similar to that of the infant cebus monkey and adult man. The low efficiency found in young squirrel monkeys was altered neither when the habitual feeding schedule was prolonged from 16 to 24 hr per day in a group of casein-fed animals nor when sulfur amino acids were added to casein.
Assuntos
Proteínas Alimentares , Haplorrinos/fisiologia , Animais , Peso Corporal , Caseínas , Lactalbumina , Macaca fascicularis/fisiologia , Proteínas de Plantas , Saimiri/fisiologia , Especificidade da EspécieRESUMO
Protein qualities of lactalbumin (L), casein (C), soy concentrate (SC), soy isolate (SI), and soy isolate plus 15.3 mg methionine/g protein (SIM) were investigated in a slope-ratio assay using 32, 8-wk old cebus monkeys. Growth (28 days) and nitrogen balance (NB) (days 19-28) data were evaluated in a multiple-regression format with nitrogen intake and body weight as the independent variables. Based upon growth, potencies compared to L were: C, 72.1; SC, 52.5; SI, 40.6; and SIM, 72.2. Based upon NB, comparable potencies were: C, 62.2; SC, 69.0; SI, 46.8; and SIM, 90.7. NB data showed that the potency of SC was significantly greater than SI and that methionine supplementation of SI improved it to a potency not distinguishable from the standard. The marked improvement from SI to SIM emphasizes the beneficial effect of sulfur amino acid supplementation of soy protein for an infant primate species.
Assuntos
Proteínas do Leite/farmacologia , Proteínas de Vegetais Comestíveis/farmacologia , Animais , Animais Lactentes , Proteínas Sanguíneas/análise , Peso Corporal , Cebus , Digestão , Feminino , Hematócrito , Absorção Intestinal , Masculino , Metionina/análise , Proteínas do Leite/metabolismo , Nitrogênio/metabolismo , Valor Nutritivo , Proteínas de Vegetais Comestíveis/metabolismo , Ratos , Proteínas de SojaRESUMO
OBJECTIVE: Management of type II diabetes is difficult, particularly in urban populations with limited resources and access to care. To evaluate the effectiveness of structured care delivered by non-physician providers, patients were studied prospectively for 6 months in a municipal hospital diabetes clinic. DESIGN AND METHODS: The population was approximately 90% African American and had median known diabetes duration of approximately 1 year, 54% had incomes below the Federal Poverty Guideline. Primary management was provided by nurse-practitioners and dietitians, and primary outcome measures were hemoglobin A1c (HbA1c), fasting plasma glucose, and changes in body weight. RESULTS: Responses were analyzed in 325 new patients returning for visits at 2, 4, 6, and 12 months; metabolic profiles at presentation were similar to those of subjects who missed intervening visits. Lean patients largely continued on pharmacologic therapy and improved HbA1c from 9.4% to 7.4% at 2 months (P < 0.001), remained stable through 6 months, then rose to 7.9% at 1 year. Obese patients (71%) received dietary instruction. Weaning of pharmacologic therapy was attempted for the first 2 months, resulting in a decline of HbA1c from 9.6% to 8.0% (P < 0.001), with 70% treated with diet alone. In the obese, HbA1c continued to decrease through 6 months (7.7%). Thereafter, providers saw patients at their own discretion and intensified therapy as needed. Although by 1 year, HbA1c had risen to only 8.2%, some patients required reinstitution of pharmacologic therapy; 59% were on diet alone. While 52% lost 4 lb or more (mean 9.3) by 2 months, little additional weight was lost. Interestingly, glycemic control was improved both in those who lost > or = 8.5 lb in the first 2 months (HbA1c 9.6% to 8.1% at 12 months), and in those who gained weight (HbA1c 10.2% to 8.2%). In the obese patients using pharmacologic agents at presentation, 35% were able to discontinue oral agents or insulin by 1 year, with good glycemic control (HbA1c < 8%). For patients who were initially on diet alone, a fasting plasma glucose > 177 mg/dL predicted the need for pharmacologic therapy with 97% certainty. CONCLUSIONS: In urban African American patients, nonpharmacologic management of type II diabetes substantially improves metabolic control; decreases in HbA1c are comparable in those who do and do not lose weight. Therapy managed by nonphysician providers can be an effective cornerstone of diabetes care in this socioeconomically disadvantaged population.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Diabetes Mellitus Tipo 2/terapia , Dietética , Profissionais de Enfermagem/estatística & dados numéricos , Ambulatório Hospitalar , População Negra , Glicemia/metabolismo , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/economia , Diabetes Mellitus Tipo 2/metabolismo , Feminino , Georgia , Hemoglobinas Glicadas/metabolismo , Hospitais Municipais , Humanos , Renda , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Ambulatório Hospitalar/economia , Ambulatório Hospitalar/estatística & dados numéricos , Pobreza , Estudos Prospectivos , Resultado do Tratamento , Saúde da População Urbana , Redução de Peso , Recursos HumanosRESUMO
The role of the following hormonal and environmental factors in the pathogenesis of diabetes in the BB rat was studied: hypophysectomy, castration, vagotomy, agents protective against beta cytotoxins, and stress. None of these factors altered the incidence of diabetes. They are thus unlikely to act as initiators or promoters of BB rat diabetes. These negative findings are complementary to previous studies reporting no influence of infection or diet on BB diabetes. To date, no hormonal or environmental factors have been identified that alter the incidence of diabetes in this animal model.
Assuntos
Diabetes Mellitus Experimental/etiologia , Diabetes Mellitus Tipo 1/etiologia , Ratos Endogâmicos , 3-O-Metilglucose , Animais , Peso Corporal , Castração , Diabetes Mellitus Tipo 1/genética , Feminino , Hipofisectomia , Masculino , Metilglucosídeos/farmacologia , Niacinamida/farmacologia , Ratos , VagotomiaRESUMO
A prospective study has been designed to investigate bone metabolism in young women taking an oral monophasic contraceptive formulation (ethinylestradiol 20 micrograms + desogestrel 0.150 mg) over 5 years. Healthy women (n = 200) between 19 and 22 years of age were divided into two groups. Group A received oral contraception, Group B did not receive any treatment. All the subjects underwent a bone mass density (BMD) evaluation at spinal level L2-L4 with Dexa (Norland XR-26) and a measurement of the serum alkaline phosphatase levels and urinary excretion of OH-proline at baseline and every 12 months over 5 years. Our results demonstrated that Group A did not show any significant BMD change after 5 years of oral contraceptive treatment, while Group B demonstrated a significant increase (p < 0.01) in the bone mass content at the end of the time of observation (+7.8% after 5 years). No significant changes were found in serum alkaline phosphatase levels and in urinary excretion of OH-proline at the end of the study in comparison with basal levels in both groups. Our data suggested that long-term treatment with an oral monophasic contraceptive formulation (ethinylestradiol 20 micrograms + desogestrel 0.150 mg) did not modify the BMD but prevented the occurrence of the physiologic peak of bone mass in young women.
PIP: Between June 1988 and March 1989 in Italy, health workers enrolled 200 women aged 19-23 attending obstetric-gynecology clinics in and around Pavia into a five-year study of the effects of an oral contraceptive (OC) with 20 mcg ethinyl estradiol and 0.15 mg desogestrel on bone mass. They were able to follow 76 of the 100 women using the OC and 71 of the 100 women using no OC for five years. Health workers conducted a bone mass density (BMD) evaluation at spinal level L2-L4 with Dexa (Norland XR-26). They measured serum alkaline phosphatase levels and urinary excretion of hydroxyproline (OH-proline) at baseline and every 12 months for five years. Neither urinary excretion of OH-proline levels nor alkaline phosphatase levels differed significantly in the two groups during the five years from baseline levels. Over the five years, the BMD of OC users did not change significantly while the BMD of the controls increased 7.8% from baseline (p 0.01). These findings suggest that this monophasic OC prevented or delayed the physiologic peak bone mass. Even though the low dosage of ethinyl estradiol (20 mcg) may have contributed to the prevention of bone mass loss, it could not achieve the peak bone mass. More studies are needed to understand the effect of long-term OC treatment on bone mineral content.