A high-glycemic index, low-fiber breakfast affects the postprandial plasma glucose, insulin, and ghrelin responses of patients with type 2 diabetes in a randomized clinical trial.

BACKGROUND: Meals with a low glycemic index (GI) and rich in fiber could be beneficial with regard to postprandial metabolic profile and satiety. OBJECTIVE: The aim of this study was to investigate the effect of 4 breakfasts with a different GI and amount of fiber on postprandial plasma glucose, insulin, and appetite in patients with type 2 diabetes. METHODS: This randomized 4-intervention crossover trial included 14 patients [7 men; ages 65.8 ± 5.2 y; glycated hemoglobin: 6.6 ± 0.9%; BMI (in kg/m(2)): 27.2 ± 3.1]. Dietary interventions were as follows: breakfasts with a high GI (60.4 ± 0.1%) and high fiber (6.0 ± 0.3 g) (HGI-HF), a high GI (60.9 ± 1.7%) and low fiber (2.5 ± 0.4 g) (HGI-LF), a low GI (37.7 ± 0.1%) and high fiber (6.2 ± 0.3 g) (LGI-HF), and a low GI (39.8 ± 1.3%) and low fiber (2.0 ± 0.1 g) (LGI-LF). Plasma glucose, insulin, and total ghrelin were evaluated postprandially (0-180 min). A visual analog scale was used to assess appetite. Data were analyzed by generalized estimating equations and post hoc least significant difference (LSD) tests. Data are reported as means ± SDs. RESULTS: The area under the curve (AUC) [mean (95% CI); P for LSD tests] for plasma glucose (mmol/L × min) was higher after patients consumed the HGI-LF breakfast [9.62 (8.39, 10.84)] than after the LGI-HF breakfast [8.95 (7.71, 10.18)] (P ≤ 0.05). Insulin AUC (µIU/mL × min) after patients consumed the HGI-LF meal [65.72 (38.24, 93.19)] was higher than after the HGI-HF meal [57.24 (32.44, 82.04)] (P ≤ 0.05). The other observed difference was higher insulin AUC after the consumption of the LGI-LF breakfast [61.54 (36.61, 86.48)] compared with the AUC after the LGI-HF breakfast [54.16 (31.43, 76.88)] (P ≤ 0.05). Plasma ghrelin decreased in comparison with baseline only after patients consumed the LGI-HF and LGI-LF breakfasts (P ≤ 0.05). Subjective satiety did not differ between breakfasts. CONCLUSIONS: Plasma glucose, insulin, and ghrelin responses were least favorable when patients with type 2 diabetes consumed a breakfast with a high GI and low fiber, which suggests that reducing the GI or increasing the fiber content or both of breakfasts may be a useful strategy to improve the postprandial metabolic profile of these patients. This trial was registered at clinicaltrials.gov as NCT01410292.

Increased protein intake is associated with uncontrolled blood pressure by 24-hour ambulatory blood pressure monitoring in patients with type 2 diabetes.

OBJECTIVE: To analyze possible associations of dietary components, especially protein intake, with blood pressure (BP) during ambulatory BP monitoring (ABPM) in patients with type 2 diabetes. METHODS: In this cross-sectional study, BP of outpatients with type 2 diabetes was evaluated by 24-hour ABPM (Spacelabs 90207) and usual diet by 3-day weighed diet records. Patients were divided into 2 groups according to their daytime ABPM: uncontrolled BP (systolic BP ≥ 135 mmHg or diastolic BP ≥ 85 mmHg) and controlled BP (systolic BP < 135 mmHg and diastolic BP < 85 mmHg). Logistic regression models unadjusted and adjusted for possible confounders (covariates) were used to analyze the association of protein and uncontrolled BP. RESULTS: A total of 121 patients with type 2 diabetes aged 62.3 years, 54.5% of whom were women, were studied. The uncontrolled BP group had higher glycated hemoglobin (HbA1C) values (8.4 ± 2.0 vs 7.6 ± 1.3%; p = 0.04) and consumed more protein (20.0 ± 3.8 vs 18.2 ± 3.6% of energy; p = 0.01) and meat, (2.6 [1.45, 2.95] vs 2.0 [1.49, 2.90] g/kg weight; p = 0.04) than the controlled BP group. In a multivariate analysis, protein intake (% of energy) increased the chance for uncontrolled BP (odds ratio [OR] = 1.16; 95% confidence interval [CI], 1.02, 1.30; p = 0.02), adjusted for body mass index (BMI), HbA1C, low-density lipoprotein (LDL) cholesterol, number of antihypertensive medications, and ethnicity. Meat consumption higher than 3.08 g/kg weight/day more than doubled the chance for uncontrolled BP (OR = 2.53; 95% CI, 1.01, 7.60; p = 0.03). CONCLUSION: High protein intake and meat consumption were associated with high daytime ABPM values in patients with type 2 diabetes. Reducing meat intake might represent an additional dietary intervention in hypertensive patients with type 2 diabetes.

Effect of dietary lipids on circulating adiponectin: a systematic review with meta-analysis of randomised controlled trials.

Different dietary interventions have been identified as potential modifiers of adiponectin concentrations, and they may be influenced by lipid intake. We identified studies investigating the effect of dietary lipids (type/amount) on adiponectin concentrations in a systematic review with meta-analysis. A literature search was conducted until July 2013 using databases such as Medline, Embase and Scopus (MeSH terms: 'adiponectin', 'dietary lipid', 'randomized controlled trials (RCT)'). Inclusion criteria were RCT in adults analysing adiponectin concentrations with modification of dietary lipids. Among the 4930 studies retrieved, fifty-three fulfilled the inclusion criteria and were grouped as follows: (1) total dietary lipid intake; (2) dietary/supplementary n-3 PUFA; (3) conjugated linoleic acid (CLA) supplementation; (4) other dietary lipid interventions. Diets with a low fat content in comparison to diets with a high-fat content were not associated with positive changes in adiponectin concentrations (twelve studies; pooled estimate of the difference in means: -0·04 (95% CI -0·82, 0·74) µg/ml). A modest increase in adiponectin concentrations with n-3 PUFA supplementation was observed (thirteen studies; 0·27 (95% CI 0·07, 0·47) µg/ml). Publication bias was found by using Egger's test (P= 0·01) and funnel plot asymmetry. In contrast, CLA supplementation reduced the circulating concentrations of adiponectin compared with unsaturated fat supplementation (seven studies; -0·74 (95% CI -1·38, -0·10) µg/ml). However, important sources of heterogeneity were found as revealed by the meta-regression analyses of both n-3 PUFA and CLA supplementation. Results of new RCT would be necessary to confirm these findings.

Adiposity markers and risk of coronary heart disease in patients with type 2 diabetes mellitus.

BACKGROUND: This cross-sectional study aimed to evaluating the association between body adiposity markers and high-risk of coronary heart disease (CHD) in patients with type 2 diabetes. METHODS: Recent adiposity markers [waist-to-height ratio, conicity index (C-index) and body adiposity index] and traditional markers [BMI, waist circumference and waist-to-hip ratio (WHR)] were measured. The 10-year risk of fatal CHD was estimated according to UKPDS risk engine scores. Patients were divided into high (CHD risk ≥20%; n = 99) or low-moderate (CHD risk <20%; n = 321) risk groups. Multiple logistic regression models were performed to analyze associations between CHD risk (outcome) and adiposity markers. RESULTS: A total of 420 patients with type 2 diabetes (61.9 ± 9.5 years; 53.5% females; HbA1c 7.6 ± 1.6%) were evaluated. The high risk group had greater proportions of elevated C-index and BMI values than patients with low-moderate risk. No between-group differences in other adiposity markers were observed. In multiple logistic regression models, only C-index values ≥1.35 were associated with CHD risk >20% (OR = 1.69; 95% CI 1.03-2.78; P = 0.039) after adjusting for confounders (sedentary lifestyle, diabetic nephropathy, serum creatinine, and diabetes duration). The association between WHR and CHD risk did not hold in this sample. CONCLUSIONS: The C-index was the body adiposity marker best associated with high risk of fatal CHD in these patients with type 2 diabetes.

Catalase activity, allelic variations in the catalase gene and risk of kidney complications in patients with type 1 diabetes.

AIMS/HYPOTHESIS: Oxidative stress is involved in the pathogenesis of diabetic nephropathy. The antioxidant enzyme catalase plays a key role in redox regulation in the kidney. We investigated associations of catalase gene (CAT) polymorphisms and plasma catalase activity with diabetic nephropathy in type 1 diabetic patients. METHODS: We genotyped nine single nucleotide polymorphisms (SNPs) in the CAT region in participants from the Survival Genetic Nephropathy (SURGENE) (340 French participants, 10 year follow-up) and the Génétique de la Néphropathie Diabétique (GENEDIAB) (444 Belgian and French participants, 8 year follow-up) study cohorts. Replication was performed in a Brazilian cross-sectional cohort (n = 451). Baseline plasma catalase activity was measured in SURGENE (n = 120) and GENEDIAB (n = 391) participants. RESULTS: The A allele of rs7947841 was associated with the prevalence of incipient (OR 2.79, 95% CI 1.21, 6.24, p = 0.01) and established or advanced nephropathy (OR 5.72, 95% CI 1.62, 22.03, p = 0.007), and with the incidence of renal events, which were defined as new cases of microalbuminuria or progression to a more severe stage of nephropathy during follow-up (HR 1.82, 95% CI 1.13, 2.81, p = 0.01) in SURGENE participants. The same risk allele was associated with incipient nephropathy (OR 3.13, 95% CI 1.42, 7.24, p = 0.004) and with the incidence of end-stage renal disease (ESRD) (HR 2.11, 95% CI 1.23, 3.60, p = 0.008) in GENEDIAB participants. In both cohorts, the risk allele was associated with lower catalase activity. Associations with incipient and established or advanced nephropathy were confirmed in the replication cohort. CONCLUSIONS/INTERPRETATION: CAT variants were associated with the prevalence and incidence of diabetic nephropathy and ESRD in type 1 diabetic patients. Our results confirm the protective role of catalase against oxidative stress in the kidney.

Functional assessment and mortality in underweight critically ill patients one year after hospital discharge: A prospective cohort study.

BACKCGROUND & AIMS: There in no data regarding outcomes after hospital discharge for underweight critically ill patients. This study aimed to assess long-term survival and functional capacity in underweight critically ill patients. MATERIALS & METHODS: Prospective observational study that included underweight critically ill patients (BMI <20 kg/cm2) followed-up one year after hospital discharge. To assess functional capacity, we interviewed patients or caregivers and performed Katz index (KI) and Lawton scale. Patients were divided into two groups: (1) poor functional capacity, if the patient had less points than the median of the Katz and IADL score, and (2) good functional capacity, if at least one score was above the median. Extremely low weight defined as less than 45 kg. RESULTS: We assessed the vital status of 103 patients. Mortality was 38.8% (median 362 [136, 422] days of follow-up). We interviewed 62 patients or proxies. No difference was observed between survivors and non-survivors regarding weight and BMI at intensive care unit admission and nutritional therapy received in the first days of intensive care admission. Patients with poor functional capacity had lower admission weight (43.9 vs 52 ± 7.9 kg, p < 0.001) and BMI (17 ± 2.1 vs 18.2 ± 1.8 kg/cm2, p = 0.028). In a multivariate logistic regression, weight under 45 kg was independently associated with poor functional capacity (OR = 13.6, 95%CI, 3.7 to 66.5) CONCLUSION: Underweight critically ill patients have high mortality and a persistent functional impairment, the last being more important in extremely low weight. CLINICAL TRIAL REGISTRY: ClinicalTrials.gov number NCT03398343.

Albuminuria is not associated with bacteriuria in patients with type 2 diabetes mellitus: a meta-analysis of observational studies.

BACKGROUND/AIMS: It has been recommended that urinary albumin be measured in sterile urine for the proper diagnosis of diabetic nephropathy. However, the association between bacteriuria and urinary albumin is controversial. METHODS: A systematic review and meta-analysis was performed to investigate the association of albuminuria and bacteriuria in patients with diabetes. Medline and Embase were searched (beginning in 1950 until November 2010). Data were extracted independently by two investigators. The pooled OR estimates were calculated using the random effects model. RESULTS: We identified 305 studies in the database searches. A total of seven studies were included, providing data from 1,552 patients (mean age 56.4 years). The OR of bacteriuria for the presence of micro- and/or macroalbuminuria was 1.60 (95% CI: 0.97-2.66, I(2) = 66.6%) as compared to patients without bacteriuria. Funnel plots and the Egger regression test suggested no significant asymmetry in the analysis (p = 0.21). In a sensitivity analysis including the five studies (1,197 participants) that evaluated microalbuminuria as the outcome, the OR of bacteriuria for microalbuminuria was 1.22 (95% CI: 0.68-2.19). CONCLUSION: In conclusion, no association was identified between albuminuria and bacteriuria considering the current literature. Further prospective studies of a large diabetic population are needed to clarify such an association.

Effect of antihyperglycemic agents added to metformin and a sulfonylurea on glycemic control and weight gain in type 2 diabetes: a network meta-analysis.

BACKGROUND: Few studies have examined the effect of adding a third antihyperglycemic drug when blood glucose control is not achieved by using metformin and a sulfonylurea. PURPOSE: To compare the efficacy of add-on antihyperglycemic drugs in patients with type 2 diabetes that is not controlled with metformin and a sulfonylurea. DATA SOURCES: MEDLINE, EMBASE, Cochrane Library, LILACS, and ClinicalTrials.gov electronic databases. STUDY SELECTION: Randomized trials at least 24 weeks in duration. Studies evaluated the effects of adding a third antihyperglycemic drug to treatment of adults aged 18 years or older with type 2 diabetes and a hemoglobin A(1c) (HbA(1c)) level greater than 7.0% who were already receiving a combination of metformin and a sulfonylurea. DATA EXTRACTION: Primary end points were change in HbA(1c) level, change in weight, and frequency of severe hypoglycemia. DATA SYNTHESIS: Eighteen trials involving 4535 participants that lasted a mean of 31.3 weeks (24 to 52 weeks) were included. Compared with placebo, drug classes did not differ in effect on HbA(1c) level (reduction ranging from -0.70% [95% credible interval {CrI}, -1.33% to -0.08%] for acarbose to -1.08% [CrI, -1.41% to -0.77%] for insulin). Weight increase was seen with insulins (2.84 kg [CrI, 1.76 to 3.90 kg]) and thiazolidinediones (4.25 kg [CrI, 2.76 to 5.66 kg]), and weight loss was seen with glucagon-like peptide-1 agonists (-1.63 kg [CrI, -2.71 to -0.60 kg]). Insulins caused twice the absolute number of severe hypoglycemic episodes than noninsulin antihyperglycemic agents. LIMITATIONS: Most of the trials were short term, and trial quality varied. With so few trials relative to antihyperglycemic agents, investigators relied on indirect comparisons, which increased the uncertainty of the findings and conclusions. CONCLUSION: There is no clear difference in benefit between drug classes when adding a third agent to treatment of patients with type 2 diabetes who are already receiving metformin and a sulfonylurea. The most appropriate option should depend on each patient's clinical characteristics. PRIMARY FUNDING SOURCE: Conselho Nacional de Desenvolvimento Científico e Tecnológico and Coordenacao de Aperfeicoamento de Pessoal de Nível Superior.

Association of genetic variants in the promoter region of genes encoding p22phox (CYBA) and glutamate cysteine ligase catalytic subunit (GCLC) and renal disease in patients with type 1 diabetes mellitus.

BACKGROUND: Oxidative stress is recognized as a major pathogenic factor of cellular damage caused by hyperglycemia. NOX/NADPH oxidases generate reactive oxygen species and NOX1, NOX2 and NOX4 isoforms are expressed in kidney and require association with subunit p22phox (encoded by the CYBA gene). Increased expression of p22phox was described in animal models of diabetic nephropathy. In the opposite direction, glutathione is one of the main endogenous antioxidants whose plasmatic concentrations were reported to be reduced in diabetes patients. The aim of the present investigation was to test whether functional single nucleotide polymorphisms (SNPs) in genes involved in the generation of NADPH-dependent O2•⁻ (-675 T → A in CYBA, unregistered) and in glutathione metabolism (-129 C → T in GCLC [rs17883901] and -65 T → C in GPX3 [rs8177412]) confer susceptibility to renal disease in type 1 diabetes patients. METHODS: 401 patients were sorted into two groups according to the presence (n = 104) or absence (n = 196) of overt diabetic nephropathy or according to glomerular filtration rate (GFR) estimated by Modification of Diet in Renal Disease (MDRD) equation: ≥ 60 mL (n = 265) or < 60 mL/min/1.73 m² (n = 136) and were genotyped. RESULTS: No differences were found in the frequency of genotypes between diabetic and non-diabetic subjects. The frequency of GFR < 60 mL/min was significantly lower in the group of patients carrying CYBA genotypes T/A+A/A (18.7%) than in the group carrying the T/T genotype (35.3%) (P = 0.0143) and the frequency of GFR < 60 mL/min was significantly higher in the group of patients carrying GCLC genotypes C/T+T/T (47.1%) than in the group carrying the C/C genotype (31.1%) (p = 0.0082). Logistic regression analysis identified the presence of at least one A allele of the CYBA SNP as an independent protection factor against decreased GFR (OR = 0.38, CI95% 0.14-0.88, p = 0.0354) and the presence of at least one T allele of the GCLC rs17883901 SNP as an independent risk factor for decreased GFR (OR = 2.40, CI95% 1.27-4.56, p = 0.0068). CONCLUSIONS: The functional SNPs CYBA -675 T → A and GCLC rs17883901, probably associated with cellular redox imbalances, modulate the risk for renal disease in the studied population of type 1 diabetes patients and require validation in additional cohorts.

High dietary glycemic index and low fiber content are associated with metabolic syndrome in patients with type 2 diabetes.

OBJECTIVE: To investigate possible associations of dietary glycemic index (GI) and fiber content with metabolic syndrome (MetS) in patients with type 2 diabetes. METHODS: In this cross-sectional study, 175 outpatients with type 2 diabetes (aged 61.1 ± 9.7 years; HbA(1c) 7.3% ± 1.4%; diabetes duration of 11 years [range, 5-17]) had food intake assessed by 3-day weighed-diet records. Dietary GI (according to FAO/WHO) and fiber content were categorized as high or low based on median values. MetS was defined according to the 2009 Joint Interim Statement. RESULTS: Patients with MetS (n = 109) had higher 24-hour GI (60.0% ± 6.3% vs 57.5% ± 6.4%), higher breakfast GI (59.8% ± 8.0% vs 55.0% ± 9.9%), and lower fiber intake at 24 hours (17.0 ± 6.6 g vs 21.2 ± 8.0 g), breakfast (1.9 [1.2-3.2] vs 3.1 [1.8-4.9] g), lunch (6.2 [3.9-8.0] vs 7.5 [4.7-9.4] g), and dinner (3.3 [2.1-5.2] vs 4.9 [3.1-6.4] g; p < 0.05 for all comparisons) than patients without MetS. In multivariate analyses, high GI (~60%) of 24 hours (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.10-4.11; p = 0.025), breakfast (OR, 2.20; 95% CI, 1.15-4.21; p = 0.017), and lunch (OR, 2.46; 95% CI, 1.28-4.74; p = 0.007) was associated with MetS. Breakfast (OR, 2.14; 95% CI, 1.04-4.41; p = 0.039) and dinner (OR, 2.27; 95% CI, 1.15-4.49; p = 0.019) with low fiber content were also associated with MetS. When high GI and low fiber intake were combined into the same variable, associations with MetS were maintained. CONCLUSIONS: Increased dietary GI and reduced fiber content were positively associated with MetS, mainly due to breakfast intake, in patients with type 2 diabetes.

Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis.

CONTEXT: Regular exercise improves glucose control in diabetes, but the association of different exercise training interventions on glucose control is unclear. OBJECTIVE: To conduct a systematic review and meta-analysis of randomized controlled clinical trials (RCTs) assessing associations of structured exercise training regimens (aerobic, resistance, or both) and physical activity advice with or without dietary cointervention on change in hemoglobin A(1c) (HbA(1c)) in type 2 diabetes patients. DATA SOURCES: MEDLINE, Cochrane-CENTRAL, EMBASE, ClinicalTrials.gov, LILACS, and SPORTDiscus databases were searched from January 1980 through February 2011. STUDY SELECTION: RCTs of at least 12 weeks' duration that evaluated the ability of structured exercise training or physical activity advice to lower HbA(1c) levels as compared with a control group in patients with type 2 diabetes. DATA EXTRACTION: Two independent reviewers extracted data and assessed quality of the included studies. DATA SYNTHESIS: Of 4191 articles retrieved, 47 RCTs (8538 patients) were included. Pooled mean differences in HbA(1c) levels between intervention and control groups were calculated using a random-effects model. Overall, structured exercise training (23 studies) was associated with a decline in HbA(1c) level (-0.67%; 95% confidence interval [CI], -0.84% to -0.49%; I(2), 91.3%) compared with control participants. In addition, structured aerobic exercise (-0.73%; 95% CI, -1.06% to -0.40%; I(2), 92.8%), structured resistance training (-0.57%; 95% CI, -1.14% to -0.01%; I(2), 92.5%), and both combined (-0.51%; 95% CI, -0.79% to -0.23%; I(2), 67.5%) were each associated with declines in HbA(1C) levels compared with control participants. Structured exercise durations of more than 150 minutes per week were associated with HbA(1c) reductions of 0.89%, while structured exercise durations of 150 minutes or less per week were associated with HbA(1C) reductions of 0.36%. Overall, interventions of physical activity advice (24 studies) were associated with lower HbA(1c) levels (-0.43%; 95% CI, -0.59% to -0.28%; I(2), 62.9%) compared with control participants. Combined physical activity advice and dietary advice was associated with decreased HbA(1c) (-0.58%; 95% CI, -0.74% to -0.43%; I(2), 57.5%) as compared with control participants. Physical activity advice alone was not associated with HbA(1c) changes. CONCLUSIONS: Structured exercise training that consists of aerobic exercise, resistance training, or both combined is associated with HbA(1c) reduction in patients with type 2 diabetes. Structured exercise training of more than 150 minutes per week is associated with greater HbA(1c) declines than that of 150 minutes or less per week. Physical activity advice is associated with lower HbA(1c), but only when combined with dietary advice.

[Characterization of patients with type 1 diabetes mellitus in southern Brazil: chronic complications and associated factors]. / Caracterização de pacientes com diabetes mellitus tipo 1 do sul do Brasil: complicações crônicas e fatores associados.

OBJECTIVE: To evaluate the prevalence of chronic vascular complications and associated factors in patients with type 1 diabetes mellitus (DM). METHODS: Cross sectional study with type 1 DM patients attending the Endocrine Division, Hospital de Clinicas de Porto Alegre. Patients were evaluated for presence of chronic vascular complications. RESULTS: We evaluated 573 patients, mean age of 33 years. The presence of diabetic retinopathy (DR) was observed in 43.3%, diabetes duration [OR: 1.07, 95% CI: 1.03 to 1.11, P <0001], the presence of diabetic nephropathy (DN) [OR: 3.40; CI 95%: 1.89 to 6.13, P <0001] and hypertension (HPT) [OR: 2.12, 95% CI: 1.16 to 3.87, P = 0014] were associated with DR. The DN was present in 34.5% and was associated with HPT [OR: 1.93, 95% CI: 1.16 to 3.21, P = 0001] and total cholesterol [OR: 1.0, 95% CI: 1.0-1.01, P = 0.05]. Seven patients had macrovascular disease. Only 22% achieved an A1c of <7.0%. HPT was 33% and 48% had levels <130/80 mm Hg and 45% of patients had values for LDL> 100 mg/dl. CONCLUSION: We observed a high prevalence of microvascular complications and HPT. Duration of DM, HPT and presence of DN were associated with DR. HPT and dyslipidemia were associated with DN. Most patients did not meet the desired glycemic control, blood pressure and lipid targets. Greater efforts are needed to intensify the pressure and metabolic control of patients with type 1 DM.

Nutritional therapy and outcomes in underweight critically ill patients.

BACKGROUND & AIMS: Critically ill patients with body mass index (BMI) < 20 kg/m2 have worse outcomes than normal/overweight patients possibly because underweight is a marker of malnutrition. To assess the effects of nutrition therapy in this population during the first week of an ICU stay. METHODS: Prospective, 2-centre, observational study. Nutritional evaluations were performed between days 2 and 3 (first) and between days 5 and 7 (second) of ICU admission. In the first evaluation, patients were divided into non-fed (without nutritional support) and early-fed (those already receiving nutritional support) groups. In the second evaluation, patients were divided according to caloric intake (≥or<20 kcal/kg) and protein intake (≥or<1.3 g of protein/kg). RESULTS: Of the 4236 patients screened and 342 were included in the cohort. Mortality was 58.5% (median 21 [11-38.25] days of follow-up). Unadjusted patient survival was worse in the non-fed group than in the early-fed group (HR 1.66; 95%CI, 1.18 to 2.32). There was no difference in mortality between groups after adjusting for the SOFA score on the day of the evaluation. At the second evaluation, unadjusted analysis showed better in-hospital survival in patients with higher caloric (HR0.58; 95%CI, 0.40 to 0.86) and protein intake (HR0.59; 95%CI, 0.42 to 0.82); there was no association between mortality and caloric or protein intake after adjusting for the SOFA score on the day of the evaluation. CONCLUSION: Nutritional therapy in the first week of ICU stay did not affect vital outcome after adjusting for the SOFA score on the day of the evaluation in underweight critically ill patients. CLINICAL TRIAL REGISTRY: ClinicalTrials.gov number NCT03398343.

Difference in sarcopenia prevalence and associated factors according to 2010 and 2018 European consensus (EWGSOP) in elderly patients with type 2 diabetes mellitus.

OBJECTIVES: The aim of this study was to establish the prevalence of sarcopenia and associated factors in elderly patients with type 2 diabetes mellitus (DM) according to 2010 (EWGSOP1) and 2018 (EWGSOP2) European consensus. DESIGN: Cross-sectional study. PARTICIPANTS: Elderly outpatients ≥60 years with type 2 DM and able to walk were recruited at the DM ambulatory care center of a public hospital in Porto Alegre from 2017 to 2018. MATERIALS AND METHODS: The diagnosis of sarcopenia was performed according to EWGSOP1 and EWGSOP2. Muscle mass (MM) was assessed using bioelectrical impedance (BIA). Muscle strength (MS) was assessed using the handgrip strength (HS) test and physical performance (PP) by timed-up-and-go (TUG) test. RESULTS: We included 242 patients with 68.3 ± 5.6 years, 54% women, 78% white, DM duration 14(8-22) years, BMI 29.5 ± 4.5 kg/m2, and HbA1c 7.8 ± 1.5%. Overall prevalence of sarcopenia was 21%. In EWGSOP1 it was 16.9%. The GLM Poisson model was used to assess sarcopenia. Male sex increased the prevalence of sarcopenia by 33% (3.330 [1.747-6.350]; p < .001), and walking >5401 steps/day had a protective effect of 70% for the prevalence of sarcopenia (0.306 [0.127-0.739]; p = .029). Finally, age had an impact of 6% on prevalence of sarcopenia (1.06 [1.015-1.108]; p = .009) according to EWGSOP1. On the other hand, the prevalence was 7%, women had more sarcopenia (88%), and BMI was lower in the sarcopenic group when defined according to EWGSOP2. CONCLUSIONS: The prevalence of sarcopenia was more than double when comparing EWGSOP1 (16.9%) and EWGSOP2 (7%). We believe that the difference in prevalence is due to modifications in MM and MS criteria. According to EWGSOP1, walking may have protective role in the prevalence of sarcopenia in elderly type 2 DM individuals.

Does bacteriuria interfere with albuminuria measurements of patients with diabetes?

BACKGROUND: Urinary albumin is the main parameter employed to diagnose diabetic nephropathy (DN). The exclusion of bacteriuria has been recommended at the time of DN diagnosis. This approach has been debated and information on this suggestion in patients with diabetes is scarce. The present case-control study was conducted to investigate the interference of bacteriuria in the interpretation of urinary albumin measurements in random urine samples of diabetic patients. METHODS: Urinary albumin concentration (UAC) was measured in random urine samples twice in diabetic patients with and without bacteriuria (> or =10(5) colony-forming units/mL). Cases (n = 81) were defined as patients who had baseline UAC measurement in the presence of bacteriuria and had the second UAC measured in a sterile urine sample. Controls (n = 80) had the two UAC measured in sterile urine specimens. RESULTS: Baseline UAC was not different between case [15.4 (1.5-2148) mg/L] and control groups [14.2 (1.5-1292) mg/L; P = 0.24], nor was the proportion of patients with normo-, micro- and macroalbuminuria. In cases, UAC measurements in the presence of bacteriuria and in sterile urine specimens were not different [15.4 (1.5-2148) versus 13.7 (1.5-2968) mg/L; P = 0.14)], nor was the proportion of normo- (51.9% versus 61.5%), micro- (40.7% versus 32.1%) and macroalbuminuria (7.4% versus 6.4%; P = 0.46). In the control group, UAC values were also not different in the two urine samples: [14.2 (1.5-1292) versus 9.7 (1.5-1049) mg/L, P = 0.22]. CONCLUSIONS: The presence of bacteriuria does not interfere significantly with urinary albumin measurements and its exclusion is not necessary to diagnose DN.

Sources of protein and polyunsaturated fatty acids of the diet and microalbuminuria in type 2 diabetes mellitus.

BACKGROUND: Albuminuria excretion rate above the reference range and below albustix positive proteinuria (20-199 microg/min) is known as microalbuminuria and has been associated with an increased risk of death and progression to renal failure. Besides hyperglicemia and high blood pressure levels, dietary factors can also influence albuminuria. OBJECTIVE: To evaluate possible associations of dietary components (macronutrients and selected foods) with microalbuminuria in type 2 diabetic patients. METHODS: In this cross-sectional study, 119 normoalbuminuric [NORMO; 24-h urinary albumin excretion (UAE) < 20 microg/min; immunoturbidimetry] and 62 microalbuminuric (MICRO; UAE 20-199 microg/min) type 2 diabetic patients, attending the Endocrine Division, Hospital de Clínicas de Porto Alegre (Brazil), without previous dietary counseling, underwent 3-day weighed-diet records, and clinical and laboratory evaluation. RESULTS: MICRO patients consumed more protein (20.5 +/- 4.4 vs. 19.0 +/- 3.5% of total energy; p = 0.01) with a higher intake from animal sources (14.5 +/- 4.7 vs. 12.9 +/- 3.8% of total energy; p = 0.015) than NORMO patients. The intakes of PUFAs (8.6 +/- 2.9 vs. 9.7 +/- 3.3% of total energy; p < 0.03), PUFAs from vegetable sources (7.3 +/- 3.4 vs. 8.6 +/- 3.7% of total energy; p = 0.029), plant oils [0.2 (0.1-0.6) vs. 0.3 (0.1-0.9) mg/kg weight; p = 0.02] and margarines [3.3 (0-75.7) vs. 7.0 (0-51.7) g/day; p = 0.01] were lower in MICRO than in NORMO. In multivariate logistic regression models, adjusted for age, gender, presence of hypertension and fasting plasma glucose, intake of total protein (% of total energy; OR 1.104; 95% CI 1.008-1.208; p = 0.032) was positively associated with microalbuminuria. The intakes of total PUFAs (% of total energy; OR 0.855; 95%CI 0.762-0.961; p = 0.008), PUFAs from vegetable sources (% of total energy; OR 0.874; 95%CI 0.787-0.971; p = 0.012) and plant oils (mg/kg weight; OR 0.036; 95% CI 0.003-0.522; p = 0.015) were negatively associated with microalbuminuria. CONCLUSIONS: In type 2 diabetic patients, the high intake of protein and the low intake of PUFAs, particularly from plant oils, were associated with the presence of microalbuminuria. Reducing protein intake from animal sources and increasing the intake of lipids from vegetable origin might-reduce the risk of microalbuminuria.

Long-term effect of a chicken-based diet versus enalapril on albuminuria in type 2 diabetic patients with microalbuminuria.

OBJECTIVE: In short-term studies, the replacement of red meat in the diet with chicken reduced the urinary albumin excretion rate (UAER) and improved lipid profile in type 2 diabetic patients with diabetic nephropathy. The present study sought to assess these effects over a long-term period, comparing the effects of a chicken-based diet (CD) versus enalapril on renal function and lipid profile in microalbuminuric type 2 diabetic patients. DESIGN: This was a randomized, open-label, controlled clinical trial with a follow-up of 1 year. SETTING: The trial involved outpatients with type 2 diabetes attending a clinic of the Division of Endocrinology at a tertiary-care hospital. PATIENTS: Twenty-eight microalbuminuric patients completed the study and were evaluated. INTERVENTIONS: Patients were randomized to an experimental diet (CD plus active placebo) or to treatment with enalapril (10 mg/day plus usual diet). MAIN OUTCOME MEASURES: The main outcome measure was UAER (according to immunoturbidimetry). Blood pressure, anthropometric indices, and compliance were also evaluated monthly. The glomerular filtration rate ((51)Cr-EDTA), and lipid, glycemic, and nutritional indices, were measured at baseline and quarterly. RESULTS: The UAER was reduced after CD (n = 13; from 62.8 [range, 38.4 to 125.1] to 49.1 [range, 6.2 to 146.5] microg/min; P < .001) and after enalapril (n = 15; from 55.8 [range, 22.6 to 194.3] to 23.1 [range, 4.0 to 104.9] microg/min; P < .001), and this was already significant at month 4. The reduction in UAER after CD (32%; 95% confidence interval, 6.7% to 57.6%) and after enalapril treatment (44.7%; 95% confidence interval, 28.3% to 61.1%; P = .366) were not significantly different. CONCLUSIONS: The CD and the angiotensin-converting enzyme inhibitor enalapril promoted a similar reduction of UAER in patients with type 2 diabetes and microalbuminuria in a 12-month follow-up period.

[Dietary factors and metabolic syndrome]. / Fatores dietéticos e síndrome metabólica.

The role of diet in metabolic syndrome (MS) has been studied regarding each one of its components: obesity, high blood pressure, dyslipidemia, and abnormal glucose metabolism. However, few studies evaluated the effects of diet in the presence of MS as a unique independent disease. The aim of this manuscript was to review the role of dietary factors and dietary recommendations for MS. Recently some studies demonstrated that intake of whole-grain foods were negatively associated with MS. Foods with high glycemic index were positively associated with insulin resistance and the prevalence of MS. Following a Mediterranean-style diet caused a reduction in the number of MS components. Also, the adoption of the DASH diet improved the profile of all MS components. A total daily energy intake to obtain and/or to maintain a desirable weight is recommended for patients with MS. The fat content, especially from saturated fat, and cholesterol must be reduced and the intake of whole-grain foods, fruits, and vegetables must be increased. Probably, dietary fibers have an important role in the management of MS. New studies to evaluate the role of diet in the presence and development of MS are needed.

Effects of individual micronutrients on blood pressure in patients with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials.

To investigate the effects of micronutrients on blood pressure (BP) in patients with type 2 diabetes through a systematic review and meta-analysis, randomized clinical trials (RCTs) of the effects of individual micronutrients on BP in patients with type 2 diabetes were searched in the Medline, Embase, Cochrane, and Clinical Trials.gov databases through April 2016. From the 28,164 studies, 11 RCTs (13 interventions, 723 patients, 54% males) with 3 to 52 weeks of follow-up were classified according to the type of micronutrient intervention: sodium (n = 1), vitamin C (n = 2), vitamin D (n = 7), and magnesium (n = 1). The available data enabled us to perform meta-analyses of vitamins C and D. Vitamin C reduced diastolic BP [WMD -2.88 mmHg (95%CI -5.31, -0.46; P = 0.020)] but not systolic BP [WMD -3.93 mmHg (95%CI -14.78, 6.92; P = 0.478)]. Vitamin D caused a reduction of 4.56 mmHg (WMD; 95%CI -7.65, -1.47; P = 0.004) for systolic BP and 2.44 mm Hg (WMD; 95%CI -3.49, -1.39; P < 0.001) for diastolic BP. In conclusion, vitamin D and possibly vitamin C have beneficial effects on BP in patients with type 2 diabetes. These interventions might represent a novel approach to the treatment of hypertension in these patients.

Plasma glucose and insulin responses after consumption of breakfasts with different sources of soluble fiber in type 2 diabetes patients: a randomized crossover clinical trial.

Background: The amount and quality of carbohydrates are important determinants of plasma glucose after meals. Regarding fiber content, it is unclear whether the intake of soluble fibers from foods or supplements has an equally beneficial effect on lowering postprandial glucose.Objective: The aim of our study was to compare the acute effect of soluble fiber intake from foods or supplements after a common meal on postprandial plasma glucose and plasma insulin in patients with type 2 diabetes (T2D).Design: A randomized crossover clinical trial was conducted in patients with T2D. Patients consumed isocaloric breakfasts (mean ± SD: 369.8 ± 9.4 kcal) with high amounts of fiber from diet food sources (total fiber: 9.7 g; soluble fiber: 5.4 g), high amounts of soluble fiber from guar gum supplement (total fiber: 9.1 g; soluble fiber: 5.4 g), and normal amounts of fiber (total fiber: 2.4 g; soluble fiber: 0.8 g). Primary outcomes were postprandial plasma glucose and insulin (0-180 min). Data were analyzed by repeated measures ANOVA and post hoc Bonferroni test.Results: A total of 19 patients [aged 65.8 ± 7.3 y; median (IQR), 10 (5-9) y of T2D duration; glycated hemoglobin 7.0% ± 0.8%; body mass index (in kg/m2) 28.2 ± 2.9] completed 57 meal tests. After breakfast, the incremental area under the curve (iAUC) for plasma glucose [mg/dL · min; mean (95% CI)] did not differ between high fiber from diet (HFD) [7861 (6257, 9465)] and high fiber from supplement (HFS) [7847 (5605, 10,090)] (P = 1.00) and both were lower than usual fiber (UF) [9527 (7549, 11,504)] (P = 0.014 and P = 0.037, respectively). iAUCs [µIU/mL · min; mean (95% CI)] did not differ (P = 0.877): HFD [3781 (2513, 5050)], HFS [4006 (2711, 5302), and UF [4315 (3027, 5603)].Conclusions: Higher fiber intake was associated with lower postprandial glucose at breakfast, and the intake of soluble fiber from food and supplement had a similar effect in patients with T2D. This trial was registered at clinicaltrials.gov as NCT02204384.