rastreamento para diabetes em hipertensos

USPSTF Recommends Screening for Diabetes in Adults With Elevated Blood Pressure
Posted 09/11/2008
Richard Saitz, MD, MPH, FACP, FASAMAuthor Information
Summary
The U.S. Preventive Services Task Force (USPSTF) has been releasing new and updated guidelines periodically. The USPSTF grades each of its recommendations according to a system described on the USPSTF website.
In 2003, the USPSTF concluded that the evidence was insufficient to recommend screening asymptomatic adults for type 2 diabetes, but it did recommend diabetes screening for adults with hypertension or hyperlipidemia. In updated recommendations, the task force suggests screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or higher. Recommendation: B (the USPSTF recommends that clinicians provide this service). It also concludes that evidence still is insufficient to assess the benefits and harms of diabetes screening in adults with blood pressure lower than 135/80 mm Hg. Recommendation: I (evidence is insufficient to assess the balance of benefits and harms; if the service is offered [e.g., based on clinical considerations], patients should understand that uncertainty exists about benefits and harms).
The USPSTF guideline cites the American Diabetes Association recommendation that measurement of fasting plasma glucose (≥126 mg/dL, repeated for confirmation) be the test of choice for diagnosing diabetes. In an evidence review, the task force identified no studies that showed whether screening asymptomatic individuals for diabetes altered health outcomes. However, fair evidence suggests that lifestyle and pharmacologic interventions can slow progression of prediabetes to type 2 diabetes. Evidence also suggests that lowering blood pressure (even below conventional targets) lowers the occurrence of cardiovascular events among people with diabetes and hypertension. For people with diabetes, but without hypertension, intensive glycemic control attenuates progression of microvascular disease among those identified clinically, but whether early identification of diabetes by screening and early treatment provide a long-term benefit over waiting until clinical diagnosis occurs is unclear. The short-term harms of diabetes screening (e.g., anxiety) are small, although the USPSTF notes that harms associated with screening and labeling large segments of the population as having diabetes might be unknown.
Comment
The American Diabetes Association recommends diabetes screening in middle-aged or older people (>45) and screening in younger people who have risk factors. But recommendations from generalist organizations (e.g., American Academy of Family Physicians diabetes screening guideline) are similar to those of the USPSTF. So, should we screen for diabetes in adults who don´t have blood pressures of 135/80 mm Hg or higher? The best evidence suggests that we should not, unless it will make a difference in management (e.g., in decisions about lipid-lowering therapy) or unless symptoms of diabetes are evident

Adiponectina e Risco de Diabetes em Mulheres

Total and High-Molecular-Weight Adiponectin and Resistin in Relation to the Risk for Type 2 Diabetes in Women Christin Heidemann, DrPH, MSc; Qi Sun, MD, ScD; Rob M. van Dam, PhD; James B. Meigs, MD, MPH; Cuilin Zhang, MD, PhD; Shelley S. Tworoger, PhD; Christos S. Mantzoros, MD, DSc; and Frank B. Hu, MD, PhD
2 September 2008 Volume 149 Issue 5 Pages 307-316
Background: Adiponectin and resistin are recently discovered adipokines that may provide a molecular link between adiposity and type 2 diabetes.
Objective: To evaluate whether total and high-molecular-weight adiponectin and resistin are associated with future risk for type 2 diabetes, independent of obesity and other known diabetes risk factors.
Design: Prospective, nested, case–control study.
Setting: United States.
Participants: 1038 initially healthy women of the Nurses' Health Study who developed type 2 diabetes after blood sampling (1989 to 1990) through 2002 and 1136 matched control participants.
Measurements: Plasma concentrations of total and high-molecular-weight adiponectin and resistin.
Results: In multivariate models including body mass index, higher total and high-molecular-weight adiponectin levels were associated with a substantially lower risk for type 2 diabetes (odds ratio [OR] comparing the highest with the lowest quintiles, 0.17 [95% CI, 0.12 to 0.25] for total adiponectin and 0.10 [CI, 0.06 to 0.15] for high-molecular-weight adiponectin). A higher ratio of high-molecular-weight to total adiponectin was associated with a statistically significantly lower risk even after adjustment for total adiponectin (OR, 0.45 [CI, 0.31 to 0.65]). In the multivariate model without body mass index, higher resistin levels were associated with a higher risk for diabetes (OR, 1.68 [CI, 1.25 to 2.25]), but the association was no longer statistically significant after adjustment for body mass index (OR, 1.28 [CI, 0.93 to 1.76]).
Limitation: The findings apply mainly to white women and could be partly explained by residual confounding from imperfectly measured or unmeasured variables.
Conclusion: Adiponectin is strongly and inversely associated with risk for diabetes, independent of body mass index, whereas resistin is not. The ratio of high-molecular-weight to total adiponectin is related to risk for diabetes independent of total adiponectin, suggesting an important role of the relative proportion of high-molecular-weight adiponectin in diabetes pathogenesis.

Cardiopatia diabética

Diabetic Cardiomyopathy: Insights into Pathogenesis, Diagnostic Challenges, and Therapeutic Options
Ashish Aneja MDa, W.H. Wilson Tang MDb, Sameer Bansilal MDa, Mario J. Garcia MDa and Michael E. Farkouh MD, MSca, ,
aThe Mount Sinai Cardiovascular Institute, New York, NY bSection of Heart Failure, Department of Cardiology, Cleveland Clinic, Ohio
Am J Medicine.
Abstract
Diabetic cardiomyopathy is the presence of myocardial dysfunction in the absence of coronary artery disease and hypertension. Hyperglycemia seems to be central to the pathogenesis of diabetic cardiomyopathy and to trigger a series of maladaptive stimuli that result in myocardial fibrosis and collagen deposition. These processes are thought to be responsible for altered myocardial relaxation characteristics and manifest as diastolic dysfunction on imaging. Sophisticated imaging technologies also have permitted the detection of subtle systolic dysfunction in the diabetic myocardium. In the early stages, these changes appear reversible with tight metabolic control, but as the pathologic processes become organized, the changes are irreversible and contribute to an excess risk of heart failure among diabetic patients independently of common comorbidities, such as coronary artery disease and hypertension. Therapeutic agents specifically targeting processes that lead to these pathophysiologic changes are in the early stages of development. Although glycemic control and early administration of neurohormonal antagonists remain the cornerstones of therapeutic approaches, newer treatment targets are currently being explored.

Ocupação e Diabetes

Occupation-Related Differences in the Prevalence of Metabolic Syndrome

Miguel-Angel Sánchez-Chaparro, MD1,2, Eva Calvo-Bonacho, MD1, Arturo González-Quintela, MD3, Carlos Fernández-Labandera, MD1, Martha Cabrera, MD1, Juan-Carlos Sáinz, MD1, Ana Fernández-Meseguer, MD1, José R. Banegas, MD4, Luis-Miguel Ruilope, MD5, Pedro Valdivielso, MD2, Javier Román-García, MD1 on behalf of the Ibermutuamur Cardiovascular Risk Assessment (ICARIA) Study Group
miguelangelsanchez@ibermutuamur.es

Diabetes Care, 08/29/08
OBJECTIVE—To investigate the prevalence of metabolic syndrome in the Spanish working population and determine how the prevalence varies according to occupation and sex.
RESEARCH DESIGN AND METHODS—This was a cross-sectional study of 259,014 workers (mean age 36.4 years, range [16–74]; 72.9% male) who underwent a routine medical checkup. The Adult Treatment Panel III (2001) definition for metabolic syndrome was used.
RESULTS—The prevalence of metabolic syndrome was 11.6% (95% CI 11.5–11.7) in male subjects and 4.1% (4.0–4.2) in female subjects and increased with age. The prevalence of metabolic syndrome varied in the different categories of occupational activity depending on the sex considered. Among female subjects, the age-adjusted prevalence of metabolic syndrome was higher in blue-collar than in white-collar workers, but this difference was not evident among male workers.
CONCLUSIONS—The prevalence of metabolic syndrome varies in the different categories of occupational activity in the Spanish working population. This variation also depends on sex

Oxidação, diabetes, doença coronariana

Oxidation, Type 2 Diabetes, and Coronary Heart Disease: A Complex Interaction
Findings from a population-based study.

Saverio Stranges, MD, PHD1,2, Joan M. Dorn, PHD2, Richard P. Donahue, PHD2, Richard W. Browne, PHD3, Jo L. Freudenheim, PHD2, Kathleen M. Hovey, MSC2 and Maurizio Trevisan, MD, MSC2
OBJECTIVE—The purpose of this study was to analyze the interrelationship among oxidation, myocardial infarction (MI), and type 2 diabetes in a population-based case-control study of MI.
RESEARCH DESIGN AND METHODS—Participants were 1,709 individuals from western New York: 257 women and men with incident MI and 1,452 healthy control subjects (aged 35–70 years). Lipid peroxidation was measured by plasma levels of thiobarbituric acid reactive substances (TBARS). History of type 2 diabetes was determined by self-reported history of medical diagnosis.
RESULTS—In multivariate analyses, there was no significant difference in TBARS levels between case and control subjects in both sexes. In subgroup analyses by diabetes status, diabetic subjects, regardless of MI status, exhibited significantly higher TBARS values than nondiabetic subjects. For diabetic women, TBARS values were 1.84 and 1.83 nmol/ml for case and control subjects, respectively. Values for nondiabetic women were 1.29 and 1.31 nmol/ml, respectively. In diabetic men, values were 1.65 and 1.97 nmol/ml for case and control subjects, respectively. Values for nondiabetic men were 1.36 and 1.36 nmol/ml, respectively.
CONCLUSIONS—Whereas type 2 diabetes may be an important correlate of lipid peroxidation, clinical coronary heart disease may not.

Diabetes e Linfoma

American Journal of Epidemiology 2008 168(5):471-480; doi:10.1093/aje/kwn160
Type 2 Diabetes Mellitus and Risk of Non-Hodgkin Lymphoma: A Systematic Review and Meta-Analysis.
(e-mail: chun.r.chao@kp.org)
for publication February 19, 2008. Accepted for publication May 8, 2008.
Type 2 diabetes mellitus is associated with altered immune function and chronic inflammation. Both of these immune conditions are implicated in the pathogenesis of non-Hodgkin lymphoma. The authors performed a systematic review to summarize findings from the current literature on the association between history of type 2 diabetes mellitus and risk of non-Hodgkin lymphoma. Ten case-control studies and three prospective cohort studies were included in this review. Meta-analysis found that a history of type 2 diabetes mellitus was positively associated with overall non-Hodgkin lymphoma risk. However, there was significant heterogeneity between studies. Study design was an important source of heterogeneity. The rate ratio between type 2 diabetes mellitus and non-Hodgkin lymphoma was found to be 1.18 (95% confidence interval: 0.99, 1.42) among case-control studies and 1.79 (95% confidence interval: 1.30, 2.47) among the prospective cohort studies. Weaknesses were identified in some of the included studies in the areas of case and control selection, measurement of covariates and non-Hodgkin lymphoma, and confounding control. Although a positive association between type 2 diabetes mellitus and risk of non-Hodgkin lymphoma was suggested, the evidence is inconclusive because of methodological limitations of the included case-control studies. More prospective studies with improved control of confounding are needed to confirm these findings.
diabetes mellitus; diabetes mellitus, type 2; lymphoma; lymphoma, non-Hodgkin; meta-analysis

Arsênico e diabetes

Arsenic Exposure and Prevalence of Type 2 Diabetes in US Adults
Ana Navas-Acien, MD, PhD; Ellen K. Silbergeld, PhD; Roberto Pastor-Barriuso, PhD; Eliseo Guallar, MD, DrPH
JAMA. 2008;300(7):814-822.
Context High chronic exposure to inorganic arsenic in drinking water has been related to diabetes development, but the effect of exposure to low to moderate levels of inorganic arsenic on diabetes risk is unknown. In contrast, arsenobetaine, an organic arsenic compound derived from seafood intake, is considered nontoxic.
Objective To investigate the association of arsenic exposure, as measured in urine, with the prevalence of type 2 diabetes in a representative sample of US adults.
Design, Setting, and Participants Cross-sectional study in 788 adults aged 20 years or older who participated in the 2003-2004 National Health and Nutrition Examination Survey (NHANES) and had urine arsenic determinations.
Main Outcome Measure Prevalence of type 2 diabetes across intake of arsenic.
Results The median urine levels of total arsenic, dimethylarsinate, and arsenobetaine were 7.1, 3.0, and 0.9 µg/L, respectively. The prevalence of type 2 diabetes was 7.7%. After adjustment for diabetes risk factors and markers of seafood intake, participants with type 2 diabetes had a 26% higher level of total arsenic (95% confidence interval [CI], 2.0%-56.0%) and a nonsignificant 10% higher level of dimethylarsinate (95% CI, –8.0% to 33.0%) than participants without type 2 diabetes, and levels of arsenobetaine were similar to those of participants without type 2 diabetes. After similar adjustment, the odds ratios for type 2 diabetes comparing participants at the 80th vs the 20th percentiles were 3.58 for the level of total arsenic (95% CI, 1.18-10.83), 1.57 for dimethylarsinate (95% CI, 0.89-2.76), and 0.69 for arsenobetaine (95% CI, 0.33-1.48).
Conclusions After adjustment for biomarkers of seafood intake, total urine arsenic was associated with increased prevalence of type 2 diabetes. This finding supports the hypothesis that low levels of exposure to inorganic arsenic in drinking water, a widespread exposure worldwide, may play a role in diabetes prevalence. Prospective studies in populations exposed to a range of inorganic arsenic levels are needed to establish whether this association is causal.

Hemoglobina glicada ou glicemia: ADAG study

A1C or Average Glucose: Take your pickThe results of the A1C-Derived Average Glucose study (ADAG), published in Diabetes Care this month, have affirmed the existence of a linear relationship between A1C and average blood glucose levels. Prior studies using limited numbers of meter glucose readings primarily in type 1 Caucasian populations had been used in the past to estimate average glucose. The international ADAG study clarified the very close linkage using about 2700 glucose readings per subject per A1C measurement, and verified that the relationship holds in people with type 1 and type 2 diabetes, of all ages, of both genders, and across ethnic/racial groups. The “new numbers” are somewhat different than those in the old tables of A1C vs. average glucose.In light of the study results, health care providers can confidently report A1C results to patients using the same units (mg/dl or mmol/l) that patients see routinely in blood glucose measurements. For more information about the ADAG study, a table of A1C and the corresponding estimated average glucose, an eAG calculator, and other materials, go to http://professional.diabetes.org/glucosecalculator.aspx

Hemoglobina glicada, internação, mortalidade na insuficiência cardíaca

The Hemoglobin A1c Level as a Progressive Risk Factor for Cardiovascular Death, Hospitalization for Heart Failure, or Death in Patients With Chronic Heart Failure. An Analysis of the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) Program
Hertzel C. Gerstein, MD, MSc; Karl Swedberg, MD, PhD; Jonas Carlsson, MSc; John J. V. McMurray, MD; Eric L. Michelson, MD; Bertil Olofsson, PhD; Marc A. Pfeffer, MD, PhD; Salim Yusuf, DPhil; for the CHARM Program Investigators
Arch Intern Med. 2008;168(15):1699-1704.
Background A progressive relationship between hemoglobin A1c (HbA1c) levels and cardiovascular (CV) events has been observed in persons with and without diabetes. To our knowledge, the nature of such a relationship in patients with symptomatic chronic heart failure (HF) has not been studied.
Methods A total of 2412 participants (907 with prior diabetes) in the Candesartan in Heart failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program with at least 1 HbA1c level were followed up for a median of 34 months. The incidence of the primary outcome (CV death or HF hospitalization), CV death, and total mortality was calculated according to eighths of the usual HbA1c level ranging from 5.8% or less to greater than 8.6%. Adjusted and unadjusted hazard ratios per 1% rise in HbA1c levels were also calculated.
Results A total of 99.6% of eligible participants were followed up until they developed an outcome or the study finished. The risk of the primary composite outcome, CV death, hospitalization for worsening HF, and total mortality rose progressively with higher levels of usual HbA1c (P for trend <.001). After age and sex were adjusted for, hazards of these outcomes per 1% higher HbA1c level were 1.25 (95% confidence interval [CI ],1.20-1.31), 1.24 (95% CI, 1.17-1.31), 1.25 (95% CI, 1.19-1.31), and 1.22 (95% CI, 1.16-1.29), respectively. This relationship was evident in patients with and without diabetes and with reduced or preserved ejection fraction and persisted after adjustment for diabetes, other risk factors, and allocation to candesartan.
Conclusion In diabetic and nondiabetic patients with symptomatic chronic HF, the HbA1c level is an independent progressive risk factor for CV death, hospitalization for HF, and total mortality.

Diabetes e Cognição

Association of Duration and Severity of Diabetes Mellitus With Mild Cognitive Impairment
Rosebud O. Roberts, MBChB, MS; Yonas E. Geda, MD; David S. Knopman, MD; Teresa J. H. Christianson, BS; V. Shane Pankratz, PhD; Bradley F. Boeve, MD; Adrian Vella, MD; Walter A. Rocca, MD, MPH; Ronald C. Petersen, MD
Arch Neurol. 2008;65(8):1066-1073.
Background It remains unknown whether diabetes mellitus (DM) is a risk factor for mild cognitive impairment (MCI).
Objective To investigate the association of DM with MCI using a population-based case-control design.
Design Population-based case-control study.
Setting Academic research.
Participants Our study was conducted, among subjects aged 70 to 89 years on October 1, 2004, who were randomly selected from the Olmsted County (Minnesota) population.
Main Outcome Measure We administered to all participants a neurologic examination, the Clinical Dementia Rating Scale, and a neuropsychological evaluation (including 9 tests in 4 cognitive domains) to diagnose normal cognition, MCI, or dementia. We assessed history of DM, DM treatment, and DM complications by interview, and we measured fasting blood glucose levels. History of DM was also confirmed using a medical records linkage system.
Results We compared 329 subjects having MCI with 1640 subjects free of MCI and dementia. The frequency of DM was similar in subjects with MCI (20.1%) and in subjects without MCI (17.7%) (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.85-1.57). However, MCI was associated with onset of DM before age 65 years (OR, 2.20; 95% CI, 1.29-3.73), DM duration of 10 years or longer (OR, 1.76; 95% CI, 1.16-2.68), treatment with insulin (OR, 2.01; 95% CI, 1.22-3.31), and the presence of DM complications (OR, 1.80; 95% CI, 1.13-2.89) after adjustment for age, sex, and education. Analyses using alternative definitions of DM yielded consistent findings.
Conclusion These findings suggest an association of MCI with earlier onset, longer duration, and greater severity of DM.

Aculturação e Diabetes

Diabetes Care 31:1621-1628, 2008 DOI: 10.2337/dc07-2182© 2008 by the American Diabetes Association of Acculturation Levels and Prevalence of Diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA)

Namratha R. Kandula, MD, MPH1, Ana V. Diez-Roux, MD, PHD2, Cheeling Chan, MS3, Martha L. Daviglus, MD, PHD3, Sharon A. Jackson, PHD4, Hanyu Ni, PHD, MPH5 and Pamela J. Schreiner, MS, PHD6
OBJECTIVE—The prevalence of type 2 diabetes among Hispanic and Asian Americans is increasing. These groups are largely comprised of immigrants who may be undergoing behavioral and lifestyle changes associated with development of diabetes. We studied the association between acculturation and diabetes in a population sample of 708 Mexican-origin Hispanics, 547 non–Mexican-origin Hispanics, and 737 Chinese participants in the Multi-Ethnic Study of Atherosclerosis (MESA).
RESEARCH DESIGN AND METHODS—Diabetes was defined as fasting glucose 126 mg/dl and/or use of antidiabetic medications. An acculturation score was calculated for all participants using nativity, years living in the U.S., and language spoken at home. The score ranged from 0 to 5 (0 = least acculturated and 5 = most acculturated). Relative risk regression was used to estimate the association between acculturation and diabetes.
RESULTS—For non–Mexican-origin Hispanics, the prevalence of diabetes was positively associated with acculturation score, after adjustment for sociodemographics. The prevalence of diabetes was significantly higher among the most acculturated versus the least acculturated non–Mexican-origin Hispanics (prevalence ratio 2.49 [95% CI 1.14–5.44]); the higher the acculturation score is, the higher the prevalence of diabetes (P for trend 0.059). This relationship between acculturation and diabetes was partly attenuated after adjustment for BMI or diet. Diabetes prevalence was not related to acculturation among Chinese or Mexican-origin Hispanics.
CONCLUSIONS—Among non–Mexican-origin Hispanics in MESA, greater acculturation is associated with higher diabetes prevalence. The relation is at least partly mediated by BMI and diet. Acculturation is a factor that should be considered when predictors of diabetes in racial/ethnic groups are examined

Impacto da Prevenção na Redução da Doença Cardiovascular

(Circulation. 2008;118:576-585) coraçaodobrasil/estrategiasdeprevençao

The Impact of Prevention on Reducing the Burden of Cardiovascular Disease.

Richard Kahn, PhD; Rose Marie Robertson, MD, FAHA; Robert Smith, PhD; David Eddy, MD, PhD
E-mail rkahn@diabetes.org
Objective— Cardiovascular disease (CVD) is prevalent and expensive. While many interventions are recommended to prevent CVD, the potential effects of a comprehensive set of prevention activities on CVD morbidity, mortality, and costs have never been evaluated. We therefore determined the effects of 11 nationally recommended prevention activities on CVD-related morbidity, mortality, and costs in the United States.
Research Design and Methods— We used person-specific data from a representative sample of the US population (National Health and Nutrition Education Survey IV) to determine the number and characteristics of adults aged 20-80 years in the United States today who are candidates for different prevention activities related to CVD. We used the Archimedes model to create a simulated population that matched the real US population, person by person. We then used the model to simulate a series of clinical trials that examined the effects over the next 30 years of applying each prevention activity one by one, or altogether, to those who are candidates for the various activities and compared the health outcomes, quality of life, and direct medical costs to current levels of prevention and care. We did this under two sets of assumptions about performance and compliance: 100% success for each activity and lower levels of success considered aggressive but still feasible.
Results— Approximately 78% of adults aged 20-80 years alive today in the United States are candidates for at least one prevention activity. If everyone received the activities for which they are eligible, myocardial infarctions and strokes would be reduced by 63% and 31%, respectively. If more feasible levels of performance are assumed, myocardial infarctions and strokes would be reduced 36% and 20%, respectively. Implementation of all prevention activities would add 221 million life-years and 244 million quality-adjusted life-years to the US adult population over the coming 30 years, or an average of 1.3 years of life expectancy for all adults. Of the specific prevention activities, the greatest benefits to the US population come from providing aspirin to high-risk individuals, controlling pre-diabetes, weight reduction in obese individuals, lowering blood pressure in people with diabetes, and lowering LDL cholesterol in people with existing coronary artery disease (CAD). As currently delivered and at current prices, most prevention activities are expensive when considering direct medical costs; smoking cessation is the only prevention strategy that is cost-saving over 30 years.
Conclusions— Aggressive application of nationally recommended prevention activities could prevent a high proportion of the CAD events and strokes that are otherwise expected to occur in adults in the United States today. However, as they are currently delivered, most of the prevention activities will substantially increase costs. If preventive strategies are to achieve their full potential, ways must be found to reduce the costs and deliver prevention activities more efficiently

Colesevelam e Complicações do Diabetes

Efficacy and Safety of Colesevelam in Patients With Type 2 Diabetes Mellitus and Inadequate Glycemic Control Receiving Insulin-Based Therapy . Ronald B. Goldberg, MD; Vivian A. Fonseca, MD; Kenneth E. Truitt, MD; Michael R. Jones, PhD Arch Intern Med. 2008;168(14):1531-1540.
Background Poor glycemic control is a risk factor for microvascular complications in patients with type 2 diabetes mellitus. Achieving glycemic control safely with insulin therapy can be challenging.
Methods A prospective, 16-week, multicenter, randomized, double-blind, placebo-controlled, parallel-group study conducted at 50 sites in the United States and 1 site in Mexico between August 12, 2004, and December 28, 2005. Subjects had type 2 diabetes mellitus that was not adequately controlled (glycated hemoglobin level, 7.5%-9.5%, inclusive) receiving insulin therapy alone or in combination with oral antidiabetes agents. In total 287 subjects (52% men; mean age, 57 years; with a mean baseline glycated hemoglobin level of 8.3%) were randomized: 147 to receive colesevelam hydrochloride, 3.75 g/d, and 140 to receive placebo.
Results Using the least squares method, the mean (SE) change in glycated hemoglobin level from baseline to week 16 was –0.41% (0.07%) for the colesevelam-treated group and 0.09% (0.07%) for the placebo group (treatment difference, –0.50% [0.09%]; 95% confidence interval, –0.68% to –0.32%; P < .001). Consistent reductions in fasting plasma glucose and fructosamine levels, glycemic-control response rate, and lipid control measures were observed with colesevelam. As expected, the colesevelam-treated group had a 12.8% reduction in low-density lipoprotein cholesterol concentration relative to placebo (P < .001). Of recipients of colesevelam and placebo, respectively, 30 and 26 discontinued the study prematurely; 7 and 9 withdrew because of protocol-specified hyperglycemia, and 10 and 4 withdrew because of adverse events. Both treatments were generally well tolerated.
Conclusions Colesevelam treatment seems to be safe and effective for improving glycemic control and lipid management in patients with type 2 diabetes mellitus receiving insulin-based therapy, and it may provide a novel treatment for improving dual cardiovascular risk factors

Padrão de Dieta, Perda de Peso e Incidência de Diabetes

Low-Fat Dietary Pattern and Risk of Treated Diabetes Mellitus in Postmenopausal Women The Women's Health Initiative Randomized Controlled Dietary Modification Trial Lesley F. Tinker, PhD; Denise E. Bonds, MD, MPH; Karen L. Margolis, MD, MPH; JoAnn E. Manson, MD, DrPH; Barbara V. Howard, PhD; Joseph Larson, MS; Michael G. Perri, PhD; Shirley A. A. Beresford, PhD; Jennifer G. Robinson, MD, MPH; Beatriz Rodríguez, MD, PhD; Monika M. Safford, MD; Nanette K. Wenger, MD; Victor J. Stevens, PhD; Linda M. Parker, DSc Arch Intern Med. 2008;168(14):1500-1511.
Background Decreased fat intake with weight loss and increased exercise may reduce the risk of diabetes mellitus in persons with impaired glucose tolerance. This study was undertaken to assess the effects of a low-fat dietary pattern on incidence of treated diabetes among generally healthy postmenopausal women.
Methods A randomized controlled trial was conducted at 40 US clinical centers from 1993 to 2005, including 48 835 postmenopausal women aged 50 to 79 years. Women were randomly assigned to a usual-diet comparison group (n = 29 294 [60.0%]) or an intervention group with a 20% low-fat dietary pattern with increased vegetables, fruits, and grains (n = 19 541 [40.0%]). Self-reported incident diabetes treated with oral agents or insulin was assessed.
Results Incident treated diabetes was reported by 1303 intervention participants (7.1%) and 2039 comparison participants (7.4%) (hazard ratio, 0.96; 95% confidence interval, 0.90-1.03; P = .25). Weight loss occurred in the intervention group, with a difference between intervention and comparison groups of 1.9 kg after 7.5 years (P < .001). Subgroup analysis suggested that greater decreases in percentage of energy from total fat reduced diabetes risk (P for trend = .04), which was not statistically significant after adjusting for weight loss.
Conclusions A low-fat dietary pattern among generally healthy postmenopausal women showed no evidence of reducing diabetes risk after 8.1 years. Trends toward reduced incidence were greater with greater decreases in total fat intake and weight loss. Weight loss, rather than macronutrient composition, may be the dominant predictor of reduced risk of diabetes.

Ingestão de frutas (vitamina C) e Incidência de Diabetes

Plasma Vitamin C Level, Fruit and Vegetable Consumption, and the Risk of New-Onset Type 2 Diabetes Mellitus
The European Prospective Investigation of Cancer–Norfolk Prospective Study
Anne-Helen Harding, PhD; Nicholas J. Wareham, FRCP, PhD; Sheila A. Bingham, PhD; KayTee Khaw, FRCP; Robert Luben, BSc; Ailsa Welch, PhD; Nita G. Forouhi, FFPH, PhD
Arch Intern Med. 2008;168(14):1493-1499.
Background Epidemiologic studies suggest that greater consumption of fruit and vegetables may decrease the risk of diabetes mellitus, but the evidence is limited and inconclusive. Plasma vitamin C level is a good biomarker of fruit and vegetable intake, but, to our knowledge, no prospective studies have examined its association with diabetes risk. This study aims to examine whether fruit and vegetable intake and plasma vitamin C level are associated with the risk of incident type 2 diabetes.
Methods We administered a semiquantitative food frequency questionnaire to men and women from a population-based prospective cohort (European Prospective Investigation of Cancer–Norfolk) study who were aged 40 to 75 years at baseline (1993-1997) when plasma vitamin C level was determined and habitual intake of fruit and vegetables was assessed. During 12 years of follow-up between February 1993 and the end of December 2005, 735 clinically incident cases of diabetes were identified among 21 831 healthy individuals. We report the odds ratios of diabetes associated with sex-specific quintiles of fruit and vegetable intake and of plasma vitamin C levels.
Results A strong inverse association was found between plasma vitamin C level and diabetes risk. The odds ratio of diabetes in the top quintile of plasma vitamin C was 0.38 (95% confidence interval, 0.28-0.52) in a model adjusted for demographic, lifestyle, and anthropometric variables. In a similarly adjusted model, the odds ratio of diabetes in the top quintile of fruit and vegetable consumption was 0.78 (95% confidence interval, 0.60-1.00).
Conclusions Higher plasma vitamin C level and, to a lesser degree, fruit and vegetable intake were associated with a substantially decreased risk of diabetes. Our findings highlight a potentially important public health message on the benefits of a diet rich in fruit and vegetables for the prevention of diabetes.

Suco de frutas e Incidência de Diabetes

Sugar-Sweetened Beverages and Incidence of Type 2 Diabetes Mellitus in African American Women Julie R. Palmer, ScD; Deborah A. Boggs, MS; Supriya Krishnan, DSc; Frank B. Hu, MD; Martha Singer, MPH; Lynn Rosenberg, ScD Arch Intern Med. 2008;168(14):1487-1492.
Background Type 2 diabetes mellitus is an increasingly serious health problem among African American women. Consumption of sugar-sweetened drinks was associated with an increased risk of diabetes in 2 studies but not in a third; however, to our knowledge, no data are available on African Americans regarding this issue. Our objective was to examine the association between consumption of sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes mellitus in African American women.
Methods A prospective follow-up study of 59 000 African American women has been in progress since 1995. Participants reported on food and beverage consumption in 1995 and 2001. Biennial follow-up questionnaires ascertained new diagnoses of type 2 diabetes. The present analyses included 43 960 women who gave complete dietary and weight information and were free from diabetes at baseline. We identified 2713 incident cases of type 2 diabetes mellitus during 338 884 person-years of follow-up. The main outcome measure was the incidence of type 2 diabetes mellitus.
Results The incidence of type 2 diabetes mellitus was higher with higher intake of both sugar-sweetened soft drinks and fruit drinks. After adjustment for confounding variables including other dietary factors, the incidence rate ratio for 2 or more soft drinks per day was 1.24 (95% confidence interval, 1.06-1.45). For fruit drinks, the comparable incidence rate ratio was 1.31 (95% confidence interval, 1.13-1.52). The association of diabetes with soft drink consumption was almost entirely mediated by body mass index, whereas the association with fruit drink consumption was independent of body mass index.
Conclusions Regular consumption of sugar-sweetened soft drinks and fruit drinks is associated with an increased risk of type 2 diabetes mellitus in African American women. While there has been increasing public awareness of the adverse health effects of soft drinks, little attention has been given to fruit drinks, which are often marketed as a healthier alternative to soft drinks.

TINSAL-T2D

Diabetes Care. 2008 Feb;31(2):289-94.

Salsalate improves glycemia and inflammatory parameters in obese young adults.
Fleischman A, Shoelson SE, Bernier R, Goldfine AB.
Harvard Medical School, Boston, Massachusetts, USA.
OBJECTIVE: Sedentary lifestyle and a western diet promote subacute-chronic inflammation, obesity, and subsequently dysglycemia. The aim of the current study was to evaluate the efficacy of the anti-inflammatory drug salsalate to improve glycemia by reducing systemic inflammation in obese adults at risk for the development of type 2 diabetes. RESEARCH DESIGN AND METHODS: In a double-masked, placebo controlled trial, we evaluated 20 obese nondiabetic adults at baseline and after 1 month of salsalate or placebo. RESULTS: Compared with placebo, salsalate reduced fasting glucose 13% (P <>

Targeting INflammation Using SALsalate in Type 2 Diabetes (TINSAL-T2D)This study is ongoing, but not recruiting participants.
Sponsors and Collaborators:
Joslin Diabetes CenterNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Information provided by:
Joslin Diabetes Center
ClinicalTrials.gov Identifier:
NCT00392678

Tratamento do diabetes em debate: estréia "Clínica e Epidemiologia"

Anunciou-se agora a suspensão do ensaio clínico em diabéticos, ACCORD.

NEJM publicou os resultados do Steno-2 realizado na Dinamarca.

O debate é muito interessante: o controle de glicemia é realmente o que vale para prevenir a doença cardiovascular no diabético tipo 2. Ou somente reduzir a pressão e elevar o HDL-colesterol já basta(m)?

Leia você mesmo, o resultado do Steno-2, o delineamento e a notícia de suspensão do Accord nas páginas de "Clínica e Epidemiologia".

Avandia: posição Sociedade Brasileira de Diabetes e da de Endocrinologia e Metabologia.

Comparem o texto abaixo - transcrito na íntegra - com o que já foi noticiado nesse blogue sobre o tema Avandia.

Rosiglitazona e Risco de Infarto do Miocárdio e Morte Cardiovascular
Diretoria SBD e SBEM - 25/05/2007 12:02 Posição conjunta da SBD e da SBEM

No dia 21 de maio corrente foi publicada uma meta-análise no The New England Journal of Medicine intitulado "Effect of Rosiglitazone on the Risk of Myocardial Infarction and Death from Cardiovascular Causes”. As conclusões da análise deste estudo sugerem que a Rosiglitazona, droga utilizada para o tratamento oral do Diabetes Mellitus tipo 2, aumenta o risco de Infarto do Miocárdio e morte por causa cardiovascular. Os autores, Steven Nissen e Kathy Wolski, cometam a dificuldade destas conclusões pois não tiveram acesso aos dados completos dos pacientes. O editorial da NEJM, publicado no mesmo dia, segue nesta mesma direção. A American Diabetes Association, American College of Cardiology e American Heart Association se posicionaram em conjunto e comentam que embora o risco pareça baixo é necessário considerar cautelosamente estes dados. A FDA (Food and Drug Administration), em seu posicionamento, liberado recentemente em nota, se preocupa com os dados, mas que os resultados publicados e não-publicados em estudos de longo prazo questionam estes achados. A FDA comenta, ainda, que os dados carecem de significado clínico e que, considerando o risco de mudança de medicação para pacientes diabéticos, afirma que a agência não está solicitando ao fabricante (GlaxoSmithKline) que estabeleça qualquer ação neste momento. O estudo RECORD, desenhado especificamente para analisar os desfechos cardiovasculares, trará, após sua análise completa, dados definitivos acerca do tema. A SBD e a SBEM (Sociedade Brasileira de Endocrinologia e Metabologia) recomendam aos seus associados que discutam com seus pacientes os resultados e eventuais mudanças de conduta. Reafirmam que para o tratamento do diabetes é necessária a participação efetiva do médico e do paciente na busca do controle estrito da glicemia e dos outros fatores de risco cardiovasculares associados.

* Os Drs. Marcos Tambascia e Ruy Lyra são os presidentes, respectivamente, da Sociedade Brasileira de Diabetes e Sociedade Brasileira de Endocrinologia e Metabologia

FDA também "acha" que Avandia aumenta o risco cardiovascular.

Voltando ao tema "Avandia". Despacho dessa tarde (25/05) da Reuters é reproduzido abaixo na íntegra para revelar a absoluta confusão reinante no órgão regulador americano. Para quem acha há despreparados e incompetentes somente abaixo do Equador, ao menos um consolo. Entidades científicas estão pedindo avaliação por pares sem conflito de interesse com o tema.

FDA review also shows Glaxo diabetes drug risk

WASHINGTON (Reuters) - A U.S. Food and Drug Administration preliminary analysis found a level of heart-attack risk with GlaxoSmithKline Plc's diabetes drug Avandia similar to what was reported in a study earlier this week, the agency confirmed on Friday.
FDA spokeswoman Julie Zawisza stressed that other data conflicted with that finding, and officials still were weighing whether to take any action.
A Cleveland Clinic analysis released Monday said the drug increased the chances of having a heart attack by 43 percent. Speaking on the Senate floor late on Thursday, Republican Sen. Charles Grassley of Iowa said preliminary findings from an FDA analysis of Glaxo's clinical trials found a 40 percent increased risk, while the company puts the figure at about 30 percent. "Those numbers seem like a high enough threshold to me for the FDA to warn the American people of the possibility of a problem," Grassley said. The FDA's Zawisza confirmed that the agency's evaluation of Glaxo's clinical trials found a higher risk of about 40 percent. But she said "this alone is not conclusive" and officials are trying to reconcile that with clinical trial data that did not show an elevated risk. "We don't have the scientific data upon which to make any conclusions or decisions yet," she said via e-mail.
If a 40 percent risk were confirmed, it would mean that a person with diabetes who does not take the drug has about a 1 percent risk of having a heart attack or other, similar problem, while someone who takes the drug would have a 1.4 percent risk, Zawisza said.Grassley also said some FDA scientists recommended months ago that Avandia carry the strongest possible warning, a "black-box," about heart-attack risk. Zawisza said she could not comment on "ongoing regulatory matters" such as whether staff had recommended a black box. Grassley also said it had been reported to him that the incidence of heart attacks with Avandia could be as many as 60,000 to 100,000 from 1999 to 2006. He did not cite the source of the numbers, and experts say it is difficult to make such estimates across a broad population. The FDA's Zawisza said a relationship between Avandia and that number of events had not been established. "We don't have data to support such a conclusion," she said. GlaxoSmithKline spokeswoman Mary Anne Rhyne said Grassley's use of the estimate was "irresponsible." "They are extrapolations of extrapolations, and do not reflect reality. If these numbers were true, we would have seen them clearly" in long-term studies and databases of real-world use, she said. Glaxo has said Avandia's cardiovascular safety is similar to other oral diabetic drugs, and the benefits of treatment outweigh the risks. The FDA is continuing to review data on Avandia and plans to ask an advisory panel of outside experts for input. The Union of Concerned Scientists and several consumer groups wrote the FDA on Friday urging officials to chose advisers with no financial ties to Glaxo for the past 36 months. "By staffing the Avandia advisory committee with scientists from diverse specialties who are non-conflicted, you will send a message that the FDA cares about avoiding conflicts of interest and evaluating drugs on the basis of unbiased scientific findings," the letter said.