The Impact of a Nutritional Intervention on Glycemic Control and Cardiovascular Risk Markers in Type 2 Diabetes.

INTRODUCTION: Nutritional management plays a crucial role in treating patients with type 2 diabetes (T2D), working to prevent and control the progression of chronic non-communicable diseases. OBJECTIVES: To evaluate the effects of individualized nutritional interventions on weight, body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), fasting blood glucose (FBG), hemoglobin A1c (HbA1c), total cholesterol (TC), LDL cholesterol (LDL-C), HDL cholesterol (HDL-C), triglycerides (TGs), systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR)} over 12 months and subsequently at follow-up (15 months). METHODS: This longitudinal experimental study (without randomization and blinding) enrolled 84 sedentary participants with T2D (both sexes, aged 18-80 years). They were divided into a control group of 40 participants who received only medical consultations, and an intervention group of 44 participants who received the same medical care along with a nutritional assessment. Consultations occurred quarterly from August 2020 to November 2022 (first-twelfth month), with six to nine patients per session. Subsequently, a follow-up was conducted from December 2022 to November 2023, during which the intervention group had only medical care (during the 12th-15th months). Personalized dietary planning was inspired by the Mediterranean/DASH diets adapted to Brazilian foods and socioeconomic cultures. STATISTICAL ANALYSIS: Normal variables were compared between groups for each time point and also within each group across different time points using a two-way ANOVA (repeated measures for intragroup) followed by the Sídák post hoc test. Non-normal variables were compared between groups for each time point using Kruskal-Wallis followed by the Dunn post hoc test, and within each group across different time points using Friedman followed by the Dunn post hoc test. Data with a Gaussian distribution were presented as mean ± standard deviation (SD), and data with a non-Gaussian distribution were presented as median ± interquartile range (IQR). For all cases, α < 0.05 and p < 0.05 were adopted. RESULTS: In the intervention group, significant reductions were observed between the first and twelfth month for all parameters (p < 0.05), (except for TC), along with an increase in HDL-C (p = 0.0105). Conversely, in the control group, there was a significant increase in HbA1c, weight, BMI, FBG, and WHR (p < 0.05) between the first and twelfth months. Regarding the comparison between groups, there was a significant difference for all analyzed parameters (p < 0.05) from the first to the twelfth month. In the follow-up, differences were also observed (p < 0.05), except for BMI (p > 0.05). CONCLUSION: The individualized nutritional intervention improved eating habits, anthropometric, biochemical, and cardiovascular markers in T2D over 12 months, with sustained results during follow-up. The dietary plan inspired by the Mediterranean and DASH diets demonstrated good adaptation to the Brazilian food culture and the patients' socioeconomic contexts. Consistent monitoring and personalized nutritional management are essential for optimizing long-term outcomes. However, more clinical trials are necessary in order to optimize the level of evidence for longitudinal interventions.

Effects of Mindful Eating in Patients with Obesity and Binge Eating Disorder.

INTRODUCTION: Binge eating disorder (BED) is a psychiatric illness related to a high frequency of episodes of binge eating, loss of control, body image dissatisfaction, and suffering caused by overeating. It is estimated that 30% of patients with BED are affected by obesity. "Mindful eating" (ME) is a promising new eating technique that can improve self-control and good food choices, helping to increase awareness about the triggers of binge eating episodes and intuitive eating training. OBJECTIVES: To analyze the impact of ME on episodes of binge eating, body image dissatisfaction, quality of life, eating habits, and anthropometric data [weight, Body Mass Index (BMI), and waist circumference] in patients with obesity and BED. METHOD: This quantitative, prospective, longitudinal, and experimental study recruited 82 patients diagnosed with obesity and BED. The intervention was divided into eight individual weekly meetings, guided by ME sessions, nutritional educational dynamics, cooking workshops, food sensory analyses, and applications of questionnaires [Body Shape Questionnaire (BSQ); Binge Eating Scale (BES); Quality of Life Scale (WHOQOL-BREF)]. There was no dietary prescription for calories, carbohydrates, proteins, fats, and fiber. Patients were only encouraged to consume fewer ultra-processed foods and more natural and minimally processed foods. The meetings occurred from October to November 2023. STATISTICAL ANALYSIS: To carry out inferential statistics, the Shapiro-Wilk test was used to verify the normality of variable distribution. All variables were identified as non-normal distribution and were compared between the first and the eighth week using a two-tailed Wilcoxon test. Non-Gaussian data were represented by median ± interquartile range (IQR). Additionally, α < 0.05 and p < 0.05 were adopted. RESULTS: Significant reductions were found from the first to the eighth week for weight, BMI, waist circumference, episodes of binge eating, BSQ scale score, BES score, and total energy value (all p < 0.0001). In contrast, there was a significant increase in the WHOQOL-BREF score and daily water intake (p < 0.0001). CONCLUSIONS: ME improved anthropometric data, episodes of binge eating, body image dissatisfaction, eating habits, and quality of life in participants with obesity and BED in the short-term. However, an extension of the project will be necessary to analyze the impact of the intervention in the long-term.

Nutritional Strategies for the Management of Type 2 Diabetes Mellitus: A Narrative Review.

BACKGROUND: Thinking about greater adherence to dietary planning, it is extremely important to be aware of all nutritional strategies and dietary prescriptions available in the literature, and of which of them is the most efficient for the management of T2DM. METHODS: A search was carried out in 2023 for randomized clinical trials, systematic reviews, meta-analyses, and guidelines in the following databases: Pubmed, Scielo, Web of Science, CrossRef and Google Scholar. In total, 202 articles were collected and analyzed. The period of publications was 1983-2023. RESULTS: There is still no consensus on what the best nutritional strategy or ideal dietary prescription is, and individuality is necessary. In any case, these references suggest that Mediterranean Diet may of greater interest for the management of T2DM, with the following recommended dietary prescription: 40-50% carbohydrates; 15-25% proteins; 25-35% fats (<7% saturated, 10% polyunsaturated, and 10% monounsaturated); at least 14 g of fiber for every 1000 kcal consumed; and <2300 mg sodium. CONCLUSIONS: Individuality is the gold standard for dietary prescriptions, however, the Mediterranean diet with low levels of carbohydrates and fats seems to be the most promising strategy for the management of T2DM.

The Effect of Transcutaneous Electrical Nerve Stimulation in Peripheral and Central Hemodynamic Parameters on Resistant Hypertension: A Case Report.

Resistant hypertension (RH) is characterized by being difficult to control, even with the use of various antihypertensive drugs and is associated with target organ lesions and other comorbidities. Thus, new treatment alternatives such as transcutaneous electrical nerve stimulation (TENS) can offer benefits to resistant hypertensive patients by reducing blood pressure (BP) in a non-invasive way and without the need for the association of more antihypertensive drugs. In this case, a patient with RH was submitted to three weekly applications of TENS on the stellate ganglion lasting 40 min each for 1 month. Peripheral and central hemodynamic assessments were performed by 24-h ambulatory BP monitoring (ABPM) before and after TENS applications. After completion of the TENS applications, significant reductions in office systolic (SBP) and diastolic BP (DBP) were observed. There was also a decrease in peripheral SBP and DBP in the 24-h ABPM and sleep and SBP during wakefulness. Additionally, central parameters including central SBP and pulse wave velocity presented a significant reduction in the 24-h ABPM, during the wakefulness and sleep. TENS is able to attenuate the sympathetic hyperactivity present in RH cases and decrease the peripheral and central hemodynamic parameters of a resistant hypertensive patient.

The Role of Heart Rate Variability (HRV) in Different Hypertensive Syndromes.

Cardiac innervation by the parasympathetic nervous system (PNS) and the sympathetic nervous system (SNS) modulates the heart rate (HR) (chronotropic activity) and the contraction of the cardiac muscle (inotropic activity). The peripheral vasculature is controlled only by the SNS, which is responsible for peripheral vascular resistance. This also mediates the baroreceptor reflex (BR), which in turn mediates blood pressure (BP). Hypertension (HTN) and the autonomic nervous system (ANS) are closely related, such that derangements can lead to vasomotor impairments and several comorbidities, including obesity, hypertension, resistant hypertension, and chronic kidney disease. Autonomic dysfunction is also associated with functional and structural changes in target organs (heart, brain, kidneys, and blood vessels), increasing cardiovascular risk. Heart rate variability (HRV) is a method of assessing cardiac autonomic modulation. This tool has been used for clinical evaluation and to address the effect of therapeutic interventions. The present review aims (a) to approach the heart rate (HR) as a CV risk factor in hypertensive patients; (b) to analyze the heart rate variability (HRV) as a "tool" to estimate the individual risk stratum for Pre-HTN (P-HTN), Controlled-HTN (C-HTN), Resistant and Refractory HTN (R-HTN and Rf-HTN, respectively), and hypertensive patients with chronic renal disease (HTN+CKD).

Effect of Sequential Nephron Blockade versus Dual Renin-Angiotensin System Blockade Plus Bisoprolol in the Treatment of Resistant Hypertension, a Randomized Controlled Trial (Resistant Hypertension on Treatment - ResHypOT).

Introduction: Hypertension is the most important modifiable risk factor for cardiovascular disease and a leading public health concern. Objectives: The primary aim was to compare sequential nephron blockade (SNB) versus dual renin-angiotensin system blockade (DRASB) plus bisoprolol in patients with resistant hypertension to observe reductions in systolic and diastolic blood pressure (SBP and DBP) levels after 20 weeks of treatment. Material and Methods: This trial was an open-label, prospective, randomized, parallel-group, clinical study with optional drug up-titration. Participants were evaluated during five visits at 28-day intervals. Results: The mean age was 55.5 years in the SNB and 58.4 years in the DRASB + bisoprolol group (p=NS). Significant office BP reductions were observed in both groups. SNB group, SBP decreased from 174.5±21.0 to 127.0±14.74 mmHg (p<0.0001), and DBP decreased from 105.3±15.5 to 78.11±9.28 mmHg (p<0.0001). DRASB group, SBP decreased from 178.4±21.08 to 134.4 ± 23.25 mmHg (p<0.0001) and DBP decreased from 102.7±11.07 to 77.33±13.75 mmHg (p<0.0001). Ambulatory blood pressure monitoring (ABPM) showed also significant SBP and DBP reductions in both groups (p<0.0001). Conclusion: In patients with RHTN adherent to treatment, SNB and DRASB plus bisoprolol showed excellent therapeutic efficacy, although SNB was associated with earlier SBP reduction.

HIPERTENSÃO E DIABETES: CONCEITOS ATUAIS NA TERAPÊUTICA / HYPERTENSION AND DIABETES: CURRENT CONCEPTS IN THERAPEUTICS

Diabetes mellitus tipo 2 (DM) cursa com alta prevalência na população, acometendo cerca de 9,3% da população mundial (463 milhões de indivíduos). Devido ao crescimento dos casos e envelhecimento populacional, estima-se que o número de diabéticos será superior a 628 milhões em 2045. Dados de 2013 estimam que 6,2% da população brasileira acima dos 18 anos de idade tenham diabetes. Rápida urbanização, transição epidemiológica, fator nutricional, estilo de vida sedentário, excesso de peso, crescimento e envelhecimento populacional são fatores associados ao aumento da prevalência. Geralmente, ao tempo do diagnóstico do DM, a hipertensão arterial sistêmica (HAS) está presente em 50% dos diabéticos. O artigo discute aspectos relacionados à fisiopatogenia do diabetes e hipertensão, as metas de pressão arterial e as principais abordagens terapêuticas no tratamento da hipertensão arterial no paciente diabético, de acordo com as diretrizes mais recentes

Type 2 Diabetes mellitus presents high prevalence in the population, responding for about 9.3% in the world population (463 million individuals). Due to cases increase and aging, it is estimated that the number of diabetic subjects will be higher than 628 million in 2045. Data of 2013 show that 6,2% of Brazilian population higher 18 years-old have diabetes. Fast urbanization, epidemiological transition, nutritional factor, physical inactivity, overweight, population growth and aging are factors associated to increase of prevalence. Generally, when of diabetes diagnosis, hypertension is present in 50% of diabetic individuals. The article discusses aspects of pathophysiology of hypertension and diabetes, the targets of blood pressure and the principal therapeutic approaches of treatment of hypertension in the diabetic patient, in according to recenter guidelines

Predictive Factors for Target Organ Injuries in Hypertensive Individuals.

BACKGROUND: The causal relationship between systemic arterial hypertension and target organ damage (TOD) is well known, as well as the association with cardiovascular risk factors (CV). Ambulatory blood pressure monitoring (ABPM) is important in monitoring hypertension and assessing the risk of TOD. OBJECTIVE: To evaluate the relationship between blood pressure (BP) and clinical and biochemical parameters in the development of TOD in hypertensive patients. METHODS: This was a retrospective cohort study with 162 hypertensive patients followed for an average period of 13 years. The TOD investigated were left ventricular hypertrophy (LVH), microalbuminuria, coronary artery disease (CAD) and stroke. Blood pressure was assessed by ABPM and LVH using echocardiogram and electrocardiogram, respectively. Biochemical-metabolic tests and 24-hour microalbuminuria were performed at baseline and follow-up. The P-value <0.05 was considered significant. RESULTS: The average age was 69±11.8 years, with a predominance of women (64.8%), white ethnicity (79.6%) and diabetics (78.4%). ABPM showed a significant reduction in BP values during follow-up, although without association with TOD (microalbuminuria, stroke, and CAD), except for LVH that showed a correlation with sleep BP ≥120/70 mmHg (P=0.044). The most frequent TODs were LVH (29.6%), microalbuminuria (26.5%), CAD (19.8%) and stroke (17.3%). In the follow-up, there was an association between LVH and diabetes; microalbuminuria was associated with diabetes and triglycerides; stroke was associated with HDL-cholesterol (HDL-c), microalbuminuria and carotid disease. CAD showed a relationship with age and HDL-c. CONCLUSION: Predictive factors for TOD are age, microalbuminuria, diabetes, HDL-c, triglycerides and carotid disease. Nocturnal BP is correlated with LVH. The absence of a relationship between ABPM and other TODs can be explained by the use of effective drugs, improvement of metabolic and blood pressure parameters.

Evidence of Nonadherence in Cases of Pseudoresistant Hypertension.

Resistant hypertension (RH) is characterized by the use of three or more antihypertensive drugs without reaching the goal of controlling blood pressure (BP). For a definitive diagnosis of RH, it is necessary to exclude causes of pseudoresistance, including the white-coat effect, errors in BP measurement, secondary hypertension, therapeutic inertia, and poor adherence to lifestyle changes and pharmacological treatment. Herein, we report the history of a patient with long-standing uncontrolled BP, even when using seven antihypertensive drugs. Causes of secondary hypertension that justified the high BP levels were investigated, in addition to the other causes of pseudo-RH. In view of the difficult-to-control BP situation, it was decided to hospitalize the patient for better investigation. After 5 days, he had BP control with practically the same medications previously used. Finally, all factors related to the presence of pseudo-RH are discussed, especially poor adherence to treatment. Poor adherence to antihypertensive treatment is common in daily medical practice, and its investigation is of fundamental importance for better management of BP.

Avaliação do Seguimento de 1 Ano dos Pacientes Incluídos no Registro da Prática Clínica em Pacientes de Alto Risco Cardiovascular (REACT) / Evaluation of 1-Year Follow-up of Patients Included in the Registry of Clinical Practice in Patients at High Cardiovascular Risk (REACT)

Resumo Fundamento Na prática clínica, há evidências de falhas na prescrição de terapias baseadas em evidências para pacientes de alto risco cardiovascular. Entretanto, no Brasil, ainda são insuficientes os dados sobre a evolução ao longo de 1 ano desses pacientes. Objetivos Descrição no acompanhamento de 12 meses da utilização de terapias baseadas em evidência e da ocorrência de desfechos cardiovasculares maiores e seus principais preditores em um registro brasileiro multicêntrico de pacientes de alto risco cardiovascular. Métodos Estudo observacional prospectivo que documentou a prática clínica ambulatorial de indivíduos acima de 45 anos e de alto risco cardiovascular tanto em prevenção primária como secundária. Os pacientes foram seguidos por 1 ano e avaliou-se a prescrição de terapias baseadas em evidência e a ocorrência de eventos cardiovasculares maiores (infarto agudo do miocárdio [IAM], acidente vascular cerebral [AVC], parada cardíaca e mortalidade por causa cardiovascular). Valores de p < 0,05 foram considerados estatisticamente significantes. Resultados De julho de 2010 até agosto de 2014, 5.076 indivíduos foram incluídos em 48 centros, sendo 91% dos 4.975 pacientes elegíveis acompanhados em centros de cardiologia e 68,6% em prevenção secundária. Em 1 ano, o uso concomitante de antiplaquetários, estatinas e inibidores da enzima conversora de angiotensina (IECA) reduziu de 28,3% para 24,2% (valor de p < 0,001). A taxa de eventos cardiovasculares maiores foi de 5,46%, e os preditores identificados foram: idade, pacientes em prevenção secundária e nefropatia diabética. Conclusões Neste grande registro nacional de pacientes de alto risco cardiovascular, foram identificados preditores de risco semelhantes aos registros internacionais, porém a adesão da prescrição médica a terapias baseadas em evidência esteve abaixo dos dados da literatura internacional e apresentou piora significativa em 1 ano. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background In clinical practice, there is evidence of failure to prescribe evidence-based therapies for patients at high cardiovascular risk. However, in Brazil, data on 1-year outcomes of these patients remain insufficient. Objectives To describe the use of evidence-based therapies and the occurrence of major cardiovascular outcomes and their major predictors in a 12-month follow-up of a Brazilian multicenter registry of patients at high cardiovascular risk. Methods This prospective observational study documented the outpatient clinical practice of managing patients over 45 years of age and of high cardiovascular risk in both primary and secondary prevention. Patients were followed-up for 1 year, and the prescription of evidence-based therapies and the occurrence of major cardiovascular events (myocardial infarction, stroke, cardiac arrest, and cardiovascular death) were assessed. P-values < 0.05 were considered statistically significant. Results From July 2010 to August 2014, a total of 5076 individuals were enrolled in 48 centers, 91% of the 4975 eligible patients were followed-up in cardiology centers, and 68.6% were in secondary prevention. At 1 year, the concomitant use of antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors reduced from 28.3% to 24.2% (p < 0.001). Major cardiovascular event rate was 5.46%, and the identified predictors were age, patients in secondary prevention, and diabetic nephropathy. Conclusions In this large national registry of patients at high cardiovascular risk, risk predictors similar to those of international registries were identified, but medical prescription adherence to evidence-based therapies was inferior and significantly worsened at 1 year. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Evaluation of 1-Year Follow-up of Patients Included in the Registry of Clinical Practice in Patients at High Cardiovascular Risk (REACT). / Avaliação do Seguimento de 1 Ano dos Pacientes Incluídos no Registro da Prática Clínica em Pacientes de Alto Risco Cardiovascular (REACT).

BACKGROUND: In clinical practice, there is evidence of failure to prescribe evidence-based therapies for patients at high cardiovascular risk. However, in Brazil, data on 1-year outcomes of these patients remain insufficient. OBJECTIVES: To describe the use of evidence-based therapies and the occurrence of major cardiovascular outcomes and their major predictors in a 12-month follow-up of a Brazilian multicenter registry of patients at high cardiovascular risk. METHODS: This prospective observational study documented the outpatient clinical practice of managing patients over 45 years of age and of high cardiovascular risk in both primary and secondary prevention. Patients were followed-up for 1 year, and the prescription of evidence-based therapies and the occurrence of major cardiovascular events (myocardial infarction, stroke, cardiac arrest, and cardiovascular death) were assessed. P-values < 0.05 were considered statistically significant. RESULTS: From July 2010 to August 2014, a total of 5076 individuals were enrolled in 48 centers, 91% of the 4975 eligible patients were followed-up in cardiology centers, and 68.6% were in secondary prevention. At 1 year, the concomitant use of antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors reduced from 28.3% to 24.2% (p < 0.001). Major cardiovascular event rate was 5.46%, and the identified predictors were age, patients in secondary prevention, and diabetic nephropathy. CONCLUSIONS: In this large national registry of patients at high cardiovascular risk, risk predictors similar to those of international registries were identified, but medical prescription adherence to evidence-based therapies was inferior and significantly worsened at 1 year. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

FUNDAMENTO: Na prática clínica, há evidências de falhas na prescrição de terapias baseadas em evidências para pacientes de alto risco cardiovascular. Entretanto, no Brasil, ainda são insuficientes os dados sobre a evolução ao longo de 1 ano desses pacientes. OBJETIVOS: Descrição no acompanhamento de 12 meses da utilização de terapias baseadas em evidência e da ocorrência de desfechos cardiovasculares maiores e seus principais preditores em um registro brasileiro multicêntrico de pacientes de alto risco cardiovascular. MÉTODOS: Estudo observacional prospectivo que documentou a prática clínica ambulatorial de indivíduos acima de 45 anos e de alto risco cardiovascular tanto em prevenção primária como secundária. Os pacientes foram seguidos por 1 ano e avaliou-se a prescrição de terapias baseadas em evidência e a ocorrência de eventos cardiovasculares maiores (infarto agudo do miocárdio [IAM], acidente vascular cerebral [AVC], parada cardíaca e mortalidade por causa cardiovascular). Valores de p < 0,05 foram considerados estatisticamente significantes. RESULTADOS: De julho de 2010 até agosto de 2014, 5.076 indivíduos foram incluídos em 48 centros, sendo 91% dos 4.975 pacientes elegíveis acompanhados em centros de cardiologia e 68,6% em prevenção secundária. Em 1 ano, o uso concomitante de antiplaquetários, estatinas e inibidores da enzima conversora de angiotensina (IECA) reduziu de 28,3% para 24,2% (valor de p < 0,001). A taxa de eventos cardiovasculares maiores foi de 5,46%, e os preditores identificados foram: idade, pacientes em prevenção secundária e nefropatia diabética. CONCLUSÕES: Neste grande registro nacional de pacientes de alto risco cardiovascular, foram identificados preditores de risco semelhantes aos registros internacionais, porém a adesão da prescrição médica a terapias baseadas em evidência esteve abaixo dos dados da literatura internacional e apresentou piora significativa em 1 ano. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Randomized Study Comparing Vildagliptin vs Glibenclamide on Glucose Variability and Endothelial Function in Patients with Type 2 Diabetes Mellitus and Hypertension.

BACKGROUND: Glucose variability (GV) is considered an important factor for cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM). High GV causes endothelial dysfunction and increased oxidative stress. Dipeptidyl peptidase-4 (DPP-4) inhibitors may improve endothelial function and decrease GV. The aim of this study was to investigate the effects of vildagliptin, a DPP-4 inhibitor, compared with glibenclamide in GV and endothelial function in patients with T2DM and arterial hypertension. METHODS: This is a prospective, randomized, open and drug-controlled study. Fifty patients older than 35 years with T2DM and hypertension without CVD were randomized to receive vildagliptin (n=25) or glibenclamide (n=25), both in added-on metformin. Laboratory tests and analysis of endothelial function were performed before and 12 weeks after treatment. Endothelial function, defined by reactive hyperemia index (RHI), was analyzed by peripheral artery tonometry (endo-PAT2000). GV was evaluated by capillary glucose with intermittent monitoring device, six measurements per day, for three days, before and after treatment. The median of standard deviation (SD) of mean blood glucose (MBG) was used to evaluate GV. RESULTS: GV decreased in the vildagliptin group (35.2 to 30.7, P=0.037) but did not change with glibenclamide (37.6 to 37.5, P=0.765). Glycated hemoglobin was similar in both groups. MBG decreased only in glibenclamide group, without difference with vildagliptin group (P=0.374). There were no changes in the RHI in both groups and there was no correlation between GV and RHI (P=0.658). CONCLUSION: Vildagliptin reduces GV; however, the action on endothelial function was not demonstrated. In addition, there was no correlation between GV and endothelial function.