Severe type 2 diabetes (T2D) remission using a very low-calorie ketogenic diet (VLCKD).

Summary: There is a close association between obesity and type 2 diabetes (T2D). The value of weight loss in the management of patients with T2D has long been known. Loss of 15% or more of body weight can have a disease-modifying effect in people with diabetes inducing remission in a large proportion of patients. Very low-carbohydrate ketogenic diets (VLCKDs) have been proposed as an appealing nutritional strategy for obesity management. The diet was shown to result in significant weight loss in the short, intermediate, and long terms and improvement in body composition parameters as well as glycemic and lipid profiles. The reported case is a 35-year-old man with obesity, dyslipidemia, and T2D for 5 years. Despite the use of five antidiabetic medications, including insulin, HbA1c was 10.1%. A VLCKD through a commercial multidisciplinary weight loss program (PnK method) was prescribed and all medications were discontinued. The method is based on high-biological-value protein preparations and has 5 steps, the first 3 steps (active stage) consist of a VLCKD (600-800 kcal/d) that is low in carbohydrates (<50 g daily from vegetables) and lipids. The amount of proteins ranged between 0.8 and 1.2 g/kg of ideal body weight. After only 3 months, the patient lost 20 kg with weight normalization and diabetes remission, and after 2 years of follow-up, the patient remained without the pathologies. Due to the rapid and significant weight loss, VLCKD emerges as a useful tool in T2D remission in patients with obesity. Learning points: Obesity and type 2 diabetes (T2D) are conditions that share key pathophysiological mechanisms. Loss of 15% or more of body weight can have a disease-modifying effect in people with T2D inducing remission in a large proportion of patients. Diabetes remission should be defined as a return of HbA1c to <6.5% and which persists for at least 3 months in the absence of usual glucose-lowering pharmacotherapy. The very low-carbohydrate ketogenic diet (VLCKD) is a nutritional approach that has significant beneficial effects on anthropometric and metabolic parameters. Due to the rapid and significant weight loss, VLCKD emerges as a useful tool in T2D remission in patients with obesity.

Prevalence and Factors Associated with Metabolic Syndrome in Patients at a Psychosocial Care Center: A Cross-Sectional Study.

BACKGROUND: Metabolic syndrome (MS) is associated with greater risk of morbimortality and it has high prevalence in people with mental illness. OBJECTIVE: Estimate the prevalence of Metabolic Syndrome (MS) and its associated factors in the patients of a Psychosocial Care Center (CAPS in Brazilian Portuguese) in the city of Salvador, state of Bahia, Brazil. METHOD: Cross-sectional study set at CAPS in the city of Salvador-Bahia between August 2019 and February 2020. MS was evaluated according to the National Cholesterol Education Program's Adult Treatment Panel III. In addition to descriptive statistics, gross and adjusted prevalence ratios were described. RESULTS: MS was found in 100 (35.2%) individuals, 116 (40.9%) were obese and 165 (58.1%) had increased waist circumference. Polypharmacy was identified in 63 (22.3%) patients and 243 (85.9%) used antipsychotics. Under gross evaluation, women (PR = 1.88; 95%CI: 1.35-2.63) and those who used antidepressants (PR = 1.41; 95%CI: 1.05-1.88) showed an association with MS. After logistic regression, depression (PR = 1.86; 95%CI: 1.38-2.51), acanthosis (PR = 1.50; 95%CI: 1.18-1.90), use of antipsychotics (PR = 1.88; 95%CI: 1.13-2.75), and hypertriglyceridemic waist (PR = 3.33; 95%CI: 2.48-4.46) were associated with MS. CONCLUSION: The prevalence of MS signals multimorbidity among individuals with mental disorders and suggests a need for clinical screening.

Effectiveness and Safety of a Very Low-Calorie Ketogenic Diet on Weight Regain Following Bariatric Surgery.

PURPOSE: Obesity is one of the major public health problems worldwide and bariatric surgery is considered the gold standard treatment for severe obesity. Although the literature supports the safety and efficacy of the very low-calorie ketogenic diet (VLCKD) in patients with obesity, there is no study analyzing the use in case of failure or weight regain after bariatric surgery. This work has the purpose of assessing the response to a VLCKD (Pnk® method) in this population. METHODS: We have conducted an observational, retrospective, and descriptive study with the analysis of medical charts of private offices where patients were examined between 2014 and 2019, totalizing 11 participants who underwent Roux-en-Y gastric bypass (RYGB) without a reduction of 50% in body weight excess or any weight regain after the surgery. The patients followed the first stage of a commercial weight loss program (Pnk® method) which consists of a VLCKD (600-800 kcal/day), low in carbohydrates and lipids. RESULTS: A significant reduction was observed (p-value < 0.05) in weight, body mass index (BMI), abdominal circumference (AC), and glycated hemoglobin (A1C) post-ketogenic diet. Uric acid, transaminases, urea, and creatinine values did not show differences between pre- and post-ketosis. During the course of the study, no serious adverse events were reported. CONCLUSION: This study has shown that the ketogenic diet can be recommended as an effective and safe treatment for patients who progressed with insufficient weight loss or regain after bariatric surgery.

Prevalence of thyroid diseases in patients with acromegaly: experience of a Brazilian center / Prevalência das doenças tireoidianas em pacientes com acromegalia: experiência de um centro brasileiro

OBJECTIVES: Acromegaly is frequently associated with thyroid diseases. In this study, we evaluated the frequency of thyroid disorders in a series of acromegalic patients. SUBJECTS AND METHODS: We evaluated 106 acromegalic patients using thyroid ultrasonography (US) and measurements of GH, IGF-I, free T4, TSH and anti-thyroperoxidase antibody levels. IGF-I was expressed in mass units and age-related standard deviation scores (SD-scores). Fine-needle aspiration biopsy (FNAB) was performed on thyroid nodules with a diameter greater than one centimeter or with suspicious characteristics. RESULTS: Thyroid disorders were found in 75 patients. Eleven patients had diffuse goiter, 42 patients had nodular goiter, and 22 patients had unspecific morphological abnormalities. Four patients (3.8%) had thyroid carcinoma. Considering the patients with diffuse or nodular goiter, thyroid volume was greater in patients with active acromegaly, and was positively correlated with GH, IGF-I, and IGF-I SD-score. CONCLUSIONS: Our study confirmed that benign thyroid diseases are frequent in acromegalic patients. The prevalence of thyroid cancer was higher than in the overall population. We suggest that thyroid US should be routinely performed in patients with acromegaly.

OBJETIVOS: Acromegalia está frequentemente associada a doenças tireoidianas. Neste estudo, avaliamos a presença de tireoidopatias em uma série de pacientes acromegálicos. SUJEITOS E MÉTODOS: Foram avaliados 106 pacientes por ultrassonografia (US) e dosagens de GH, IGF-1, T4 livre, TSH e anticorpo antitireoperoxidase. O IGF-I foi expresso em unidades de massa e desvio-padrão (DP-IGF-I). Punção aspirativa por agulha fina (PAAF) foi realizada quando os nódulos eram maiores que um centímetro ou tinham características suspeitas. RESULTADOS: Alterações tireoidianas foram encontradas em 75 pacientes. Onze apresentavam bócio difuso, 42, bócio nodular e 22, alterações morfológicas inespecíficas. Houve quatro casos (3,8%) de câncer diferenciado de tireoide. Considerando os pacientes com bócio difuso ou nodular, o volume tireoidiano foi maior naqueles com acromegalia em atividade e correlacionou-se positivamente com os níveis de GH, IGF-1 e DP-IGF-1. CONCLUSÕES: Nosso estudo confirmou que as doenças tireoidianas benignas são frequentes nos pacientes acromegálicos. A prevalência de câncer diferenciado de tireoide foi maior que na população geral. Sugerimos que US de tireoide seja realizado rotineiramente nos pacientes com acromegalia.

Prevalence of thyroid diseases in patients with acromegaly: experience of a Brazilian center.

OBJECTIVES: Acromegaly is frequently associated with thyroid diseases. In this study, we evaluated the frequency of thyroid disorders in a series of acromegalic patients. SUBJECTS AND METHODS: We evaluated 106 acromegalic patients using thyroid ultrasonography (US) and measurements of GH, IGF-I, free T4, TSH and anti-thyroperoxidase antibody levels. IGF-I was expressed in mass units and age-related standard deviation scores (SD-scores). Fine-needle aspiration biopsy (FNAB) was performed on thyroid nodules with a diameter greater than one centimeter or with suspicious characteristics. RESULTS: Thyroid disorders were found in 75 patients. Eleven patients had diffuse goiter, 42 patients had nodular goiter, and 22 patients had unspecific morphological abnormalities. Four patients (3.8%) had thyroid carcinoma. Considering the patients with diffuse or nodular goiter, thyroid volume was greater in patients with active acromegaly, and was positively correlated with GH, IGF-I, and IGF-I SD-score. CONCLUSIONS: Our study confirmed that benign thyroid diseases are frequent in acromegalic patients. The prevalence of thyroid cancer was higher than in the overall population. We suggest that thyroid US should be routinely performed in patients with acromegaly.

Two hour mean GH is not superior to basal GH for the follow-up of acromegalic patients treated with Octreotide LAR.

BACKGROUND: GH secretion, in acromegaly, is characterized by increased basal levels, as well as by increased frequency and amplitude of pulses. Evaluation of disease activity during follow-up of treated patients is frequently done with mean GH levels, although there is no established protocol for sample collection. OBJECTIVE: Determine mean GH value of 5 blood samples collected 30 min apart for 2 consecutive hours in the follow-up of acromegalic patients treated with octreotide LAR. METHODS: Ninety-one GH curves of 44 patients (25 women) were evaluated as were the respective IGF-I values (basal). Normal IGF-I for age and sex was considered standard for control of disease activity. Correlations between basal and mean GH were studied as were correlations between both values and %IGF-I above the upper limit of reference values (%ULRV). RESULTS: Median age of the group was 45.5 years (range 28-73). Twenty-five patients (56.8%) had previous surgery and 7 (15.9%) had both surgery and radiotherapy. A positive correlation was found between mean and basal GH (r=0.953; p<0.001). Both basal and mean GH were correlated to %ULRV (r=0.645 and 0.661; p<0.001 for both). In only 3 of the 91 curves (3.3%) there were discordances between basal GH and IGF-I, however the latter was concordant with mean GH. In 3 other curves there was concordance between basal GH and IGF-I although the latter was discordant with mean GH. CONCLUSIONS: There was no benefit to perform GH curves with the present protocol. It may be due to our established outpatient follow up protocol. The use of more complex protocols and the cost of multiple GH assays should be acknowledged, and probably reserved for patients with basal GH levels between 1 and 5 microg/L with discordant GH and IGF-I.

O papel da glicemia capilar de jejum no diagnóstico precoce do diabetes mellitus: correlação com fatores de risco cardiovascular / The role of fasting capillary glycemia in the early diagnosis of diabetes mellitus: correlation with cardiovascular risk factors

O diabetes mellitus (DM) tem alta prevalência na população mundial. Para avaliar o papel da glicemia capilar dejejum (GCJ) no seu diagnóstico, 277 indivíduos (202F/75M) foram estudados. Os voluntários aparentavam ser saudáveis, tinham mais de 30 anos, e foram recrutados num posto de saúde quando estavam acompanhando pacientes ou se preparavam para fazer um exame de sangue de rotina. Gestação e conhecimento prévio de DM serviram de critérios de exclusão. Após avaliação antropométrica, a GCJ era medida. Os casos com GCJ >96mg/dl eram reavaliados com dosagens de glicemia plasmática em jejum e 2 horas após 75g de dextrosol. Cento e oitenta e sete (67,5 por cento) tiveram GCJ s96mg/dl e 90 (32,5 por cento) GCJ >96mg/dl. Quando os parâmetros idade, peso, índice de massa corporal, cintura abdominal e quadril dos 2 grupos foram comparados entre si, os valores foram sempre estatisticamente maiores (p< 0,01) no grupo com GCJ >96mg/dl. A incidência de DM foi de 7,2 por cneto e de intolerância à glicose, 4,3 por cento. Em conclusão, a GCJ se mostrou um instrumento valioso no diagnóstico precoce do DM.