Autocuidado e diabetes: descubra o "sabor" de uma vida saudável / Autocuidado e diabetes: descubra o "sabor" de uma vida saudável

Produto do projeto: Impacto da coordenação e acompanhamento do cuidado por telemonitoramento na qualidade da assistência prestada aos usuários do SUS portadores de doenças crônicas, egressos de internação hospitalar em Belo Horizonte, MG, Brasil.

Type 1 diabetes mellitus: can coaching improve health outcomes?

OBJECTIVE: To evaluate the introduction of coaching in the interdisciplinary care of individuals with type 1 diabetes mellitus in the public health care system. SUBJECTS AND METHODS: Ten patients routinely attending a public health care service and with a glycated hemoglobin (HbA1c) level above 75% participated in eight coaching sessions. This study evaluated the patients' self-management of the disease and personal behavior. The participants were assessed at the beginning of the program and on two occasions after the intervention, with evaluation of biochemical and anthropometric data, and frequency of self-monitoring of blood glucose (SMBG). Questionnaires were applied during these evaluations to analyze emotional burden (B-PAID), medication adherence (Morisky Adherence Scale), and self-efficacy (IMDSES). RESULTS: HbA1c had a median level of 8.0% (range 76-10.3%) at the beginning of the study and reduced significantly 3 months after initiation of the intervention (7.78% [6.5-10%], p = 0.028), with no significant increase at 6 months (8.3% [713-9.27%], p = 0.386). SMBG improved significantly from the beginning to the end of the study, with the median number of glucose tests per week varying from 16.5 (range 0-42) at baseline to 29.0 (7-42) at 3 months and 27.5 (10-48) at 6 months (p = 0.047). No significant differences were observed in anthropometric parameters or in the scores of the instruments between the three measurements. CONCLUSION: A coaching intervention focused on patients' values and sense of purpose may provide added benefit to traditional diabetes education programs and could be an auxiliary method to help individuals with type 1 diabetes achieve their treatment goals.

Type 1 diabetes mellitus: can coaching improve health outcomes?

ABSTRACT Objective: To evaluate the introduction of coaching in the interdisciplinary care of individuals with type 1 diabetes mellitus in the public health care system. Subjects and methods: Ten patients routinely attending a public health care service and with a glycated hemoglobin (HbA1c) level above 75% participated in eight coaching sessions. This study evaluated the patients' self-management of the disease and personal behavior. The participants were assessed at the beginning of the program and on two occasions after the intervention, with evaluation of biochemical and anthropometric data, and frequency of self-monitoring of blood glucose (SMBG). Questionnaires were applied during these evaluations to analyze emotional burden (B-PAID), medication adherence (Morisky Adherence Scale), and self-efficacy (IMDSES). Results HbA1c had a median level of 8.0% (range 76-10.3%) at the beginning of the study and reduced significantly 3 months after initiation of the intervention (7.78% [6.5-10%], p = 0.028), with no significant increase at 6 months (8.3% [713-9.27%], p = 0.386). SMBG improved significantly from the beginning to the end of the study, with the median number of glucose tests per week varying from 16.5 (range 0-42) at baseline to 29.0 (7-42) at 3 months and 27.5 (10-48) at 6 months (p = 0.047). No significant differences were observed in anthropometric parameters or in the scores of the instruments between the three measurements. Conclusion: A coaching intervention focused on patients' values and sense of purpose may provide added benefit to traditional diabetes education programs and could be an auxiliary method to help individuals with type 1 diabetes achieve their treatment goals.

Association of different biomarkers of renal function with D-dimer levels in patients with type 1 diabetes mellitus (renal biomarkers and D-dimer in diabetes).

Objective This study aimed to evaluate the association between different renal biomarkers with D-Dimer levels in diabetes mellitus (DM1) patients group classified as: low D-Dimer levels (< 318 ng/mL), which included first and second D-Dimer tertiles, and high D-Dimer levels (≥ 318 ng/mL), which included third D-Dimer tertile. Materials and methods D-Dimer and cystatin C were measured by ELISA. Creatinine and urea were determined by enzymatic method. Estimated glomerular filtration rate (eGFR) was calculated using CKD-EPI equation. Albuminuria was assessed by immunoturbidimetry. Presence of renal disease was evaluated using each renal biomarker: creatinine, urea, cystatin C, eGFR and albuminuria. Bivariate logistic regression analysis was performed to assess which renal biomarkers are associated with high D-Dimer levels and odds ratio was calculated. After, multivariate logistic regression analysis was performed to assess which renal biomarkers are associated with high D-Dimer levels (after adjusting for sex and age) and odds ratio was calculated. Results Cystatin C presented a better association [OR of 9.8 (3.8-25.5)] with high D-Dimer levels than albuminuria, creatinine, eGFR and urea [OR of 5.3 (2.2-12.9), 8.4 (2.5-25.4), 9.1 (2.6-31.4) and 3.5 (1.4-8.4), respectively] after adjusting for sex and age. All biomarkers showed a good association with D-Dimer levels, and consequently, with hypercoagulability status, and cystatin C showed the best association among them. Conclusion Therefore, cystatin C might be useful to detect patients with incipient diabetic kidney disease that present an increased risk of cardiovascular disease, contributing to an early adoption of reno and cardioprotective therapies.

Association of different biomarkers of renal function with D-dimer levels in patients with type 1 diabetes mellitus (renal biomarkers and D-dimer in diabetes)

ABSTRACT Objective This study aimed to evaluate the association between different renal biomarkers with D-Dimer levels in diabetes mellitus (DM1) patients group classified as: low D-Dimer levels (< 318 ng/mL), which included first and second D-Dimer tertiles, and high D-Dimer levels (≥ 318 ng/mL), which included third D-Dimer tertile. Materials and methods D-Dimer and cystatin C were measured by ELISA. Creatinine and urea were determined by enzymatic method. Estimated glomerular filtration rate (eGFR) was calculated using CKD-EPI equation. Albuminuria was assessed by immunoturbidimetry. Presence of renal disease was evaluated using each renal biomarker: creatinine, urea, cystatin C, eGFR and albuminuria. Bivariate logistic regression analysis was performed to assess which renal biomarkers are associated with high D-Dimer levels and odds ratio was calculated. After, multivariate logistic regression analysis was performed to assess which renal biomarkers are associated with high D-Dimer levels (after adjusting for sex and age) and odds ratio was calculated. Results Cystatin C presented a better association [OR of 9.8 (3.8-25.5)] with high D-Dimer levels than albuminuria, creatinine, eGFR and urea [OR of 5.3 (2.2-12.9), 8.4 (2.5-25.4), 9.1 (2.6-31.4) and 3.5 (1.4-8.4), respectively] after adjusting for sex and age. All biomarkers showed a good association with D-Dimer levels, and consequently, with hypercoagulability status, and cystatin C showed the best association among them. Conclusion Therefore, cystatin C might be useful to detect patients with incipient diabetic kidney disease that present an increased risk of cardiovascular disease, contributing to an early adoption of reno and cardioprotective therapies.

Evaluation of creatinine-based and cystatin C-based equations for estimation of glomerular filtration rate in type 1 diabetic patients.

Objective Several formulas based in different biomarkers may be used to estimate glomerular filtration rate (GRF). However, all of them have some limitations, and it is very important to evaluate their performances in different groups of patients. Therefore, we compared GFR, as estimated by creatinine-based and cystatin C-based equations, according to albuminuria, in type 1 diabetes (T1DM), in an observational case-control study. Subjects and methods T1DM patients were classified according to albuminuria: normoalbuminuric (n = 63), microalbuminuric (n = 30), macroalbuminuric (n = 32). GFR was calculated using creatinine-based and cystatin C-based (aMDRD, CKD-EPIcr, CKD-EPIcys, MacIsaac, Tan and CKD-EPIcrcys) equations. Spearman Correlation was used to evaluate the correlation of GFR estimated by the formulas with albuminuria. ROC curves were constructed to compare AUCs of GFR estimated by equations, in reference to macroalbuminuria. Sensibility, specificity and accuracy were calculated for a cut-off < 60 mL/min/1.73 m2. Results GFR estimated by creatinine-based and cystatin C-based equations significantly differed among normoalbuminuric, microalbuminuric and macroalbuminuric patients. Spearman correlation and AUCs of GFR estimated by creatinine-based and cystatin C-based formulas were very similar to each other, though cystatin C-based equations presented better correlation with albuminuria and higher AUCs than the creatinine-based ones, and the best accuracy to detect macroalbuminuric patients. Conclusion Although GFR estimated by all creatinine-based and cystatin C-based equations permitted the differentiation between T1DM patients, according to albuminuria, cystatin C-based equations presented best accuracy to detect macroalbuminuria in T1DM patients and should be considered in the clinical routine in order to increase the possibility of early diagnostic of chronic renal disease.

Evaluation of creatinine-based and cystatin C-based equations for estimation of glomerular filtration rate in type 1 diabetic patients

ABSTRACT Objective Several formulas based in different biomarkers may be used to estimate glomerular filtration rate (GRF). However, all of them have some limitations, and it is very important to evaluate their performances in different groups of patients. Therefore, we compared GFR, as estimated by creatinine-based and cystatin C-based equations, according to albuminuria, in type 1 diabetes (T1DM), in an observational case-control study. Subjects and methods T1DM patients were classified according to albuminuria: normoalbuminuric (n = 63), microalbuminuric (n = 30), macroalbuminuric (n = 32). GFR was calculated using creatinine-based and cystatin C-based (aMDRD, CKD-EPIcr, CKD-EPIcys, MacIsaac, Tan and CKD-EPIcrcys) equations. Spearman Correlation was used to evaluate the correlation of GFR estimated by the formulas with albuminuria. ROC curves were constructed to compare AUCs of GFR estimated by equations, in reference to macroalbuminuria. Sensibility, specificity and accuracy were calculated for a cut-off < 60 mL/min/1.73 m2. Results GFR estimated by creatinine-based and cystatin C-based equations significantly differed among normoalbuminuric, microalbuminuric and macroalbuminuric patients. Spearman correlation and AUCs of GFR estimated by creatinine-based and cystatin C-based formulas were very similar to each other, though cystatin C-based equations presented better correlation with albuminuria and higher AUCs than the creatinine-based ones, and the best accuracy to detect macroalbuminuric patients. Conclusion Although GFR estimated by all creatinine-based and cystatin C-based equations permitted the differentiation between T1DM patients, according to albuminuria, cystatin C-based equations presented best accuracy to detect macroalbuminuria in T1DM patients and should be considered in the clinical routine in order to increase the possibility of early diagnostic of chronic renal disease.

Association of Haemostatic and Inflammatory Biomarkers with Nephropathy in Type 1 Diabetes Mellitus.

This study aimed at investigating the association between haemostatic biomarkers, proinflammatory, and anti-inflammatory cytokines with chronic kidney disease in type 1 diabetic patients. Patients were divided into two groups: with nephropathy (albuminuria ≥ 30 mg/g and/or GFR < 60 mL/min/1.73 m(2)), n = 65; and without nephropathy (albuminuria < 30 mg/g and GFR ≥ 60 mL/min/1.73 m(2)), n = 60. INF-γ, IL-6, IL-10, and TNF-α plasma levels were determined by flow cytometry. VWF, ADAMTS13 antigen, and D-Dimer plasma levels were determined by enzyme-linked immunosorbent assay and ADAMTS13 activity was assessed by fluorescence resonance energy transfer assay. Elevated levels of INF-γ, VWF, ADAMTS13 antigen, D-Dimer, and reduced ADAMTS13 activity/antigen ratio were observed in patients with nephropathy as compared to those without nephropathy (P = 0.001, P < 0.001, P < 0.001, P < 0.001, and P < 0.001, resp.). Cytokines and haemostatic biomarkers remained associated with nephropathy after adjustments (use of statin, acetylsalicylic acid, angiotensin converting enzyme inhibitor, and angiotensin antagonist). INF-γ, TNF-α, and IL-10 significantly correlated with haemostatic biomarkers. Inflammatory and hypercoagulability status are associated with nephropathy in type 1 diabetes mellitus and an interrelationship between them may play an important role in pathogenesis of diabetic nephropathy.

Von Willebrand Factor, ADAMTS13 and D-Dimer Are Correlated with Different Levels of Nephropathy in Type 1 Diabetes Mellitus.

We have investigated whether von Willebrand factor, ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13), and D-Dimer were associated with different levels of renal function in patients with type 1 diabetes. Patients were classified according to level of renal function through estimated glomerular filtration rate: ≥90 and <130mL/min/1,73m2, n=52 (control group), ≥60 and <90mL/min/1,73m2, n=29 (mild renal dysfunction group), <60mL/min/1,73m2, n=28 (severe renal dysfunction group); and through urinary albumin excretion: normoalbuminuria, microalbuminuria and macroalbuminuria. Von Willebrand factor, ADAMTS13, and D-Dimer plasma levels were determined by enzyme-linked immunosorbent assay. ADAMTS13 activity was determined by fluorescence resonance energy transfer assay. Von Willebrand factor levels were increased in patients with mild (P=0.001) and severe (P<0.001) renal dysfunction as compared to the control group. ADAMTS13 levels were also increased in mild (P=0.029) and severe (P=0.002) renal dysfunction groups in comparison to the control group, while ADAMTS13 activity was increased only in the severe renal dysfunction group as compared to the control group (P=0.006). No significant differences were observed among the groups regarding von Willebrand factor/ADAMTS13 ratio. ADAMTS13 activity/ADAMTS13 levels ratio was reduced in patients with mild (P=0.013) and severe (P=0.015) renal dysfunction as compared to the control group. D-Dimer levels were increased in patients with mild (P=0.006) and severe (P<0.001) renal dysfunction as compared to the control group; it was also higher in patients with severe renal dysfunction as compared to the mild renal dysfunction group (P=0.019). Similar results were found for albuminuria classification. Increased von Willebrand factor, ADAMTS13, and D-Dimer levels and decreased ADAMTS13 activity/ADAMTS13 levels ratio are associated with renal dysfunction in patients with type 1 diabetes, suggesting that endothelial dysfunction and hypercoagulability are associated with nephropathy in type 1 diabetes.

Insulin resistance and associated factors in patients with Type 1 Diabetes.

OBJECTIVE: To assess the presence of insulin resistance (IR) in patients with type 1 diabetes (T1DM) according to the estimated glucose disposal rate formula (eGDR) and the insulin sensitivity score (ISS) and to estimate the correlation between these two measures and identify the clinical and laboratory markers related to IR. RESEARCH DESIGN AND METHODS: Cross-sectional study of adults with T1DM (n = 135). The results of the formulas that estimate IR were separated into quartiles and correlated with demographic data, clinical characteristics and laboratory parameters. We analyzed the total and regional adiposity by dual-energy X-ray absorptiometry and skin fold thickness measurements. RESULTS: Two thirds of the patients were overweight or obese. A moderate correlation was found between eGDR and ISS (r = 0.612). The results of both formulas were positively correlated with BMI (r = -0.373 eGDR and r = -0.721 ISS), thoracic-abdominal fat (r = -0.484 eGDR and r = -0.758 ISS), waist/height ratio (r = -0.537 eGDR and r = -0.779 ISS), subscapular skinfold (mm) (r = -0.356 eGDR and r = -0.569 ISS), total dose insulin IU/lean mass (kg) (r = -0.279 eGDR and r = -0.398 ISS), age (years) (r = -0.495 eGDR and r = -0.190 ISS) and diabetes duration (years) (r = -0.428 eGDR and r = -0.187 ISS). A moderate agreement (Kappa 0.226) was observed between the 1st quartile of results determined by the formulas in 10.4% of the patients, but the 4th quartile presented a strong correlation (Kappa 0.679). The individuals with IR that were classified in the 1st quartile by the ISS formula had a higher chance of presenting with acanthosis nigricans (OR = 5.58, 95% CI =1.46-21.3). CONCLUSIONS: The correlations found in this study indicate the possibility of using clinical and laboratory data to estimate IR in patients with TDM1. The detection of IR in T1DM patients may allow early intervention and possibly impact on future diabetes complications.

Neonatal maternal separation affects endocrine and metabolic stress responses to ether exposure but not to restraint exposure in adult rats.

We investigated prolactin secretion and metabolic changes in stress response in adult male rats submitted to periodic maternal separation (MS; 180 min/day) at 2 weeks of life. Restraint and ether exposure were randomly performed when the animals were 10-12 weeks of age. Restraint exposure: the animals were placed into plastic tubes (21 cm long, 4.5 cm diameter) for 20 min. Ether exposure: the rats were exposed to ether for 10 min. Atrial cannulation for blood sampling was performed through the jugular vein 5 days before the experiments. In both protocols, blood samples were taken immediately before (0), and 5, 15 and 20 min after the beginning of stress exposure. Ours results showed attenuated endocrine and metabolic responses to ether exposure in the maternal separation (MS) group compared to the control group. The measured metabolic parameters, plasma glucose, prolactin, lactate, and insulin secretion, were 32%, 55%, 41%, 73% lower (P < 0.01), respectively, in MS than in control animals. On the other hand, the endocrine and metabolic stress responses to restraint exposure were not affected by maternal separation. There was no difference between the MS and the control groups in any of the parameters studied. Our data demonstrated that early life experiences affect the hormonal systems beyond the hypothalamic-pituitary-adrenal axis, such as the central neuronal pathways, and their activities related to hormonal and metabolic responses to stress in adulthood. More importantly, these modifications were specific, but dependent on stress situation affecting mainly the circuitry related to the stress response to ether exposure.

High-sensitivity C-reactive protein levels in HIV-infected patients treated or not with antiretroviral drugs and their correlation with factors related to cardiovascular risk and HIV infection.

AIMS: To compare high-sensitivity C-reactive protein (hsCRP) in HIV-infected patients treated or not with antiretroviral (ARV) drugs and to correlate hsCRP levels with traditional cardiovascular risk factors and parameters of HIV infection. METHODS: One hundred and seventy-one HIV-infected patients were included (129 ARV-treated and 42 ARV-naïve). Evaluations included anthropometric measurements, blood pressure, laboratory tests, ultrasonographic measurement of fat thickness and impedance analysis. RESULTS: hsCRP levels were higher in ARV-treated compared to ARV-naïve patients (p<0.001). Seventy-two (56%) ARV-treated patients and 11 (26%) ARV-naïve patients had hsCRP concentrations >3 mg/dl (high risk for cardiovascular complications) (OR 3.56; 95%CI: 1.55-8.29; p=0.001, chi(2) test). hsCRP levels correlated positively with waist measurement (p=0.004), waist-to-hip ratio (p<0.001), systolic (p=0.05) and diastolic (p=0.03) blood pressure, intra-abdominal fat thickness (p=0.02), triglycerides (p=0.001), total cholesterol (p=0.01), fasting glucose (p=0.01), and glucose (p<0.001) and insulin levels (p=0.02) measured 2 h after load. No correlation was found between hsCRP levels and CD4 cell counts and HIV-viral load. Independent factors associated with hsCRP levels were therapy with current non-nucleoside reverse transcriptase inhibitors (NNRTI) (p=0.003), waist-to-hip ratio (p=0.006), fasting glucose (p=0.049) and glucose levels 2 h after load (p=0.003) in multivariate analysis model 1 and current NNRTI therapy (p<0.001), protease inhibitor therapy (p=0.016) and cardiometabolic syndrome (p=0.022) in multivariate analysis model 2. CONCLUSION: hsCRP in HIV-infected patients is associated with traditional cardiovascular risk factors, principally in ARV-treated patients. hsCRP levels are not associated with CD4 cell counts and HIV-viral load and may constitute a marker for cardiovascular risk related to HIV infection and ARV therapy.

Medial preoptic area adrenergic receptors modulate glycemia and insulinemia in freely moving rats.

In order to investigate the role of medial preoptic area (MPOA) adrenoceptors in regulation of plasma glucose and insulin secretion, we injected 40 nmol of noradrenaline, clonidine or isoproterenol into the MPOA of freely moving Wistar rats. The animals were fitted with chronic jugular catheters for blood sampling and unilateral intracerebral cannulae placed into MPOA. The results showed that noradrenaline injection into MPOA produced a rapid increase in plasma glucose levels and insulin secretion, reaching a peak at 15 min post stimulus (25% over basal, P<0.01) for plasma glucose and at 30 min for insulin secretion (94% over basal, P<0.05). Injection of the alpha2-adrenergic agonist clonidine into MPOA produced a faster, more intense and longer-lasting hyperglycemic response (69% over basal, P<0.01). In contrast to the noradrenaline effect on insulin secretion, clonidine markedly decreased plasma insulin levels, reaching a maximal suppression at 10 min (72% below basal, P<0.01). On the other hand, the beta-adrenergic agonist isoproterenol only produced a small, transient increase in plasma glucose levels. When rats were pre-treated with guanethidine (10 mg/100 g, i.p.), despite reduced baseline of plasma glucose (35% smaller then control group, P<0.01) and increased plasma insulin baseline (300% higher then control group, P<0.01), they still showed a hyperglycemic response to noradrenaline injection into MPOA. We conclude that the activation of preoptic alpha2-adrenoceptors induced hyperglycemia and inhibit insulin secretion, probably by activation of the sympathoadrenal system that cannot be blocked by prior administration of guanethidine.

Acute metabolic effects of thiopental anesthesia on fed and fasted rats chronically treated with bromocriptine.

We investigated the acute effects of thiopental anesthesia (4 mg/100 g, i.v.) on plasma glucose, insulin, triacylglycerol, and prolactin levels in rats treated with bromocriptine (BR) (0.4 mg/100 g body wt, i.p., for two weeks). Thiopental anesthesia induced a rapid increase in plasma insulin that was more pronounced in the animals treated with BR (116%, P <0.05). Thiopental anesthesia also produced a 55% decreased in plasma prolactin levels (P <0.01) in control fed rats, and a 22% reduction in plasma triacylglycerol (P <0.05) in both controls and BR-treated rats. We conclude that BR may constitute and additional sympatholytic factor in animals submitted to thiopental anesthesia.