Implementation of a systematic approach to diabetes in primary care in Bahia, Brazil improves metabolic outcomes: PRODIBA-Programa de Interiorização da Assistência ao Diabetes na Bahia (Project for Dissemination of Diabetes Care in the State of Bahia).

BACKGROUND: Staged Diabetes Management (SDM) improves glycaemic control and reduces diabetes-related complications in primary care. METHODS: An 18-month randomized controlled cohort study was conducted in two municipalities in the state of Bahia, Brazil, involving 100 patients with Type 2 diabetes in each municipality. In one municipality, healthcare professionals were trained to use SDM customized protocols for clinical decisions and, in the other municipality, no protocols for diabetes care were implemented. We hypothesized that, in the municipality with SDM trained professionals, patients would have better outcomes, including a fall in glycated haemoglobin (HbA(1c)). RESULTS: Improvements in some metabolic parameters were observed in the SDM group, including a 22% decrease in mean random glucose, a significant 15% decrease in mean HbA(1c), a 6% decrease in systolic blood pressure and an 11% decrease in diastolic blood pressure. There were no differences in body mass index and lipid profile. CONCLUSIONS: SDM customized algorithms are effective, practical and easy to use in primary healthcare teams with very limited resources.

Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes.

OBJECTIVE: To evaluate American Diabetes Association (ADA) and World Health Organization (WHO) diagnostic criteria for gestational diabetes mellitus (GDM) against pregnancy outcomes. RESEARCH DESIGN AND METHODS: This cohort study consecutively enrolled Brazilian adult women attending general prenatal clinics. All women were requested to undertake a standardized 2-h 75-g oral glucose tolerance test (OGTT) between their estimated 24th and 28th gestational weeks and were then followed to delivery. New ADA criteria for GDM require two plasma glucose values > or = 5.3 mmol/l (fasting), > or = 10 mmol/l (1 h), and > or = 8.6 mmol/l (2 h). WHO criteria require a plasma glucose > or = 7.0 mmol/l (fasting) or > or = 7.8 mmol/l (2 h). Individuals with hyperglycemia indicative of diabetes outside of pregnancy were excluded. RESULTS: Among the 4,977 women studied, 2.4% (95% CI 2.0-2.9) presented with GDM by ADA criteria and 7.2% (6.5-7.9) by WHO criteria. After adjustment for the effects of age, obesity, and other risk factors, GDM by ADA criteria predicted an increased risk of macrosomia (RR 1.29, 95% CI 0.73-2.18), preeclampsia (2.28, 1.22-4.16), and perinatal death (3.10, 1.42-6.47). Similarly, GDM by WHO criteria predicted increased risk for macrosomia (1.45, 1.06-1.95), preeclampsia (1.94, 1.22-3.03), and perinatal death (1.59, 0.86-2.90). Of women positive by WHO criteria, 260 (73%) were negative by ADA criteria. Conversely, 22 (18%) women positive by ADA criteria were negative by WHO criteria. CONCLUSIONS: GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria predicts adverse pregnancy outcomes.

Short stature and gestational diabetes in Brazil. Brazilian Gestational Diabetes Study Group.

AIMS/HYPOTHESIS: To examine the association between maternal stature and gestational diabetes mellitus. METHODS: We studied a sample of 5564 consecutive Brazilian women 20 or more years old, who were pregnant for approximately 21-28 weeks, had no history of diabetes outside pregnancy and were attending general prenatal care units in six state capitals in Brazil from 1991 to 1995. We did a 2-h, 75-g oral glucose tolerance test, defining gestational diabetes by World Health Organisation criteria. RESULTS: Those in the shortest quartile of height (< or = 151 cm) had a 60% increase in the odds of having gestational diabetes, independently of prenatal clinic, age, global obesity, family history of diabetes, skin colour, referral pattern, waist circumference, parity, previous gestational diabetes, education, ambient temperature and gestational age compared with the tallest quartile [odds ratio (OR) = 1.60, p = 0.005]. This association was observed for those with above median values of skinfold thickness (OR = 1.74, p = 0.006) but not for those with below median values (OR = 1.22, p = 0.51). Associations of short stature with high 2-h glycaemia (> or = 7.8 mmol/l) (OR = 1.61, p = 0.005) were essentially the same as those for gestational diabetes. There was, however, no association between short stature and gestational hyperglycaemia when the latter was defined exclusively by fasting values (OR = 0.97, p = 0.90). CONCLUSION/INTERPRETATION: In Brazil short stature associates with gestational diabetes, principally in women with greater fat mass. This difference in glycaemic levels is present postprandially but not in the fasting state.

The effect of magnesium supplementation in increasing doses on the control of type 2 diabetes.

OBJECTIVE: Hypomagnesemia occurs in 25-38% of patients with type 2 diabetes. Several studies have suggested an association between magnesium (Mg) depletion and insulin resistance and/or reduction of insulin secretion in these cases. Our purpose was to evaluate if Mg supplementation (as magnesium oxide [MgO]) would improve metabolic control in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: We studied 128 patients with type 2 diabetes (32 men, 96 women, aged 30-69 years), treated by diet or diet plus oral antidiabetic drugs, in the Bahia Federal University Hospital, Brazil. Patients at risk for hypomagnesemia or with reduced renal function were excluded. This study was a clinical randomized double-blind placebo-controlled trial. Patients received either placebo, 20.7 mmol MgO, or 41.4 mmol MgO daily (elementary Mg) for 30 days. Mg concentrations were measured in plasma, in mononuclear cells, and in 24-h urine samples. Fasting blood glucose, HbA1, and fructosamine were used as parameters of metabolic control. RESULTS: Of the patients, 47.7% had low plasma Mg, and 31.1% had low intramononuclear Mg levels. Intracellular Mg in patients with diabetes was significantly lower than in the normal population (62 blood donors; 1.4 +/- 0.6 vs. 1.7 +/- 0.6 micrograms/mg of total proteins). No correlation was found between plasma and intracellular Mg concentrations (r = -0.179; P = 0.15) or between Mg concentrations and glycemic control (r = -0.165; P = 0.12). Intracellular Mg levels were lower in patients with peripheral neuropathy than in those without (1.2 +/- 0.5 vs. 1.5 +/- 0.6 micrograms/mg). Similar findings were observed in patients with coronary disease (1.0 +/- 0.5 vs. 1.5 +/- 0.6 micrograms/mg). In the placebo and in the 20.7 mmol Mg groups, neither a change in plasma and intracellular levels nor an improvement in glycemic control were observed. Replacement with 41.4 mmol Mg tended to increase plasma, cellular, and urine Mg and caused a significant fall (4.1 +/- 0.8 to 3.8 +/- 0.7 mmol/l) in fructosamine (normal, 1.87-2.87 mmol/l). CONCLUSIONS: Mg depletion is common in poorly controlled patients with type 2 diabetes, especially in those with neuropathy or coronary disease. More prolonged use of Mg in doses that are higher than usual is needed to establish its routine or selective administration in patients with type 2 diabetes to improve control or prevent chronic complications.

[Autonomic neuropathy in patients with impaired glucose tolerance]. / Neuropatia vegetativa em pacientes com tolerância diminuída a glicose.

UNLABELLED: Impaired glucose tolerance (IGT) is a clinical situation characterized by mild hyperglycemia, which is estimated to afflict 7.8% of the Brazilian population. Diabetic neuropathy is the most common complication in diabetes mellitus and it is related to morbidity and lethality in this disease. The association between IGT and peripheral neuropathy is still a matter of great concern. PURPOSE AND METHOD: In order to determine if IGT is associated with autonomic neuropathy a cross-sectional study in 44 patients with impaired glucose tolerance test (Group 1) was performed. The patients were compared to 43 control individuals (Group 2). Every patient in each group underwent anamnesis and standardized autonomic tests which consisted of heart frequency test, Valsalva maneuver, postural test and sinus arrhythmia. Routine hematologic exams as well as GTT were also made. RESULTS: Patients in group 1 had more systemic arterial hypertension, centripetal obesity, fasting and post-feeding hyperglycemia and dyslipidemia when compared with group 2. When we analysed the autonomic tests, the sinus arrhythmia test was abnormal in 54.5% of the patients in group 1 and in 32.5% in group 2 (p = 0.0039) and the Valsalva maneuver was abnormal in 34.1% of group 1 and in 7% of group 2 (p = 0.004). The postural test was not different in both groups (p = 0.334). CONCLUSION: Our results show that the involvement of the autonomic nervous system was more frequent in patients with IGT when compared to controls. These findings can explain the increased lethality due to vasculopathies observed in this group of patients and also alert physicians to care for patients with impaired glucose tolerance test.

Carbohydrate metabolism and plasma levels of insulin and glucagon in patients with atherosclerotic vascular disease.

In non-obese, non-diabetic patients suffering acute myocardial infarction, angina pectoris, previous myocardial infarction and peripheral vascular disease, the plasma levels of glucose, insulin, C-peptide and glucagon were determined in basal condition and during an intravenous glucose tolerance test. In the four groups there was a high frequency of glucose intolerance. Basal hyperinsulinism was present in all groups; in groups; in those which maintained normal glucose tolerance there was a high B-cell response to the sugar. Basal hyperglucagonemia was found in the early stage of acute ischemic heart disease, in patients with previous myocardial infarction and in those with peripheral vascular disease. The elevated plasma glucagon levels may play a role in the complex disturbance of carbohydrate metabolism present in patients with atherosclerotic vascular disease.

Alguns aspectos da sindrome de Mc Cune-Albright. Relato de um caso e revisao da literatura. / Mc Cune-Albright Syndrome. Report of a case and review of the literature

Os autores relatam um caso de uma paciente portadora da sindrome de Mc Cune-Albright, tecem comentarios sobre os aspectos geneticos endocrinos, radiologicos e anatomopatologicos dessa sindrome. Sao discutidas as diversas hipoteses da patogenese das manifestacoes apresentadas, concluindo-se que ate o presente nao existe hipotese capaz de explicar todas as alteracoes. Cuidadosa revisao da literatura sobre o assunto e tambem apresentada