NRS-2002 e circunferência da panturrilha como preditores de dinapenia em pacientes idosos hospitalizados

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Hipotensão ortostática, quedas e mortalidade intra-hospitalar entre pacientes idosos com e sem diabetes tipo 2

A hipotensão ortostática (HO) é definida como a redução sustentada de, pelo menos, 20 mmHg da pressão arterial sistólica (PAS) e/ou de 10 mmHg da pressão arterial diastólica (PAD) dentro de três minutos após a adoção da ortostase. A queda pressórica diminui o fluxo sanguíneo cerebral e pode provocar sintomas como tonturas, náuseas, alterações visuais e até mesmo síncope. A HO é muitas vezes assintomática e tem relação com a disfunção autonômica primária (como a insuficiência autonômica pura e a insuficiência autonômica na doença de Parkinson) ou secundária (como a causada por polineuropatias associadas a presença de diabetes, doenças autoimunes ou uso de fármacos), além de outros fatores não neurogênicos, como a hipovolemia, função cardíaca deprimida e idade avançada. Estudos evidenciam a associação positiva entre HO e quedas, independente da população e desenho do estudo, qualidade, definição de HO e método de medida da pressão arterial. O Diabetes tipo 2 (DM2) é uma causa conhecida de HO e idade avançada é um fator predisponente. O avanço da idade traz consequências como redução da sensibilidade dos receptores responsáveis pela atenuação da resposta de frequência cardíaca e declínio da função do sistema nervoso autonômico. Evidências mostram que os pacientes com DM2 caem com mais frequência quando comparados aos indivíduos sem diabetes e o fato também pode ser explicado pelo número de medicamentos utilizados. Diante do exposto acima, o objetivo dessa dissertação foi avaliar a associação de quedas e mortalidade intra-hospitalar com a presença de HO em pacientes com DM2 e identificar se a HO avaliada em 1 minuto ou em 3 minutos pode predizer quedas e mortalidade. Para tanto, utilizamos uma análise secundária de um estudo prospectivo que incluiu pacientes internados no Hospital de Clínicas de Porto Alegre (HCPA) entre julho de 2015 e dezembro de 2017, maiores de 60 anos e com até 48 horas de admissão hospitalar. Foram realizados teste de desempenho Timed Up and Go (TUG), a atividade física foi autorreferida e o nível de independência foi avaliado pelas atividades instrumentais da vida diária (AIVD). A presença de quedas foi identificada em prontuário e o risco de quedas foi através do questionário Morse preenchido pela equipe de enfermagem como rotina clínica. A HO foi avaliada através da aferição da pressão arterial nas 3 posições (decúbito dorsal, sedestação e ortostática), considerando como HO a redução de 20 mmHg na pressão arterial sistólica ou de 10 mmHg na pressão arterial diastólica. As análises foram realizadas pelo programa SPSS (versão 18), este trabalho foi aprovado pelo Comitê de ética do HCPA sob número 150068. Foram incluídos 306 pacientes com DM2 e 304 no grupo controle. Dentre os pacientes com DM2 houve uma maior prevalência de episódios de HO (68% vs. 31%; p<0,001), de sobrepeso (54,5% vs.38%, p:0,003), pacientes eram mais lentos no TUG (12.26 ± 3.16 vs 16.08 ± 5.96 segundos, p:0,001) e sofreram mais quedas (30% vs 10%; p<0,001) quando comparados ao grupo controle. Foram identificados como fatores de risco para quedas intra hospitalar: sedentarismo, presença de DM2, TUG (<20s) e HO. Após ajustes, pacientes com DM2 e com HO, apresentaram 2,7 vezes maior risco de queda intra hospitalar quando comparados aos pacientes idosos sem DM2 e sem hipotensão. A queda intra hospitalar é um agravante para os pacientes idosos. Nesta amostra, pacientes sedentários, mais lentidão no teste de caminhada (TUG) e pior cognição apresentaram maior risco de quedas. A prevalência de quedas foi maior em pacientes com DM2 e quando coexistente com a HO o risco de quedas dobrou.Orthhostatic hypotension (OH) is defined as a sustained reduction of at least 20 mmHg in systolic blood pressure (SBP) and/or 10 mmHg in diastolic blood pressure (DBP) within three minutes after adopting orthostasis. Pressure drop decreases cerebral blood flow and can cause symptoms such as dizziness, nausea, visual changes and even syncope. OH is often asymptomatic and is related to primary autonomic dysfunction (such as pure autonomic failure and autonomic failure in Parkinson's disease) or secondary (such as that caused by polyneuropathies associated with the presence of diabetes, autoimmune diseases or drug use).in addition to other non-neurogenic factors, such as hypovolemia, depressed cardiac function and advanced age. Studies show a positive association between HO and falls, regardless of population and study design, quality, definition of HO or method of measuring blood pressure. Type 2 Diabetes (T2D) is a known cause of OH and advanced age is a predisposing factor. Advancing age brings consequences such as reduced sensitivity of the receptors responsible for attenuating the heart rate and decline of the function of the autonomic nervous system. Evidence shows that patients with T2D fall more frequently when compared to individuals without diabetes, and this fact can also be explained by polymedication. The objective of this study was to evaluate the association of falls and in-hospital mortality with the presence of OH in patients with T2D and to identify whether OH evaluated in 1 minute or in 3 minutes can predict falls and mortality. We used a secondary analysis of a prospective study that included patients admitted to the Hospital de Clínicas de Porto Alegre (HCPA) between July 2015 and December 2017, aged over 60 years and with up to 48 hours of hospital admission. A Timed Up and Go (TUG) performance test was performed, physical activity was self-reported and the level of independence was assessed through instrumental activities of daily living (IADL). The presence of falls was identified in the medical records and the risk of falls was through the Morse questionnaire completed by the nursing team as a clinical routine. HO was assessed by measuring blood pressure in the 3 positions (supine position, sitting and standing), considering as HO a reduction of 20 mmHg in systolic blood pressure or of 10 mmHg in diastolic blood pressure. The analyzes were carried out using the SPSS program (version 18), this work was approved by the Ethics Committee of the HCPA under number 150068. Three hundred six T2D patients and 304 controls were included. Among T2D subjects there was a higher prevalence of episodes of HO (68% vs. 31%; p<0.001), overweight (54.5%vs.38%, p:0.003), patients were slower in the TUG (12.26 ± 3.16 vs 16.08 ± 5.96 seconds, p:0.001) and had more falls (30% vs 10%; p<0.001) when compared to the control group. The following were identified as risk factors for intra-hospital falls: sedentary lifestyle, presence of diabetes, TUG (<20s) and HO. After adjustments, diabetes and OH had a 2.7 times greater risk of in-hospital falls when compared to elderly patients without T2D and without hypotension. The intra-hospital fall is an aggravating factor for elderly patients. In this sample, sedentary patients, slower walking test (TUG) and worse cognition had a higher risk of falls. The prevalence of falls was higher in patients with diabetes and when coexisting with OH, the risk of falls doubled

Association of Subjective Global Assessment and adductor pollicis muscle thickness with the Sarcopenia in older patients with type 2 diabetes

Background and Aim: Sarcopenia is prevalent in older patients and increases the risk for negative outcomes during hospitalization and after hospital discharge. In patients with type 2 diabetes (T2D) this association may be even worse. Upon hospital admission, it is often difficult to identify sarcopenia, so the objective of this study was to assess whether the subjective global assessment (SGA), the European Society for Clinical Nutrition and Metabolism (ESPEN) and Global Leadership Initiative on Malnutrition (GLIM) criteria and/or usual anthropometric measures can predict sarcopenia. A secondary objective, to evaluate the accuracy of variables in the prediction of sarcopenia. Methodology: Patients 60 years old and with T2D were included. Malnutrition was evaluated in accordance with the guidelines of ESPEN and GLIM, and SGA. Anthropometric measurements were performed by Mid-arm circumference (MAC), mid-upper arm muscle circumference (MUAMC), and adductor pollicis muscle thickness (APMT) was performed. The sarcopenia was evaluated by handgrip strength, timed Up and Go (TUG) test and muscle mass by measuring the calf circumference (CC). Logistic regression was performed to assess the association of variables with Sarcopenia. Results: A total of 311 patients were included. The prevalence of malnutrition in accordance to ESPEN, GLIM and SGA was 18 (5.8%), 65 (21%) and 15 (4%), respectively. The MAC and MUAMC showed a negative relationship with sarcopenia (HR: 0.92 CI95% 0.85-0.99). However, patients with overweight had a 66% reduction in the risk of sarcopenia (HR: 0.34 CI95% 0.19-0.59). After adjustments, malnourished patients according to the SGA had a risk of HR: 5.65 (CI95% 1.64-19.38) of sarcopenia, similarly to patients with APMT <5 th HR: 2.81 (CI95% 1.53-5.13), ESPEN and GLIM criteria presented HR:3.10 (CI95%1.12-8.22) and HR:2.94 (CI95%1.64-5.27), respectively. The interaction between SGA and APMT after adjusting the model has been significant (HR: 7.23 CI95% 2.98-17.67). In the area under the curve (ROC), only SGA and APMT showed greater accuracy in the prediction of sarcopenia (AUC: 0.713 CI95% 0.650-0.803). Conclusion: In our sample, it was possible to predict sarcopenia through the malnutrition criteria of ESPEN and GLIM, SGA, MAC and APMT. Measures such as APMT associated with the SGA tool seem to better predict sarcopenia in older patients with T2D

Body adiposity markers and insulin resistance in patients with type 1 diabetes

Objectives: Body composition changes are associated with adverse effects such as increased insulin resistance (IR) in individuals with diabetes mellitus. This study aims to evaluate the association between different body adiposity markers and IR in adults with type 1 diabetes (T1D). Subjects and methods: The cross-sectional study included outpatient adults with T1D from a university public hospital in southern Brazil. The body adiposity markers studied were waist circumference (WC), waist-height ratio (WHtR), body mass index (BMI), conicity index (CI), lipid accumulation product (LAP) and body adiposity index (BAI). IR was calculated using an Estimated Glucose Disposal Rate (EGDR) equation (analyzed in tertiles), considering an inverse relation between EGDR and IR. Poisson regression models were used to estimate the odds ratio (OR) and 95% CIs of association of adiposity markers with IR. Results: A total of 128 patients were enrolled (51% women), with a median EGDR of 7.2 (4.4-8.7) mg.kg-1.min-1. EGDR was negatively correlated with WC (r = -0.36, p < 0.01), WHtR (r = -0.39, p < 0.01), CI (r = -0.44, p < 0.01), LAP (r = -0.41, p < 0.01) and BMI (r = -0.24, p < 0.01). After regression analyses, WC (OR = 2.07; CIs: 1.12-3.337; p = 0.003), WHtR (OR = 2.77; CIs: 1.59-4.79; p < 0.001), CI (OR = 2.59; CIs: 1.43-4.66; p = 0.002), LAP (OR = 2.27; CIs: 1.25-4.11; p = 0.007) and BMI (OR = 1.78; CIs: 1.09-2.91; p = 0.019) remained associated with IR. Conclusions: The authors suggest using the studied adiposity markers as a routine since they were shown to be suitable parameters in association with IR

Higher fiber intake is associated with lower blood pressure levels in patients with type 1 diabetes

Objective: The present investigation sought to evaluate the potential association between dietary fiber intake and blood pressure (BP) in adult patients with type 1 diabetes (T1D). Subjects and methods: A cross-sectional study was carried out in 111 outpatients with T1D from Porto Alegre, Brazil. Patients were predominantly male (56%) and white (88%), with a mean age of 40 ± 10 years, diabetes duration of 18 ± 9 years, BMI 24.8 ± 3.85 kg/m2, and HbA1c 9.0 ± 2.0%. After clinical and laboratory evaluation, dietary intake was evaluated by 3-day weighed-diet records, whose reliability was confirmed by 24-h urinary nitrogen output. Patients were stratified into two groups according to adequacy of fiber intake in relation to American Diabetes Association (ADA) recommendations: below recommended daily intake (< 14g fiber/1000 kcal) or at/above recommended intake (≥ 14g/1000 kcal). Results: Patients in the higher fiber intake group exhibited significantly lower systolic (SBP) (115.9 ± 12.2 vs 125.1 ± 25.0 mmHg, p = 0.016) and diastolic blood pressure (DBP) (72.9 ± 9.2 vs 78.5 ± 9.3 mmHg, p = 0.009), higher energy intake (2164.0 ± 626.0 vs 1632.8 ± 502.0 kcal, p < 0.001), and lower BMI (24.4 ± 3.5 vs 26.2 ± 4.8, p = 0.044). Linear regression modelling, adjusted for age, energy intake, sodium intake, and BMI, indicated that higher fiber intake was associated with lower SBP and DBP levels. No significant between-group differences were observed with regard to duration of diabetes, glycemic control, insulin dosage, or presence of hypertension, nephropathy, or retinopathy. Conclusion: We conclude that fiber consumption meeting or exceeding current ADA recommendations is associated with lower SBP and DBP in patients with T1D