Metabolic effects of an enteral nutrition formula for diabetes: comparison with standard formulas in patients with type 1 diabetes

AIM

To evaluate the metabolic response (glucose, cholesterol, triglycerides and beta-hydroxy-butyrate) in patients with type 1 diabetes after a trial breakfast with an enteral nutrition formula designed for patients with diabetes and compare it with standard formulas (with and without fibre).

MATERIAL AND METHODS

Each of 11 patients with type 1 diabetes consumed three types of liquid breakfast with a 1 week interval between each. (1). A standard diet (SD) with 49% carbohydrates, 35% lipids, 16% proteins-casein-and without fibre; (2). A fibre-enriched diet (FD): with 49% carbohydrates, 35% lipids, 16% casein and 15 g/1000 ml fibre; (3). A diet designed for patients with diabetes (DD) with 45% carbohydrates, 38% lipids, 16% soy protein and 15 g/1000 ml fibre. Each subject consumed 250 ml of each preparation at 9.00 AM after having administered their usual insulin dose, which was the same for each diet. Blood samples were taken at baseline and each 30 min, up to 150 min.

RESULTS

The increase in postprandial glycaemia was lower with DD than with the standard preparations, reaching statistical significance at 60 min. There were no significant variations in the levels of cholesterol, triglycerides or beta-hydroxy-butyrate between the three preparations.

CONCLUSIONS

After a trial breakfast, a diet designed for patients with diabetes provoked lower increases in postprandial glycaemia (with no changes in lipid or beta-hydroxy-butyrate levels) compared to the standard diets evaluated (with and without fibre).

Prevalence of obesity in south-east Spain and its relation with social and health factors

Recent studies have confirmed important regional differences in the prevalence of obesity, as well as a tendency for this prevalence to increase. Determination of the social factors involved in obesity may be very useful to design intervention and prevention strategies. This transverse study was undertaken in Pizarra (Malaga, Spain) from a random sample of the population between 18 and 65 years of age (n = 1226). All participants were interviewed and given a physical examination. Standardized anthropometrical measurements were made, and a baseline blood sample was taken after an oral glucose tolerance test. The overall prevalence of obesity (BMI > 30 kg/m2) was 28.8%. This figure increased continuously from 10% in the group aged 18-25 years to above 50% in the groups aged over 55 years. This prevalence is higher than that reported in most other studies in Spain. The obese persons ate differently, at least from a qualitative viewpoint, probably more saturated fats and fewer unsaturated fats, and had a different behaviour concerning alcohol and smoking. Marital status was related with the rate of obesity, and the close relation between the level of education and the risk of obesity was confirmed (OR = 3.8 for being obese and having no education compared to having university studies). The most important consequence of the study was that all these factors are potentially modifiable and preventable. An increased level of general education in the population may well contribute decisively to a reduction in the prevalence of obesity.

Actividad física y factores de riesgo cardiovascular y metabólico en la población general

BACKGROUND AND OBJECTIVE

Our purpose was to evaluate in a cross-section, populational study the association between daily physical activity and various metabolic and cardiovascular disease risk factors.

PATIENTS AND METHOD

A total of 1226 randomly selected persons (aged 18-65 years) from a town in southeast Spain were evaluated for studying the association between the level of daily physical activity, both in and out of working hours, and the following variables: body mass index, plasma lipids, hypertension, obesity, altered baseline glycemia, and abnormal glucose tolerance.

RESULTS

The intensity of the physical activity at work was related negatively with insulin resistance and levels of LDL cholesterol, and positively with HDL cholesterol. The probability of hypertension, altered baseline glycemia, and abnormal glucose tolerance was greater in those undertaking less daily physical activity.

CONCLUSIONS

Daily physical activity, considered as part of the lifestyle, is related with the presence of components of the metabolic syndrome. An increase in daily physical activity should contribute to improve preventible cardiovascular risk factors.

Redistribution of abdominal fat after a period of food restriction in rats is related to the type of dietary fat

The aim of the present experiment was to test the hypothesis that during refeeding a redistribution of intra-abdominal fat takes place and that both the recovery of weight and the redistribution of intra-abdominal fat are related to the type of dietary fat. The experimental study was carried out using male Sprague-Dawley rats. Three groups of animals were fed diets with three different fatty acid profiles. Each group contained two branches, one fed normally and the other fed initially with a 50 % energy reduction followed by refeeding ad libitum with the same isoenergetic diet as the control branch, giving a total of six treatments. Measurements were made of the final and incremental weight of the rat, weight of the intra-abdominal adipose tissue (total intra-abdominal, epididymal, omental and retroperitoneal adipose tissue weight), and feed efficacy (weight increment/metabolizable energy intake). Carcass, epididymal, omental, and muscle lipid contents, carcass protein and energy density were also measured. The results revealed that diets rich in fish oil or olive oil increase catch-up growth more than diets rich in saturated fats. During refeeding the lipid content in the adipose tissue increases while that of muscle tissue decreases. A diet rich in saturated fats induces a relative increase in the amount of intra-abdominal adipose tissue. The lipid content in adipose and muscle tissues and the distribution of intra-abdominal fat can all be modified by the type of dietary fat.

Is there a gender difference of somatostatin-receptor density in the human brain?

Animal experiments and observations in human brains have convincingly shown that sexual differentiation not only concerns the genitalia but also the brain. This has been investigated also in the light of a possible explanation of a presumed biological aetiology of transsexuality. The volume of the central subdivision of the bed nucleus of the stria terminalis, a brain area that is essential for sexual behaviour, has been reported to be larger in men than in women. Additionally, the number of somatostatin expressing neurons in this region was shown to be higher in men than in women. As neuronal production of somatostatin is involved the idea is striking whether somatostatin-receptor density in the cortex of cerebral hemispheres might be related to gender identity. We investigated in vivo the density of somatostatin-receptors in selected regions of the human brain in both sexes by means of receptor scintigraphy. Basal ganglia tracer uptake of 111-In-Pentreotide was equally low in both genders at 0,80% +/ 0,26 (related to tracer uptake of the whole brain layer). Temporal cortex accumulated at 2,9% +/ 1,1 in men and at 2,3% +/ 0,76 in women. Frontal brain region had an uptake of 3,0% +/ 1,4 in male and of 2,5% +/ 1,3 in female. This shows a tendency in males for relatively augmented uptake indicating higher somatostatin receptor density in temporal and frontal cerebral cortex.

Intestinal permeability in adult patients with growth hormone deficiency

Pathological disruption of the intestinal mucosa increases the paracellular pathway, leading to an increase in the penetration of large molecules. Since growth hormone (GH) has a trophic intestinal effect, we used a double marker test to enable examination of intestinal permeability, which reflects the state of integrity of the intestinal mucosa. We recruited 22 adult patients, mean age 54+/-13.3 years, with GH deficiency due to partial or total hypopituitarism. None had received GH treatment at any time, although they were all in optimized replacement therapy. A control group was composed of 19 healthy age-matched relatives. The intestinal permeability test was performed with lactulose (5 g) and mannitol (1 g) after an oral load of 100 ml of aqueous solution. The urinary lactulose/mannitol ratio and the percentages of lactulose and mannitol excreted were determined on a 5-h urine collection. There were no significant differences between the patients and the control group in the lactulose/mannitol ratio (0.087+/-0.059 vs 0.077+/-0.064, respectively) or in the urinary excretion percentages of lactulose (0.067+/-0.048% vs 0.073+/-0.070%, respectively) or mannitol (5.127+/-3.269% vs 5.068+/-2.985%, respectively). In conclusion, no increase in intestinal permeability was detected in patients with GH deficiency, so that in spite of the known trophic effects of GH on the epithelial crypt cells, there was no intestinal hyperpermeability in these patients.

The auditory threshold in a school-age population is related to iodine intake and thyroid function

The aim of this study was to determine the relationship between auditory capacity and urinary iodine, taking into account thyroid volume and function, in a population of school-age children. Audiometry was carried out in 150 children (ages 6-14 years), together with measurements of thyroid volume, thyrotropin (TSH), free T3, free T4, thyroglobulin, antiperoxidase and anti-TSH receptor antibodies, as well as iodine in a casual urine sample. Children with a TSH >5 microU/mL were excluded from the study. In the children with palpable goiter, there was an inverse relation between the auditory threshold at all frequencies and ioduria. Children with thyroglobulin values >10 ng/mL had a higher auditory threshold at all frequencies. In the children with palpable goiter and ioduria <100 microg/L, the levels of thyroglobulin and ioduria and the age accounted for 75% of the decibel (dB) variance at 2000 (Hertz), with similar results at other frequencies. The children with a thyroid sized at the >95th percentile had an odds ratio of 3.86 (95% confidence interval: 2.59-5.10) of having a threshold >20 dB. The results warn that iodine prophylaxis is needed to prevent not only goiter but also other iodine-deficiency disorders, such as involvement of the auditory threshold in school-age children.

[Incidence of amputaciones of the lower extremities in the population with diabetes mellitus in Málaga (1996-1997)]

OBJECTIVE

To find the frequency of amputations of lower limbs (ALL) with the aim of designing a programme to prevent ALL in people with diabetes mellitus (DM).

DESIGN

Retrospective observation study.

SETTING

Population study in Malaga and its province.

PATIENTS

The clinical records of everyone with ALL in public or subsidized hospitals in the province of Malaga between January 1 1996 and December 31 1997 were reviewed. Traumatic or tumoural ALL were excluded. Cumulative incidence, relative risk (RR) of ALL and the mortality rate of people with DM were calculated.

RESULTS

449 ALL took place during the period studied, 316 (70.3%) in people with DM and 133 (29.6%) in people not suffering DM. The incidence of ALL per 100,000 people and per year was 6.3 (CI: 4.7-7.8) in the population without DM and 136.1 (CI: 114.9-157.3) in people with DM. The RR of ALL was 21.6 (CI: 17.6-26.4) for the population with DM, with differences between men and women (16.8 vs. 36.1, respectively). Mean age of ALL was significantly greater (p < 0.05) for the population with DM (70.0 +/- 10.2 vs. 68.9 +/- 15.9 years old). Older ALL were more numerous in both women and men in the two groups studied. The mortality rate, complications and mean stay in hospital were greater in the population with DM.

CONCLUSIONS

This study confirmed the greater risk of ALL run by people with DM. The incidence of ALL in this study was less than in countries of Northern Europe, the USA and Australia, but more than in any study published before in Spain.

[Trends of antidiabetic drug prescriptions in Andalucia (1986-1994)]

OBJECTIVE

Tendencies in the consumption of antidiabetic agents in Andalusia between 1986-1994 were analysed, with special emphasis on the impact of the introduction of acarbose and mechanized systems for the injection of insulin.

METHODS

The information concerning consumption was obtained from the data bases of the Andalusian Health Service and the Ministry of Health which contain details of the items sold in community chemists and charged to the National Health System. Data are expressed as defined daily doses per 1000 inhabitants per day (DID).

RESULTS

Insulin consumption rose from 4.67 DID in 1986 to 9.33 DID en 1994, an increase (delta) of 99.8%. All types of insulins contributed to the increase, with the mixtures rising most (delta 275%). Intermediate insulins were the most used. Prefilled syringes accounted for 25% of all insulin dispensed in 1994. Consumption of oral antidiabetic agents (OAA) rose from 12.75 DID in 1986 to 20.92 DID in 1994 (delta 64%). The most prescribed OAAs during these years were second generation sulphonylureas, representing 83% of those dispensed in 1994, followed by acarbose (11%), biguanides (3.8%), and first generation sulphonylureas (2.1%).

CONCLUSIONS

There was a notable increase in the consumption of insulins and OAAs. Although the tendency in the consumption differs from that expected according to consensus agreements, qualitative changes were seen, suggesting an improvement in prescription habits. The appearance of mechanized injection systems for insulin and of acarbose have clearly modified prescription habits.

[Factors influencing the prescription of insulin and oral antidiabetics in primary care]

OBJECTIVES

To analyse the prescription of insulin and oral diabetic medication (ODM) in primary health care, and to evaluate which variables, depending on the prescribing doctor, work-place or population attended, explain quality and/or quantity variations in prescription.

DESIGN

Crossover, observational study.

SETTING

Málaga-Este Health District, Málaga.

PARTICIPANTS

21,166 prescriptions issued by 144 doctors in the Málaga-Este Health District during the first quarter of 1997 were analysed.

MEASUREMENTS AND MAIN RESULTS

Insulin consumption of 10.63 defined daily doses per 1,000 inhabitants and day (DID) and ODM of 18.51 DID were calculated. No significant differences were observed in insulin or ODM prescription for sex, and few for age, job or doctors' specialty via MIR (intern) training. Working in a centre with MIR teaching and in a reformed centre were significantly associated with a greater use of insulin (p < 0.0001 and p < 0.02, respectively). Having a higher allocation of patients drawing pensions meant a greater consumption of insulin (p < 0.01) and even more of ODM (p < 0.0001). The population allocated being older was associated with greater consumption of ODM without any changes in insulin prescription.

CONCLUSIONS

The personal features of doctors working in primary care affect very little the quantity and quality of insulin and ODM prescription. The characteristics of the work-place (reformed centre and centre entitled to teach) and the population attended (older and drawing a pension) are the main factors conditioning the amount of prescription of insulin and ODM, respectively. Nevertheless, in all cases ODM prescription quality is low.

[Use of reagent materials for self-monitoring in the metropolitan area of Malaga (1994-1996)]

OBJECTIVES

To find the evolution of consumption of self-analysis material used to control Diabetes (reactive strips of glucose) and the costs involved, in the metropolitan area of Málaga from July 1994 to the first quarter of 1996.

DESIGN

Descriptive retrospective study.

SETTING

Metropolitan area of Málaga (580, 586 inhabitants), which is divided in two HEALTH DISTRICTS: Málaga East and West.

PATIENTS

All diabetics using reactive strips in the metropolitan area of Málaga which are charged to the National Health system.

MEASUREMENTS AND MAIN RESULTS

The data base of the health districts of the metropolitan area of Málaga was used for the review of public prescriptions of reactive strips. Consumption in relation to the total population was analysed and the average consumption per diabetic was calculated. The total number of patients for whom reactive strips were prescribed increased considerably over the three years studied.

CONCLUSIONS

A considerable increase in consumption of glucose reactive strips was observed in recent years in the metropolitan area of Málaga, mainly because of its generalised use among elderly patients. Consumption of urine strips was small and tended to fall.

[Pheochromocytoma and cardiac insufficiency]

Catecholamine-induced cardiomyopathy is a rare complication of pheochromocytoma. We present a case of pheochromocytoma that developed preoperative heart failure. Left ventricular dilation and severe hypokinesia were demonstrated by echocardiography. Heart failure was successfully treated with digitalis, diuretics and captopril. There were no surgical complications and the follow up showed and improvement on the systolic function evaluated by echocardiography and isotope ventriculography, 3 and 6 months after surgery. We review the pathophysiology and evolution of catecholamine induced cardiomyopathy. Preload reserve can be one of the adaptive mechanisms of the ventricle in catecholamine-induced cardiomyopathy. Conventional therapy of hypertension and heart failure can be effective to correct the symptoms of cardiac dysfunction.

Lipid, protein, and calorie content of different Atlantic and Mediterranean fish, shellfish, and molluscs commonly eaten in the south of Spain

We undertook a systematic evaluation of the lipid, protein, calorie, and fatty acid composition in 35 species of fish, shellfish and molluscs commonly consumed throughout the four seasons of the year in Andalusia, Spain. Using a portion of muscle tissue the following were measured in each study unit: total lipids (extraction using Folch's method and gravimetry), protein concentration (Kjehldal's method), total calories (direct calorimetry), and composition of fatty acids (gas chromatography). The lipid, protein, and different fatty acid concentrations found are presented in table form. There was a high degree of inter-species variability in the concentration of lipids and the various fatty acids. There was also a high degree of intra-species seasonal variability in some cases. The relative proportion of fatty acids was not independent of the total concentration of lipids, independently of the season studied. This systematic study of a large group of species shows that the cataloguing of fish as 'white' or 'blue' depends especially on the time of year they are captured. For example, in spring the mackerel (Scomber scombrus), a fish considered traditionally to be 'blue' (fatty), has the same lipid concentration as the dover sole (Solea vulgaris), commonly considered to be 'white' (little fat), and the sea pike (Merluccius merluccius) has a higher lipid concentration in autumn than the jack mackerel (Trachurus trachurus). Even greater differences existed when the fish were classified according to their richness in n-3 fatty acids. These differences in the total lipid concentration and the composition of fatty acids, as well as the inter-relations between them, may, under certain circumstances, be important for the calculation of dietary calories and nutritional values, and may explain the differences found between the various tables of food composition, as well as the divergent results in epidemiological studies on the association between fish in diets and various diseases, such as diabetes or ischaemic cardiopathy.

Altered bioavailability due to changes in the formulation of a commercial preparation of levothyroxine in patients with differentiated thyroid carcinoma

OBJECTIVES

In July 1995 we began noticing an unusually high rate of elevated TSH levels in patients with differentiated thyroid cancer treated with levothyroxine-specifically the brand Levothroid-becoming more obvious from September 1995. Faced with the possibility that these findings had some relationship to the drug taken, we carried out a prospective study, changing this brand of levothyroxine for another.

DESIGN AND PATIENTS

We studied 58 patients with differentiated thyroid carcinoma (50 women and eight men; aged 22-75 years) who were being treated with levothyroxine and who had previously had adequate TSH suppression. Their Levothroid tablets were changed to the same dose of Dexnon tablets, and their clinical and analytical response was evaluated 2 months later. The patients were divided into two groups according to their TSH level at the start of the study: group 1, 42 patients with TSH > 0.2 mU/l (not suppressed) and group 2, 16 patients with TSH < or = 0.2 mU/l (suppressed).

RESULTS

After 2 months with Dexnon the TSH levels in group 1 fell significantly (P < 0.0001) also decreasing in group (P < 0.09). The free T4 and free T3 rose significantly in both groups. After the change to Dexnon, 17 patients (40%) in group 1 had suppressed TSH and 26 (62%) had free T4 levels above the upper limit of normal vs none at baseline (P < 0.001). The group 2 patients maintained their inhibited TSH values after treatment with Dexnon, and the free T4 was above the upper limit of normal in 15 (94%) vs 3 (19%) at baseline (P < 0.001). The Levothroid tablets collected from the patients in both groups formed part of those which the manufacturer later withdraw from the market. These batches possessed the correct dosage, but they had been made from 'non-micronized' raw materials from another supplier.

CONCLUSIONS

The most probable cause of the inadequate TSH suppression in our patients was the reduction in bioavailability in certain batches of Levothroid, although we are unable to rule out the possibility that the results obtained after the changeover to Dexnon were due to its greater bioavailability. Simple changes in the manufacture of levothyroxine tablets may produce important variations in their bioavailability, having an adverse effect on the clinical control of the patients, and causing extra expense by the need for repeated patient visits and thyroid function tests.

[Fat, protein and caloric content of different fish, seafood and mollusks, Atlantic and Mediterranean habitually consumed in the south of Spain]

OBJECTIVE

To evaluate in a systematic manner, the fat, protein, caloric, and fatty acids contents of 35 species of fish, seafood and mollusks, usually consumed in Andalucía (Spain).

MATERIALS AND METHODS

35 different species, representative of those usually consumed in Andalucía in the course of the four seasons of the year, are studied. In all units of the study, in a portion of the muscle tissue, measurements were taken to evaluate the total fat (extraction by the Folch method and by gravimetry), protein concentration (Kjehldal method), total calories (gas chromatography).

RESULTS

A table shows the concentration of fat, protein and different fatty acids found in the studied species. There is a great interspecies variability in the fat concentration and in that of the different fatty acids. In the same way there is a great interspecies seasonal variety for some of those studied. Independently of the season studied, the relative proportion of fatty acids was not independent of the total concentration of fat.

DISCUSSION

From the nutritional, culinary and gastronomic point of view, in the Mediterranean area it is common to classify the fish as "white" (low fat) and "blue" (fat). However, the systematic study of a large number of species shows that the categorization of "white" or "blue" depends on the time of year in which they are captured. For example, in spring the horse-mackerel (Scomber scombrurus), a fish traditionally considered "blue" (fat), has the same fat concentration as the sole (Soles vulgaris), generally considered "white" (low fat). And the hake (Merluccius merluccius), in autumn, has a fat concentration which is greater than that of the carangoid sea-fish (Trachurus trachurus). Even greater differences can be seen if we classify the fish according to their richness in n-3 fatty acids. These differences in the total fat concentration and in the composition of fatty acids, as well as the inter-relations between both, may be important in determining the circumstances for the caloric and nutritional calculation of a diet, and may explain the differences found between the different tables of food composition, as well as the divergent results found in the epidemiological studies on the association between the fish of the diet and the different diseases such as diabetes or ischemic heart disease.

A multicenter double-blind study comparing lovastatin and gemfibrozil in the treatment of primary hypercholesterolemia

The efficacy and tolerability of lovastatin and gemfibrozil were compared in a randomized double-blind 12-week study including 182 patients with primary hypercholesterolemia, from 7 hospitals in Spain. Inclusion criteria were total-cholesterol of at least 250 mg/dl and triglycerides less than 350 mg/dl. Patients were stratified in two groups: group 1, cholesterol less than 300 mg/dl, and group II, cholesterol equal to or more than 300 mg/dl. Patients were randomized to gemfibrozil (600 mg b.i.d.) or lovastatin (20 mg q.p.m., group I and 40 mg q.p.m., group II). If after 6 weeks of treatment cholesterol remained above 200 mg/dl, lovastatin does were doubled. In group I, lovastatin decreased cholesterol by 20%, LDL-C by 28%, and triglycerides by 17%, and increased HDL-C by 8%. In group II the results were: -26%, -33%, -19% and +6% respectively. The corresponding results with gemfibrozil were: -8%, -9%, -28% and +14% (group I); and -13%, -14%, -33% and +9% (group II). In both groups, lovastatin was more effective in reducing cholesterol and LDL-C (P less than 0.001) and gemfibrozil in reducing triglycerides (P less than 0.05 group I and P less than 0.01 group II). Both drugs were well tolerated. Thus, lovastatin and gemfibrozil are effective lipid-lowering agents; lovastatin has more pronounced effects in patients with hypercholesterolemia.