The triglyceride and glucose index is useful for recognising insulin resistance in children

AIM

Although recognising insulin resistance (IR) in children is particularly important, the gold standard test used to diagnose it, the euglyceamic glucose clamp, is costly, invasive and is not routinely available in our clinical settings in Mexico. This study evaluated whether the triglyceride-glucose (TyG) index would provide a useful alternative.

METHODS

A total of 2779 school children aged seven to 17 years, from Durango, Mexico, were enrolled during 2015-2016. The gold standard euglyceamic-hyperinsulinemic clamp test was performed in a randomly selected subsample of 125 children, and diagnostic concordance between the TyG index and the homoeostasis model assessment of IR was evaluated in all of the 2779 enrolled children.

RESULTS

The best cut-off values for recognising IR using the TyG index were 4.65 for prepubertal girls and boys, 4.75 for pubertal girls and 4.70 for pubertal boys. Concordance between the TyG index and the homoeostasis model assessment of IR was 0.910 and 0.902 for the prepubertal girls and boys, 0.932 for the pubertal girls and 0.925 for the pubertal boys.

CONCLUSION

The TyG index was useful for recognising IR in both prepubertal and pubertal children and could provide a feasible alternative to the costly and invasive gold standard test for IR in resource-limited settings.

Tumor necrosis factor haplotype diversity in Mestizo and native populations of Mexico

The so-called tumor necrosis factor (TNF) block includes the TNFA, lymphotoxin alpha and beta (LTA and LTB) genes with single-nucleotide polymorphisms (SNP) and microsatellites with an allele frequency that exhibits interpopulation variability. To date, no reports have included both SNPs and microsatellites at the TNF block to study Mestizo or Amerindian populations from Mexico. In this study, samples of five Mexican Mestizo populations (Durango, Guadalajara, Monterrey, Puebla, and Tierra Blanca) and four native-Mexican populations (North Lacandonians, South Lacandonians, Tepehuanos, and Yaquis) were genotyped for two SNPs (LTA+252A>G and TNFA-308G>A) and four microsatellites (TNFa, d, e, and f), to analyze the genetic substructure of the Mexican population. Allele and haplotype frequencies, linkage disequilibrium (LD), and interpopulation genetic relationships were calculated. There was significant LD along almost all of the TNF block but the lowest D' values were observed for the TNFf-TNFd pair. Mestizos showed higher allele and haplotype diversity than did natives. The genetic differentiation level was reduced among Mestizos; however, a slightly, but significant genetic substructure was observed between northern and southern Mexican Mestizos. Among the Amerindian populations, the genetic differentiation level was significantly elevated, particularly in both North and South Lacandonians. Furthermore, among Southern Lacandonians, inhabitants of Lacanja town were the most differentiated from all the Mexicans analyzed. The data presented here will serve as a reference for further population and epidemiological studies including these TNF polymorphisms in the Mexican population.

Dietary factors related to the increase of cardiovascular risk factors in traditional Tepehuanos communities from Mexico. A 10 year follow-up study

BACKGROUND AND AIMS

Tepehuanos Indians, a traditional Mexican ethnic group, followed a vegetarian diet exhibiting a low prevalence of obesity and the absence of diabetes. However, from the year 2000 the traditional diet of the Tepehuanos was modified by the introduction of western food. In this study we examine the changes in their customary diet and its impact on the prevalence of cardiovascular risk factors in this group.

METHODS AND RESULTS

Individuals from 12 Tepehuanos communities were randomly enrolled during 1995-1996 and 2006-2007. Using a 64-item semiquantitative food frequency questionnaire macronutrient intakes were calculated from values of Mexican food-composition tables. Cardiovascular risk factors such as obesity, hypertension, hyperglycemia and dyslipidemia were determined. The median (25, 75 percentile) of total caloric intake (1476 [1083, 1842]-2100 [1366, 2680]kcal/day, p<0.001) as well as the percentage of energy consumed from saturated fat (3.0 [2.7,4.1]-7.2 [3.9,7.4], p<0.0001) and protein (8.2 [7.8,8.9]-16.8 [16.3,17.1], p<0.0001) increased, whereas the percentage of total calorie intake from carbohydrates (66.4 [61.3,69.5]-61.3 [61,68.8], p<0.0001), polyunsaturated fat (11.2 [10.3,12.1]-4.0 [3.9,4.3], p<0.0001), and the polyunsaturated:saturated fat ratio (3.84-0.53%, p<0.0001) decreased during the period of study. The prevalence of obesity (11.1-21.9%, p=0.04), impaired fasting glucose (5.9-14.9%, p=0.04), diabetes (0.0-0.88%, p=0.48), hypertension (1.7-3.4%, p=0.43), triglycerides (2.6-16.7%, p=0.0006), and low HDL-cholesterol (10.2-71.1%, p<0.0001) increased.

CONCLUSIONS

Changes in the customary diet introduced in the Tepehuanos communities are related to the increase of cardiovascular risk factors.

Serum magnesium and C-reactive protein levels

OBJECTIVE

To assess the hypothesis that magnesium deficiency is associated with elevated high-sensitivity C-reactive protein (hsCRP) levels.

DESIGN

Community-based cross-sectional study.

SETTING

488 apparently healthy children aged 10-13 years were randomly enrolled from Durango, a city in northern Mexico, through two-stage cluster sampling.

MAIN OUTCOME MEASURES

Serum magnesium and hsCRP levels, lipid profile, glucose and insulin levels.

RESULTS

A total of 109 (22.3%) and 101 (20.7%) children had elevated hsCRP concentrations and low serum magnesium levels; among them, 87.1% exhibited both. Children who had both elevated hsCRP levels (2.45 (10.6) mg/l) and hypomagnesemia (1.3 (0.3) mg/dl) exhibit the highest fasting glucose (96.0 (13.9) mg/dl), insulin (13.6 (7.5) microU/ml) and triglycerides (131.5 (43.5) mg/dl) levels as well as the lowest HDL-cholesterol (46.4 (9.0) mg/dl) levels. Adjusted multivariate logistic regression analysis showed a strong association between low serum magnesium and high hsCRP levels (odds ratio 4.1; 95% confidence interval 1.3 to 10.8).

CONCLUSIONS

Magnesium depletion is independently associated with elevated hsCRP levels, suggesting that hypomagnesemia and low-grade inflammation are interactive risk factors.

Hypomagnesaemia and risk for metabolic glucose disorders: a 10-year follow-up study

BACKGROUND

Although several lines of evidence suggest that hypomagnesaemia is a risk factor for developing type 2 diabetes, there are no studies regarding the association between hypomagnesaemia and the risk for developing impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Our objective was to examine the association between serum magnesium levels and the risk for developing IFG, IGT and type 2 diabetes.

MATERIALS AND METHODS

A total of 1122 individuals (20-65 years of age) were enrolled between 1996 and 1997, and 817 individuals re-examined about 10 years later. New-onset IFG (5.6-7.0 mmol L(-1) fasting glucose), IGT (7.8-11.1 mmol L(-1) glucose 2-h postload), and type 2 diabetes were determined from the number of subjects who had these conditions at the second examination without evidence that they were present at the first one. The relative risk of new-onset metabolic glucose disorders and diabetes (dependent variables) was computed using Poisson regression model adjusted for age, sex, family history of diabetes, waist circumference and homeostasis model assessment for insulin resistance index. Serum magnesium levels of < 0.74 mmol L(-1) (independent variable) defined the exposed group.

RESULTS

At baseline, 420 (51.4%) individuals had hypomagnesaemia. New-onset IFG and IGT was identified in 276 (33.8%) individuals. The relative risk for IFG, IGT and IFG + IGT was 1.11 (95% confidence interval, 0.5-5.1), 1.38 (95% confidence interval, 1.1-6.3) and 1.49 (95% confidence interval, 1.1-4.9), respectively. New-onset diabetes was identified in 78 (9.5%) individuals (relative risk 2.54; 95% confidence interval, 1.1-4.1).

CONCLUSIONS

Hypomagnesaemia is independently associated with the development of IGT, IFG + IGT and type 2 diabetes, but not with the development of IFG.

Placental immaturity and hyperinsulinaemia in full-term newborns

BACKGROUND

Evidence from large studies suggests that low birthweight is a risk factor for cardiovascular disease and glucose metabolism disorders in adulthood, but the physiological mechanisms involved in intrauterine growth conditioning low birthweight are not completely understood. The objectives of this study were to determine whether placental immaturity (PI), defined as the lower quartile of placental maturity index (PMI), is associated to hyperinsulinaemia at birth and to identify the risk factors associated with PI.

MATERIALS AND METHODS

Cross-sectional study conducted at medical research units of two Mexican general hospitals. A total of 272 full-term newborns with gestational age >/= 38 and < 41 weeks were allocated into the corresponding group according to the quartile distribution of PMI. Data from the lower (PMI < 13.3) and higher quartile (PMI >/= 24.3) were compared. The PMI was estimated by dividing the number of epithelial plates by the average thickness of the epithelial plate. Serum measures included cord glucose and insulin levels of the newborns at birth.

RESULTS

A total of 74 (27.2%) children had hyperinsulinaemia at birth, of them 47 (63.5%) with PI. The adjusted multiple regression analysis showed a strong association between PI and hyperinsulinaemia at birth [odds ratio (OR) 2.6; CI 95% 1.3-4.3). Additional adjusted analysis showed that both mother's age </= 16 years (OR 1.75; CI95% 1.2-9.1) and maternal cigarette smoking (OR 2.7; CI95% 1.3-8.9) are associated to PI.

CONCLUSIONS

The PI is independently associated with hyperinsulinaemia at birth: smoking and mother's age lower than 16 years are risk factors for development of PI.

Assessing progression to impaired glucose tolerance and type 2 diabetes mellitus

BACKGROUND

A prospective evaluation of the relationship between insulin secretion and insulin sensitivity, derived from the fasting state, is needed in clinical practice in order to identify the worsening of glucose metabolism. In this study the authors examine whether the product of insulin sensitivity and insulin secretion, assessed from the fasting state, predicts progression from normal glucose tolerance (NGT) to impaired fasting glucose (IFG) and from impaired glucose tolerance (IGT) to type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

A cohort of 300 subjects with NGT and 75 subjects with IGT were followed up over a 5-year period. Insulin sensitivity was calculated using the Belfiore index (B) and insulin secretion by the homeostasis model analysis beta-cell (HOMA-beta cell) index: the product of B-beta is expressed as: (40 x Ins(0) pmol L(-1))/Glu(0) mmol L(-1){[(Glu(0) mmol L(-1)x Ins(0) pmol L(-1)) + 1] - 3.5[(Glu(0) mmol L(-1) x Ins(0) pmol L(-1)) - 1]}, where Glu(0) is fasting glucose and Ins(0) is fasting insulin.

RESULTS

From baseline at the end of the follow-up period, the product B-beta decreased 10.7% and 52.2% in progressors to IGT and T2DM, respectively. The product B-beta predicts the progression from NGT to IGT [relative risk (RR) 2.7, CI(95%) 1.2-9.1] and from IGT to T2DM (RR 5.3, CI(95%) 1.3-8.55). The cut-off point for the product B-beta that better predicts progression from NGT to IGT is 0.25 (sensitivity 88%, specificity 92%) and from IGT to T2DM 0.15 (sensitivity 92%, specificity 95%).

CONCLUSIONS

Adaptation of insulin secretion to compensate for decreased insulin sensitivity during transition to IGT and T2DM can be successfully assessed with simple measures derived from the fasting state. The product B-beta predicts the development to IGT and T2DM.

Early decrease of the percent of HOMA ɛ-cell function is independently related to family history of diabetes in healthy young nonobese individuals

OBJECTIVE

To determine the relationship between family history of diabetes (FHD) and decrease in percent of HOMA beta-cell function (HOMA-beta%) index in healthy betanon-obese Mexican subjects.

MATERIALS AND METHODS

Forty-eight individuals (30 women and 18 men) with FHD were compared vs 48 control subjects (30 women and 18 men) in a cross-sectional study matched by age, sex, and Waist-to-Hip ratio. Pregnancy, obesity, being overweight, alcohol consumption, high blood pressure, and heavy physical activity were exclusion criteria. All the participants were required to have a Body Mass Index < 25 kg/m2 and serum fasting and 2-hours postload glucose levels lower than 6.1 mmol/l and 7.8 mmol/l, respectively. The reciprocal of serum fasting insulin concentrations (1/Ins0) (microU/ml) and HOMA-B% index were used as indicators of insulin sensitivity and beta-cell function.

RESULTS

Average age was of 19.4 +/- 3.6 vs 19.8 +/- 2.6, P = 0.66 for the subjects with and without FHD. HOMA-beta% index was significantly lower in the subjects with FHD (186.1 +/- 74.1 vs 252.7 +/- 149.5, P = 0.01). For similar levels of insulin sensitivity, subjects with FHD showed lower HOMA-beta% index than control subjects (P < 0.001). Multivariate regression analysis showed a strong and independent relationship between FHD and decrease of HOMA-beta% index (OR 2.6, CI95% 1.2-4.3, P = 0.01).

CONCLUSIONS

This study shows that normal-weight offspring of type 2 diabetes subjects exhibited a significant decrease of HOMA-beta% index suggesting that FHD exerts an independent early negative effect on beta-cell function.

Pentoxifylline is as effective as captopril in the reduction of microalbuminuria in non-hypertensive type 2 diabetic patients - a randomized, equivalent trial

AIMS

To compare the efficacy of pentoxifylline and captopril on urinary albumin excretion (UAE) rate in non-hypertensive diabetic patients with microalbuminuria.

METHODS

450 subjects were screened; of these 130 eligible, non-hypertensive, type 2 diabetic subjects were enrolled and randomly allocated to receive either pentoxifylline 400 mg t.i.d. (n = 65) or captopril 25 mg t.i.d. (n = 65) for six months in a randomized equivalent trial design study. Patients were eligible to participate if they had microalbuminuria, defined by UAE rate of 20-200 microg/min, and systolic/diastolic blood pressure lower than 140/85 mmHg. Diagnosis of high blood pressure and renal failure were exclusion criteria. In addition, subjects receiving ACE inhibitors or pentoxifylline were not included.

RESULTS

Both treatments were well tolerated, without serious adverse events; nonetheless, one subject (1.6%) in the group with pentoxifylline had severe headache, and three (4.7%) subjects in the group with captopril had intense dry cough and nasal congestion that required stopping pentoxifylline and captopril. In addition, slight headache and mild dry cough that did not require specific treatment or interruption of medication were present in two (3.2%) and five (7.8%) subjects treated with pentoxifylline and captopril. Four subjects dropped-out (one in the pentoxifylline group and three in the captopril group). Blood pressure and fasting glucose levels were similar between the two groups throughout the study. The UAE rate decreased from the first month of treatment in the subjects of both groups, a reduction that was sustained in the following months. At the end of the study, the average UAE rate in the subjects of both groups was lower than 25 microg/min.

CONCLUSIONS

Pentoxifylline showed to be an effective alternative to ACE inhibitors in reducing UAE in non-hypertensive diabetic patients with microalbuminuria.

Oral Magnesium supplementation improves insulin sensitivity in non-diabetic subjects with insulin resistance. A double-blind placebo-controlled randomized trial

OBJECTIVE

Although hypomagnesemia reduces insulin sensitivity, benefits of magnesium supplementation to non-diabetic insulin resistant subjects has not been established. Our purpose was to determine whether oral magnesium supplementation with magnesium chloride (MgCl2) 2.5 g daily modify insulin sensitivity in non-diabetic subjects.

MATERIAL AND METHODS

This study was a 3 months randomized double-blind placebo-controlled trial. Apparently healthy subjects were eligible to participate if they had insulin resistance (HOMA-IR index equal or greater than 3.0) and hypomagnesemia (Serum magnesium levels equal or lower than 0.74 mmol/l). Subjects were randomized to receive either, MgCl2 2.5 g daily or placebo by 3-months.

RESULTS

At baseline there were not significant anthropometric or laboratory differences between both groups. At ending of the study, magnesium-supplemented subjects significantly increased their serum magnesium levels (0.61 +/- 0.08 to 0.81 +/- 0.08 mmol/l, p<0.0001) and reduced HOMA-IR index (4.6 +/- 2.8 to 2.6 +/- 1.1, p<0.0001), whereas control subjects did not (0.62 +/- 0.08 to 0.61 +/- 0.08 mmol/l, p=0.063 and 5.2 +/- 1.9 to 5.3 +/- 2.9, p=0.087).

CONCLUSIONS

Oral magnesium supplementation improves insulin sensitivity in hypomagnesemic non-diabetic subjects. Clinical implications of this finding have to be established.

Pioglitazone increases serum magnesium levels in glucose-intolerant subjects. A randomized, controlled trial

Although thiazolidinediones and magnesium supplementation improves insulin action and increases HDL-cholesterol, the potential link between serum magnesium and thiazolidinediones has received little attention. Focusing on the increase of serum magnesium, 63 eligible subjects were enrolled and randomly allocated to receive either 30 mg Pioglitazone once daily (Group A) or lifestyle intervention (Group B) during 12 weeks. Subjects were eligible if they were glucose-intolerant, and excluded if they had high blood pressure, diabetes or abnormal liver function tests. The personnel assessing outcomes were blinded to group assignment. Of the 63 eligible subjects, 3 dropped out (one in group A, and two in Group B) because they moved out of the city. So, 30 subjects in each group, who satisfactorily completed the follow-up, were included in the analysis of data. There were no serious adverse events or side effects due to Pioglitazone or lifestyle intervention. At baseline, the groups did not differ significantly in serum magnesium levels 1.73 +/- 0.17 versus 1.72 +/- 0.14 mg/dl, p = 0.80. Subjects who received Pioglitazone significantly increased their serum magnesium to 1.93 +/- 0.16 mg/dl whereas in the lifestyle intervention group the increase was 1.74 +/- 0.25 mg/dl, p < 0.0001. What this study showed was a significant increase in the serum magnesium levels of glucose-intolerant subjects who received 30 mg Pioglitazone once daily.

Elevated concentrations of C-reactive protein in subjects with type 2 diabetes mellitus are moderately influenced by glycemic control

The aim of this study was to establish whether glycemic control results in decrease of C-reactive protein (CRP) in Type 2 diabetic subjects. Newly diagnosed Type 2 diabetic subjects were recruited and followed-up by 6-month intensive medical management. All the participants were carefully interviewed, clinically examined, and laboratory tested to exclude conditions likely to provoke an inflammatory response, which was an exclusion criterium. CRP was measured by automated microparticle enzyme immunoassay (IMx, Abbott Laboratories, USA). Two-hundred and forty-eight patients were included in the analysis of data. At baseline, average CRP levels were of 9.6 +/- 6.2 mg/l. Only 14 (5.7%) patients showed a fasting glucose equal or lower than 6.1 mmo/l (5.6 +/- 0.4 mmo/l); of them, 6 (42.8%) had elevated CRP levels (8.8 +/- 6.7 mg/l). The fasting glucose in the 234 (94.3%) non-controlled subjects was 13.1 +/- 4.8 mmol/l; of them 179 (76.5%) subjects showed elevated CRP levels (10.9 +/- 6.5 mg/I). At the end of the 6-month follow-up, the average fasting glucose and HbA1c in the overall group decreased from 12.5 +/- 5.0 to 9.0 +/- 1.6 mmol/l, p < 0.00001, and 13.0 +/- 4.9 to 8.9 +/- 2.9%, p < 0.00001, which resulted in a significant reduction of CRP levels (9.6 +/- 6.2 to 6.3 +/- 3.0 mg/l, p < 0.00001). Seventy-one (28.6%) patients reached glycemic control; however, only 29 (40.8%) of them reduced the CRP levels to 3 mg/l or less (1.3 +/- 1.9 mg/l), and the remaining 42 controlled patients maintained high CRP concentration (4.2 +/- 1.2 mg/I), p < 0.00001. Concentration of CRP is moderately influenced by glycemic control in the Type 2 diabetic subjects.

Relation of C-reactive protein to features of the metabolic syndrome in normal glucose tolerant, impaired glucose tolerant, and newly diagnosed type 2 diabetic subjects

OBJECTIVE

To determine the relationship between CRP levels and the components of MS in normal glucose tolerant (NGT), impaired glucose tolerant (IGT), and Type 2 diabetic subjects.

MATERIAL AND METHODS

A based cross-sectional population study was performed. Eligible subjects, men and non-pregnant women, 30 to 64 year of age, were randomly recruited. Subjects with acute or chronic diseases were excluded. Only newly diagnosed type 2 diabetic or hypertensive subjects were included. Disorders related to CRP increase, also were exclusion criteria. In accordance to WHO proposal, components of MS were: High Blood Pressure, Dyslipidemia, Obesity, and Microalbuminuria, and MS was defined, for the NGT, if at least two of the criteria were fulfilled and in addition the subject had insulin resistance. The MS in IGT and DM subjects was defined if at least two of the criteria were fulfilled.

RESULTS

CRP was significantly associated with MS for the NGT (Odds ratio -OR- 3.8, CI(95%) 1.6-14.8), IGT (OR 4.9, CI(95%) 1.2-15.5), and diabetes (OR 5.6, CI(95%) 1.9-10.2). For NGT, after adjustment for obesity, CRP was not longer associated with MS. After adjust for obesity and fasting glucose (FG), the relationship between CRP and MS for IGT was lost. Finally, after adjustment for obesity, FG, and microalbuminuria, CRP was not longer associated with MS for diabetic subjects.

CONCLUSIONS

This study show a significant relationship between CRP and MS which is maintained only by obesity in the NGT, by obesity and FG in the IGT, and by obesity, FG, and microalbuminuria in the newly diagnosed diabetic subjects.

Insulin resistance is independently related to age in Mexican women

Whether the decrease of insulin action is a biological consequence of age or a result of lifestyle changes in elderly people is uncertain. Therefore, we rigorously controlled potential confounders to evaluate the relationship between age and insulin resistance in Mexican women. A total of 100 glucose-tolerant, non-hypertensive women, 30-65 yr of age, inhabitants of the same neighborhood of Durango, a city in the North of Mexico, were randomly enrolled to participate in a case-control study. The study was designed to include 50 cases and 50 controls. Insulin-resistant women were considered as cases and compared vs a control group of non-insulin resistant women, matched by BMI and Waist-to-Hip ratio (WHR). HOMA-IR index equal or greater than 3.0 defined the presence of insulin resistance. Endocrine diseases, pregnancy, smoking, alcohol consumption, and physical activity were exclusion criteria. The results showed insulin resistant women were significantly older than control women (53.7 +/- 12.2 vs 46.3 +/- 10.4, p = 0.0004). Women in the case group showed a direct correlation between age and HOMA-IR index (0.427, p = 0.02), whereas control women did not (0.09, p = 0.626). Step-wise forward selection logistic regression analysis showed an independent relationship between HOMA-IR index and age (OR 1.5, CI95% 1.4-1.8, p = 0.002). The results of this study show an independent relationship between age and high HOMA-IR index in Mexican women, supporting the hypothesis that age per se could be associated with the impairment of insulin action.

Low serum magnesium levels and metabolic syndrome

Low serum magnesium levels are related to diabetes mellitus (DM) and high blood pressure (HBP), but as far as we know, there are no previous reports that analyzed the serum magnesium concentration in individuals with metabolic syndrome (MS). We performed a cross-sectional population-based study to compare 192 individuals with MS and 384 disorder-free control subjects, matched by age and gender. Magnesium supplementation treatment and conditions likely to provoke hypomagnesemia, including previous diagnosis of diabetes mellitus (DM) and/or high blood pressure (HBP), were exclusion criteria. In this regard, only incident cases of DM and HBP were included. MS was defined by the presence at least of two of the following features: hyperglycemia (> or =7.0 mmol/l); HBP (> or =160/90 mmHg); dyslipidemia (fasting triglycerides > or =1.7 mmol/l and/or HDL-cholesterol <1.0 mmol/l); and obesity (body mass index > or =30 kg/m(2) and/or waist-to-hip ratio > or =0.85 in women or > or =0.9 in men). Low serum magnesium levels were identified in 126 (65.6%) and 19 (4.9%) individuals with and without MS, p<0.00001. The mean serum magnesium level among subjects with MS was 1.8+/-0.3 mg/dl, and among control subjects 2.2+/-0.2 mg/dl, p<0.00001. There was a strong independent relationship between low serum magnesium levels and MS (odds ratio (OR)=6.8, CI(95%) 4.2-10.9). Among the components of MS, dyslipidemia (OR 2.8, CI(95%) 1.3-2.9) and HBP (OR 1.9, CI(95%) 1.4-2.8) were strongly related to low serum magnesium levels. This study reveals a strong relationship between decreased serum magnesium and MS.

Relationship between serum magnesium levels and C-reactive protein concentration, in non-diabetic, non-hypertensive obese subjects

OBJECTIVE

To examine the association between serum magnesium levels and C-reactive protein (CRP) in non-diabetic, non-hypertensive obese subjects.

DESIGN

Cross-sectional study.

SUBJECTS

A total of 371 subjects, 101 men and 270 women. Of them 138 lean (37.2%), 133 (35.9%) overweight, and 100 (26.9%) were obese, matched by age.

MEASUREMENTS

Fasting and 2 h serum glucose following a 75 g oral glucose load. Fasting serum total cholesterol, HDL- and LDL-cholesterol, triglycerides, C-reactive protein (CRP), albumin; and magnesium levels; urinary protein excretion; body mass index (BMI), waist-to-hip ratio (WHR), and blood pressure.

RESULTS

The presence of CRP was documented in four (2.9%) lean, 13 (9.8%) overweight, and 20 (20.0%) obese subjects, and decreased magnesium levels (equal or less than 1.8 mg/dl), in 2 (1.45%) lean, 7 (5.2%) overweight, and 19 (19%) obese subjects. The lowest serum magnesium levels and the highest CRP concentrations were documented in the obese subjects. Twenty-three (82.1%) of the subjects with low serum magnesium (five overweight and 18 obese) showed CRP concentration equal or more than 10 mg/l. There was a graded significant decrease between CRP concentration and serum magnesium levels (r = -0.39, P = 0.002). The odds ratio (CI95%) between magnesium and CRP adjusted by age, sex, BMI and glucose tolerance status for the subjects within the low quartile of magnesium distribution was 2.11 (1.23-3.84).

CONCLUSION

The results of this study show that low serum magnesium levels are independently related to elevated CRP concentration, in non-diabetic, non-hypertensive obese subjects.

[Diabetes family history is associated with early insulin response, in healthy Hispanic-Mexican subjects]

OBJECTIVE

To identify the associated risk factors to the increase of early insulin response in healthy Hispanic-Mexican subjects.

METHODS

Comparative cross-sectional study including 130 nonpregnant women and 54 men older than 30 years of age, randomly selected from Durango City, an urban population from the North of Mexico. According to the insulinogenic index value that assesses the early insulin response, subjects were distributed into quartiles. Subjects with increased insulin response (4th quartile) were compared against a control group (2nd and 3rd quartile).

RESULTS

There were no significant differences by obesity (body mass index 29.2 +/- 5.1 vs. 28.7 +/- 4.5 kg/m2), nor fasting nor 2-h post dose glucose (85.2 +/- 16.1 vs 82.1 +/- 10.4 mg/dL, and 95. +/- 25.5 vs. 99.1 +/- 23.1 mg/dL) between subjects in the 4th quartile vs. subjects in the 2nd and 3rd quartile, respectively. The family history of diabetes (FHD) (Odds ratio 3.9; C1(95%) 1.3-9.1, p < 0.01) was a powerful risk factor associated to increased early insulin response.

CONCLUSIONS

FHD is an independent predictor for increased early insulin response in Hispanic-Mexican subjects.

Insulin action and secretion in healthy Hispanic-Mexican first-degree relatives of subjects with type 2 diabetes

The aim of this study was to assess the early insulin secretion and insulin action of healthy non-diabetic Hispanic-Mexican subjects with and without family history of Type 2 diabetes (FHD). One hundred and twenty non-relative subjects were compared against 115 first-degree relatives of individuals with Type 2 diabetes. To assign the subjects to the correspondent group, the FHD was carefully ascertained by clinical examination of the participants' parents. Age and gender were matched criteria. Incomplete or unclear data about FHD, previous diagnosis of diabetes or chronic diseases were exclusion criteria. Subjects in both groups were required to have fasting glucose <6.1 mmol/l, and 2-h PG<7.7 mmol/l. Insulin action and secretion were estimated by HOMA (homeostasis model insulin analysis resistance index) and insulinogenic index, respectively. Logistic regression analysis showed an independent relationship between BMI and insulin resistance (HOMA score >5.0) (odds ratio, OR, 1.42, p=0.03), and between FHD and insulin resistance (OR 1.27, p=0.04). On the other hand, there was a strong and independent relationship between FHD and high early insulin secretion (insulinogenic index >0.72) (OR 1.64, p=0.01) but not between BMI and high early insulin secretion (OR 0.93, p=0.3). Healthy Mexican first-degree relatives of subjects with Type 2 diabetes show an independent relationship between FHD and both high early insulin response and decreased insulin action, whereas BMI was only related to insulin resistance.

Low serum magnesium levels and foot ulcers in subjects with type 2 diabetes

BACKGROUND

Hypomagnesemia is associated with the development of neuropathy and abnormal platelet activity, both of which are risk factors for the progression of ulcers of the feet. Thus, the aim of this study was to determine the relationship between low serum magnesium and foot ulcer in subjects with type 2 diabetes.

METHODS

Thirty-three out-patients with type 2 diabetes and foot ulcers (16 women and 17 men) were compared with a control group of 66 out-patients with type 2 diabetes without foot ulcers (35 women and 31 men), matched by age, diabetes duration, HbA1c, and glycemia. Patients with foot ulcers were included in the study only if a foot ulceration onset not exceeding 2 months was established. Patients diagnosed with reduced renal function, a history of alcohol intake, or as having received magnesium supplementation or diuretics were not included. Serum magnesium was measured by colorimetric method. The relationship between serum magnesium and foot ulcers was assessed by logistic regression.

RESULTS

Hypomagnesemia was identified in 31 (93.9%) subjects with foot ulcers, and 49 (73.1%) control subjects, p = 0.02. Subjects with foot ulceration had lower serum magnesium levels (1.48 +/- 0.33) than those in the control group (1.68 +/- 0.32), p <0.001. Logistic regression analysis showed a significant relationship between low serum magnesium levels and foot ulcers (odds ratio [OR] 2.9, CI 95% 1.7-6.8; p = 0.01).

CONCLUSIONS

Serum magnesium depletion is present and shows a strong relationship with foot ulcers in subjects with type 2 diabetes and foot ulcers, a relationship not previously reported.

Fasting plasma glucose diagnostic criterion, proposed by the American Diabetes Association, has low sensitivity for diagnoses of diabetes in Mexican population

To determine the best cutoff value of fasting plasma glucose (FPG) for diagnosis of diabetes, using the 2-h postglucose load (2-h PG) as the gold standard, in Mexican population and compare it to the 7.0 mmol/l limit proposed by the American Diabetes Association (ADA). 712 apparently healthy Mexican individuals were included in a cross-sectional randomized population survey. Sensitivity of FPG criterion for diagnoses of type 2 diabetes was calculated from a fourfold table. Glycemia value 2-h PG of >or=11.1 mmol/l was the "gold standard" diagnostic test. The optimal FPG value for diagnoses of diabetes was established on a receiver operating characteristic (ROC) scatter plot. On the basis of the "gold standard" diagnostic test, diagnosis of type 2 diabetes was established in 65 (9.12%) subjects, whereas the ADA FPG diagnostic criterion only identified 39 (5.47%) subjects; that is a sensitivity of 60% (CI(95%) 47.1-72.0). The ROC scatter plot showed the best cutoff value of FPG for diagnoses of diabetes that corresponds to 6.1 mmol/l, which has the highest sensitivity (0.985). FPG diagnostic criterion proposed by the ADA Expert Committee for diagnosis of type 2 diabetes has low sensitivity in Mexican population. For epidemiological purposes, estimates of diabetes prevalence in Mexico based on a FPG value of >or=6.1 mmol/l will improve the success of the screening.

[Family support of treatment compliance in essential arterial hypertension]

OBJECTIVE

To assess the relationship between family support and drug therapy compliance in essential hypertension.

MATERIAL AND METHODS

A case-control study was conducted between May and December 1999, at Mexican Institute of Social Security Regional Hospital in Durango, among 80 hypertensive subjects; 40 were cases and 40 controls. Cases were subjects who complied with drug therapy and controls were those who did not, matched by age, gender, schooling, hypertensive disease duration, and marital status. Differences were analyzed using the chi-squared test and Student's t test. Odds ratios were obtained to assess the strength of associations. Subjects diagnosed with secondary hypertension or other chronic diseases were excluded.

RESULTS

There were no differences in sociodemographic variables, therapy modality, and knowledge about hypertensive disease between cases and controls. Thirty-one (77.5%) compliant subjects, and 31 (77.5%) non-compliant subjects had arterial blood pressure values in normal ranges (p = 0.003). A strong and independent relationship between family support and therapy compliance was found (OR 6.9, 95% CI 2.3-21.1).

CONCLUSIONS

Therapy compliance is strongly related with family support provided to the hypertensive patient. The English version of this paper is available at: http://www.insp.mx/salud/index.html

[Games as an alternative for teaching basic health concepts]

OBJECTIVE

To determine, for the teaching of basic health concepts to school-age children, the effectiveness of an educational strategy based on traditional children's games.

METHODS

Intervention study carried out in the city of Durango, Mexico, in June 2000 with 300 children from 9 to 11 years old. The children were randomly divided into two groups. The children in Group A used a modified version of a Mexican popular game called Serpientes y Escaleras (Snakes and Ladders) that included messages on basic health concepts; the children in Group B made up the control group and did not play the modified game.

RESULTS

At baseline there were no significant differences between the two groups in terms of age, grade level, or their scores on a knowledge test of basic health concepts. After the educational intervention, the health concepts test scores, out of a maximum possible of 10, were 9.3 +/- 0.8 for Group A and 7.5 +/- 1.1 for Group B (P < 0.001).

CONCLUSIONS

Using games that include health and hygiene messages can be an alternative for teaching basic health concepts.

Glucose intolerance is predicted by the high Fasting Insulin-to-Glucose ratio

OBJECTIVE

To determine whether impaired glucose tolerance (IGT) is predicted by high Fasting Insulin-to-Glucose (FIG) ratio and to establish its correlation with insulin resistance and fasting insulin.

MATERIAL AND METHODS

A population-based three-year follow-up study was performed. The target population consisted of healthy volunteers, men and non-pregnant women aged 30 years or over. Participants were required to have normal referenced ranges of OGTT and blood pressure. Previous diagnosis of chronic diseases was an exclusion criterion. At baseline and at the 3-yr of follow-up, an OGTT was performed. The ratio of serum Fasting Insulin (microUI/ml)/Fasting Glucose (mg/dl) was used to calculate the FIG ratio. Insulin action and secretion were estimated by HOMA and Insulinogenic index, respectively.

RESULTS

The FIG ratio was directly correlated with the HOMA index (r=0.83, p<0.01) and fasting insulin (r=0.95, p<0.001). Multivariate logistic regression analysis showed that IGT was more likely to develop in subjects with high FIG ratio (RR 5.01; CI(95%) 1.9-12.2, p=0.02), high HOMA index (RR 6.1; CI(95%) 2.1-11.1, p=0.01), and fasting hyperinsulinemia (RR 4.7 CI(95%) 2.7-13.2, p<0.05). The cutoff point of FIG ratio for determining the risk of developing IGT was 0.25 +/- 0.05.

CONCLUSIONS

The FIG ratio could be a reliable alternative for the screening of apparently healthy subjects in high risk groups.

[Cuff pressure in endotracheal intubation: should it be routinely measured?]

OBJECTIVE

To determine the relationship between endotracheal tube cuff pressure and post-surgical tracheal pain.

MATERIAL AND METHODS

Cross-sectional study of forty subjects who required endotracheal intubation for elective surgery allocated into two groups according to tube cuff pressure. Subjects who had cuff pressure equal to or less than 42 Mmhg were assigned to Group A, and those with cuff pressure higher than 42 Mmhg to group B. Cuff pressure measurements were carried out previously to removing the endotracheal tube. Low-pressure, high-volume type of tube was used in all subjects. Tracheal pain was evaluated at 60 min and 24 h after extubation.

RESULTS

There were not differences in the intubation time required (117 +/- 36.9 min vs. 133 +/- 64.9 min, p = 0.3) or in the number of tracheal tubes used in both groups. Tracheal pain was similar in both groups 60 min after extubation, but at 24 h persisted only in 10% of subjects in group A and 53.3% of B, p = 0.02. The correlation between tracheal pain and tube cuff pressure at 24 h was 0.76, p = 0.00001.

CONCLUSIONS

High tube cuff pressure is a related factor to the tracheal pain so must be considered a routine monitoring of cuff pressure and device to avoid cuff pressure that exceeds the necessary minimum.

The parental phenotype of diabetes, but not of essential hypertension, is linked to the development of metabolic syndrome in Mexican individuals

Studies on the role of parental history on the risk of developing metabolic syndrome (MS) show inconsistent data that may depend on misclassification of the parental history. Confirming carefully the parental phenotype (PF) of type 2 diabetes mellitus (DM) and essential hypertension (EH) of participants' parents, we determined the relationship between PF of either DM or EH and the risk of developing MS in Mexican individuals. A case-control study of 210 subjects randomly recruited from Durango, Mexico was carried out. Subjects with MS (cases) were compared with a control group of subjects without MS matched by age and gender. MS was defined by the presence of two or more of the following: fasting glucose > or =7.0 mmol/l; blood pressure > or =160/90 mmHg; fasting triglycerides > or =1.7 mmol/l and/or HDL-cholesterol <1.0 mmol/l; and obesity (body mass index > or =30 kg/m2 and/or waist-to-hip ratio > or =0.85). The PF of DM and EH was confirmed by direct clinical examination and/or review of certificates of death of each of the participants' parents. Incomplete or unclear data about PH were exclusion criteria. Multivariate analysis showed that PF of DM without EH (odds ratio (OR) 2.6; 95% CI, 1.3-7.8, p=0.044) and PF of both DM and EH (OR, 3.1; 95% CI, 1.5-9.1, p=0.0001), but not the PF of EH without DM are independent predictors for developing MS in Mexican individuals. In the offspring generation of Mexican subjects, the PF of DM seems to increase the risk of developing MS, whereas PF of EH does not.

Impaired glucose tolerance is a more advanced stage of alteration in the glucose metabolism than impaired fasting glucose

BACKGROUND

Recent reports have shown a lack of agreement between the impaired glucose tolerance (IGT) and the impaired fasting glucose (IFG) categories, suggesting that correspond to different impaired glucose metabolism stages.

OBJECTIVE

To determine the differences of serum insulin levels between subjects with IFG and IGT diagnoses.

METHODS

Cross-sectional study of 52 subjects with IFG and 48 with IGT diagnosis, and a euglycemic group of 140 subjects. Serum glucose and insulin were measured in both fasting and 2-h 75-g oral post-load glucose (2-h PG).

RESULTS

Subjects with IFG showed the highest fasting and 2-h PG serum insulin levels, whereas subject with IGT the lowest. Serum insulin values showed no significative changes between the fasting and 2-h PG conditions in the subjects with IGT, whereas the subjects with IFG showed significative hyperinsulinemia. The serum glucose 2-h PG showed an increase of 0.2 mmol/l (CI(95%) 0.07-0.33), 0.5 mmol/l (CI(95%) 0.41-0.58) and 3.6 mmol/l (CI(95%) 3.39-3.81) with respect to basal values, whereas the increase of serum insulin 2-h PG was of 54 pmol/l (CI(95%) 53.71-55.29), 918 pmol/l (CI(95%) 917.49-918.51) and 0.5 pmol/l (CI(95%) 0.15-0.84) for the euglycemic, IFG and IGT subjects, respectively.

CONCLUSIONS

This study demonstrates that subjects with IFG show hyperinsulinemia whereas those with IGT have low insulin secretion in response to oral load glucose, suggesting that IFG and IGT correspond to different stages of impaired glucose metabolism.

[Circadian arterial blood pressure variation in non hypertensive type 2 diabetic patients]

OBJECTIVE

To determine the characteristics of the blood pressure circadian rhythm in non-hypertensive type 2 diabetic subjects.

MATERIAL AND METHODS

Cross-sectional study on 57 individuals with type 2 diabetes without hypertension (31 women and 26 men) and 57 healthy subjects in a control group (29 women and 28 men). High blood pressure, renal or hepatic diseases were exclusion criteria. Using patient activated semiautomatic portable blood pressure recorder (Omron Healthcare Inc., Vernon Hills, Ill 60061), self-measured blood pressure of 24-h was registered. Subjects who blood pressure measures were not appropriately recorded in equal or more than 10% of the lectures were not included.

RESULTS

The average systolic and diastolic blood pressure of 24-h was similar between the groups studied. The percentage decrease in the nocturnal systolic/diastolic blood pressure was of 4.6%/1.2% and 3.8%/6.8% for the diabetic women and men respectively, and of 8.6%/9.9% and 6.8%/8.2% in the control women and men. For the last nocturnal and first diurnal hours the systolic/diastolic blood pressure of diabetic subjects showed a lower increase with a higher duration than that observed for the control group.

CONCLUSIONS

Non hypertensive type 2 diabetic subjects shown both nocturnal blood pressure fall of less than 10% and a lower increase, with prolonged duration in the first diurnal hours, than that observed in healthy subjects.

Hypomagnesemia is linked to low serum HDL-cholesterol irrespective of serum glucose values

Hypomagnesemia is common in diabetic subjects, and is especially common in poorly controlled diabetes, suggesting that diabetes low serum magnesium status is osmotic diuresis-dependent. To assess the relationship between serum magnesium and HDL-cholesterol concentration adjusted by serum glucose values. We assessed the serum magnesium levels of 50 controlled (HbA(1c)</=7.5% and FPG<126 mg/dl), 110 non-controlled (HbA(1c)>7.5% and FPG>/=126 mg/dl) type II diabetic patients, 40 subjects with impaired fasting glucose (IFG) (FPG>/=110 mg/dl and <126 mg/dl) and 190 healthy volunteers (FPG<110 mg/dl). Healthy volunteers were required to have normal blood pressure and normal laboratory tests. Subjects in the groups included were matched by age and body mass index (BMI). The average of diabetes duration was of 11.4+/-6.6, and 10.9+/-6.2 years, P=NS, for the controlled and non-controlled diabetic patients, respectively. Thirty (60.0%) controlled diabetic subjects, 58 (52. 7%) non-controlled diabetic patients, 21 (52.5%) subjects with IFG, and 39 (20.5%) healthy volunteers had serum magnesium levels </=1.7 mg/l. Serum HDL-cholesterol value showed significant graded increase with serum magnesium levels irrespective of glucose values. Results of this study suggest that hypomagnesemia by an etiopathogenic pathway glycemia independent seems to be involved to decrease HDL-cholesterol.

Prevalence of hypertension in indigenous inhabitants of traditional communities from the north of Mexico

The purpose of this study was to estimate the prevalence and risk factors of hypertension in adults indigenous to their traditional communities from the north of Mexico. The study was based on a cross- sectional survey of inhabitants from Mexicaneros, Huicholes and Tepehuanos communities, which have not been influenced by a western lifestyle. A home interview and clinical examination that included blood pressure and anthropometric measurements of 217 men and 598 non-pregnant women aged between 35 to 64 years was carried out. Eligible indigenous subjects must have had no migratory history to partially or totally urbanised areas. Target population represented approximately 100% of the indigenous people who have spent all their life time in the community of birthplace. Age and body mass index average was 48.9+/-12.9 years and 25.6+/-5.1 kg/m2. Hypertension was identified in 56 individuals, 45 women and 11 men (prevalence 6.87%, 95% confidence interval (CI) 5.1-8.6). Forty-one percent of the hypertensive subjects were aware of being hypertensive. Hypertensive subjects had a higher intake of saturated fats than non-hypertensives. Salt consumption was lower than 6 g per day in subjects with and without hypertension. High intake of saturated fats (odds ratio 6.4, 95% CI 2.1-12.3; P<0.01) was an independent predictor for hypertension. This study presents, for the first time, data concerning hypertension in adults who are indigenous to and living in traditional communities from Mexico. Prevalence of hypertension was lower than in the partly urbanised rural communities with a westernised lifestyle and the urban areas of Mexico.

Hyperinsulinemia and abdominal obesity are more prevalent in non-diabetic subjects with family history of type 2 diabetes

BACKGROUND

This study was undertaken in order to identify the relationships between family history of type 2 diabetes and cardiovascular risk factors in non-diabetic Mexican individuals.

METHODS

The design was a cross-sectional, population-based study stratified by age and sex. Participants consisted of 189 non-diabetic volunteers 30-64 years of age, both males and non-pregnant females randomly selected from a middle income neighborhood in Durango, Mexico and distributed into two groups, with and without family history of type 2 diabetes mellitus. Hypertensive subjects were excluded. Body mass index (BMI) and waist-to-hip ratio (WHR) were assessed. Hematocrit, both fasting and 2-h post 75-g glucose load insulin, and glucose levels, lipid profile, serum albumin, and proteinuria were measured.

RESULTS

Ninety-four (49.7%) individuals with family history of type 2 diabetes, and 95 (50.3%) in the control group were included. The prevalence of obesity was greater among women with family history of diabetes, 39 (73.6%) vs. 27 (50.0%) of the control group, p = 0.02. Adiposity tended to be centrally distributed in 86 subjects, of whom 22 (25. 6%) males and 54 (62.8%) females were in the group with family history of diabetes and four (4.6%) males and six (7.0%) females in the control group, p <0.000. Multivariate logistic regression analysis showed a strong relationship between family history of type 2 diabetes with both abdominal obesity (odds ratio [OR] 4.2, CI 95% 1.9-10.1, p <0.05) and fasting hyperinsulinemia (OR 3.1, CI 95% 1. 4-11.2, p <0.05).

CONCLUSION

In the absence of additional risk factors such as diabetes and hypertension, there is a strong relationship between family history of diabetes with hyperinsulinemia and abdominal obesity in middle-aged Mexican individuals.

[Fasting glucose/insulin index and insulin levels 2-h after glucose load are predictors of the development of type 2 diabetes]

To determine whether fasting glucose/insulin (FG/I) ratio and insulin levels 2 h after 75-g oral load of glucose (IL-2 h PG) are predictors for type 2 diabetes mellitus, a comparative 2 year follow-up study was conducted. Ninety-six healthy subjects 30 years of age or older, randomly selected from the general population of Durango, Mexico were included in two groups: 1) risk group: members had both baseline FG/I ratio and IL 2-h PG within the lower and upper quartile, respectively, and 2) control group, whose members had baseline FG/I ratio and IL 2-h PG within the second and third quartiles, respectively. Multivariate logistic regression was used to compute the relative risk for the development of type 2 diabetes. The family history of diabetes (RR 10.1; IC95% 2.7-15.8, p < 0.01), glucose intolerance (RR 9.8; IC95% 1.7-13.4, p < 0.01), abdominal obesity (RR 6.1; IC95% 1.5-10.1, p < 0.01), and the low FG/I ratio and high IL 2-h PG (RR 3.3; IC95% 1.4-8.2, p < 0.05) were strong predictors for type 2 diabetes. Critical values for predicting criteria of FG/I ratio and IL 2-h PG were of 4.0 y 180 microUI/ml, respectively. In conclusion, the measurement of FG/I ratio and IL 2-h PG is an accurate indicator for estimating the risk of developing type 2 diabetes.

[Estimating forced expiratory volume in one second based on breath holding in healthy subjects]

Cross sectional study to evaluate a linear correlation model to calculate forced expiratory volume in one second (FEV1) on the basis of breath-holding time (BHT) in healthy subjects aged 16 years or older. BHT was defined as the maximum time in seconds that a person can voluntarily hold his or her breath measured between the end of a deep breath until he or she begins to exhale in the third of three consecutive maneuvers. To calculate FEV1 on the basis of BHT (FEV1-BHT) the general straight-line equation (y = a + bx) was applied, with x being Logn of BHT and y being FEV1. The a and b values had been previously estimated by gender using multiple linear regression in which FEV1 measured spirometrically was the dependent variable and the age and Logn of BHT were the independent variables. One hundred ninety-seven subjects [97 women (49.2%) and 100 men (50.8%)] were enrolled. Mean FEV1 measured by spirometry (FEV1-Sp) and FEV1-BHT were similar. The correlation (R2) between FEV1 and BHT for women and men was 0.585 (95% CI 0.213-0.753) and 0.702 (95% CI 0.630-1.496), respectively. The ratio FEV1-BHT:FEV1-Sp was higher than 80% for 96 women (98.96%) and 98 men (98.0%). FEV1 can be reliably estimated using BHT.

Proteinuria is an independent risk factor for ischemic stroke in non-insulin-dependent diabetes mellitus

BACKGROUND AND PURPOSE

Proteinuria is an independent risk factor for cardiovascular disease in patients with NIDDM. The aim of this study was to assess the relationship between proteinuria and ischemic stroke in subjects with NIDDM, and to determine whether proteinuria is an independent risk factor for stroke.

METHODS

We performed a case-control study of 59 diabetic patients with first-ever ischemic stroke due to thrombotic arterial occlusion, who were considered cases, and 180 diabetic patients without stroke, matched by gender, age, and diabetes duration, as a control group. WHO criteria for verified definite or possible stroke were used to ascertain the diagnosis of stroke. For the purpose of this study proteinuria was defined as a 24-hour urinary protein excretion rate of >/=20 and <200 microg/min. Risk factors included were smoking, blood pressure, body mass index, serum total cholesterol, hyperglycemia, and proteinuria.

RESULTS

Subjects with stroke had higher proteinuria proportion and systolic and diastolic blood pressures. Both frequency of antihypertensive treatment and antihypertensive drugs used were similar among subjects with and without stroke. In multivariate logistic regression analysis, the ORs and 95% CIs for the variables identified as risk factors for stroke were as follows: systolic pressure (OR 3.10; 95% CI 3.01 to 4.21; P=0.03); diastolic pressure (OR 3.30; 95% CI 1.04 to 4.48; P<0.0001); fasting glucose >/=11.1 mmol (OR 1.82; 905% CI 1.4 to 3.8; P=0.04), HbA1c >/=9.5% (OR 1.7; 95% CI 1.3 to 5.1; P<0.01), and proteinuria (OR 3.23; 95% CI 1.06 to 4.36; P<0.0001).

CONCLUSIONS

Our case-control study gives evidence that proteinuria is an independent risk factor for ischemic stroke in patients with NIDDM.

Increased levels of C-reactive protein in noncontrolled type II diabetic subjects

Type II diabetes is an hemorheological disease in which hyperglycemia increases the shear stress contributing to inflammation and dysfunction of endothelium. The purpose of this study was to identify the relationship between serum C-reactive protein and glucose levels in noncontrolled type II diabetic subjects. A cross-sectional study was conducted, including 62 noncontrolled type II diabetic subjects that were assigned to two groups. One group was patients with acute diarrhea or urinary tract infection and the other group was diabetic subjects who were infectious-disease free. Sixty-two subjects without diabetes constituted the respective control groups. Heart failure, other acute febrile illnesses, asymptomatic infection, renal, hepatic, malignant or chronic inflammatory illness, and macrovascular disease were considered as exclusion criteria. Laboratory measurements were performed. Thirty (96.7%) and 29 (93.5%) diabetic patients in the groups with and without infectious disease, and 28 (90.3%) control subjects with infectious disease had elevated C-reactive protein levels (> or =10 mg/L). In contrast, healthy control subjects did not have elevated serum C-reactive protein levels. Multiple regression analysis showed a significant association between C-reactive protein levels and hyperglycemia (Odds ratio = 7.4; IC95% 2.3-11.2). This study show that hyperglycemia is a related factor to the increase of serum CRP levels in noncontrolled type II diabetic subjects.

[Electrocardiographic changes and cardiovascular risk factors in patients with type-2 diabetes]

OBJECTIVE

To determine the most frequent alterations in rhythm and cardiac conduction in patients with type 2 diabetes without previous cardiopathy, and to establish the association of this disease with cardiovascular risk factors.

MATERIAL AND METHODS

Subjects with type 2 diabetes, without cardiopathy antecedents were included in the study. Cardiovascular risk factors, body mass index and serum glucose, cholesterol and trygliceride levels were determined. A resting electrocardiogram was recorded. The association between the variables under study and arrhythmia was calculated with a multivariate analysis adjusted by sex.

RESULTS

A total of 199 patients were included: 113 women (56.8%) and 86 men (43.2%). Arrhythmia was registered in 29.1% of the subjects. Anterior hemiblock (AH) and right bundle branch block (RBBB) constituted 75.9% of the identified alterations. Patients with arrhythmia and conduction disorders have higher levels of cholesterol and triglycerides. Appearance of arrhythmia is directly related to aging (r = 0.75, p = 0.01). The multivariate analysis adjusted by sex revealed that hypercholesterolemia and aging are significantly associated with arrhythmia and conduction alterations: OR 1.5, CI 95%, 1.1-4.6, p < 0.05 and OR 1.3, CI 95% 1.0-5.2, p < 0.05, respectively.

CONCLUSIONS

The most frequent arrhythmia and conduction disorders in type 2 diabetes are AH and RBBB. Hypercholesterolemia and aging are the strongest and most frequent factors associated to the presence of this disease.

[Folic acid deficiency and its association with neural tube defects in northern Mexico]

OBJECTIVE

To evaluate folic acid deficiency and other risk factors and their relationship with the occurrence of neural tube defects (NTD), in the rural population of northern Mexico (Chihuahua, Durango and Zacatecas).

MATERIAL AND METHODS

A multicentric case-control study was performed. Cases were both live and stillborn with NTD, and controls were healthy newborns without congenital malformations. Exposure to known risk factors was determined, establishing its association with NTD using multiple logistic regression analysis.

RESULTS

Risk factors associated to NTD were: folic acid deficiency (OR 11.1; CI 95% 1.2-106.2, p = 0.04); the antecedents of previous NTD pregnancies (OR 3.3; CI 95% 1.1-18.8, p = 0.05) and stillbirths (OR 7.1; CI 95% 1.1-46.3, p = 0.04).

CONCLUSIONS

Folic acid deficiency is one of the major risk factors associated to NTD among the rural population of northern Medico. Further investigations are necessary to determine the role of involved risk factors and implement adequate preventive measures.

Lipid- and glucose-lowering efficacy of Plantago Psyllium in type II diabetes

The beneficial effect of dietary fiber in the management of type II diabetes is still controversial and has not been totally demonstrated. The purpose of this study was to determine the plasma-lowering effects of 5 g t.i.d. of Plantago Psyllium, as an adjunct to dietary therapy, on lipid and glucose levels, in patients with type II diabetes. Patients were randomly selected from an outpatient clinic of primary care to participate in a double-blind placebo-controlled study in which Plantago Psyllium or placebo was given in combination with a low fat diet. One hundred twenty-five subjects were included in the study that consisted in a 6-week period of diet counseling followed by a 6-week treatment period. Fasting plasma glucose, total plasma cholesterol, LDL cholesterol, HDL cholesterol and triglyceride levels were measured every 2 weeks. The test products (Psyllium or placebo) were supplied to subjects in identically labeled foil packets containing a 5-g dose of product, to consume three doses per day (of 5 g each one), before regular meals. There was an excellent tolerance to Psyllium, without significant adverse effects. No significant changes were observed in the patient's weight for both groups (not significant). Fasting plasma glucose, total cholesterol, LDL cholesterol, and triglycerides levels, showed a significant reduction (p < 0.05), whereas HDL cholesterol increased significantly (p < 0.01) following Psyllium treatment. Our results show that 5 g t.i.d. of Psyllium is useful, as an adjunct to dietary therapy, in patients with type II diabetes, to reduce plasma lipid and glucose levels, resolving the compliance conflict associated with the ingest of a great amount of fiber in customary diet.

Relationship of microalbuminuria with the diabetic foot ulcers in type II diabetes

Microalbuminuria is a significant risk factor associated with nephropathy, retinopathy, and cardiovascular disease; however, there are no previous reports on the relationship of microalbuminuria with diabetic foot ulcers or stroke, despite the fact that microalbuminuria is a marker of vascular damage. The purpose of this study was to determine the relationship of microalbuminuria with diabetic foot ulcers in type II diabetes patients. In this, cross-sectional clinical study, outpatients of the offices at first level medical care in Durango, Mexico, were included in one of two groups; (a) patients with diabetic foot ulcers and (b) control of group patients without diabetic foot ulcers. Diabetic foot diagnosis was established on the basis of clinical criteria and pletismography. Patients diagnosed with renal disease, urinary tract infection, acute febrile illness, or heart failure and those receiving angiotensin-converting enzyme inhibitors were excluded from the study. Microalbuminuria was measured, on a 24-h urine collection, by precipitation with sulfasalicylic acid, and turbidity was determined by measuring absorbance with a spectrophotometer. The study included 670 diabetic patients. Using both odds ratio and logistic regression analyses, diabetes duration, cigarette smoking, aging, and microalbuminuria showed a strong relationship with diabetic foot ulcers. Microalbuminuria should be considered as an independent risk factor for diabetic foot ulcers.

[Accumulated probability of hypertension in diabetes and of diabetes in hypertension]

OBJECTIVE

To determine the cumulative probability of hypertension in type 2 diabetic patients, and of diabetes in patients with essential arterial hypertension.

METHODS

A 15-years follow-up study of 308 subjects, 156 with type 2 diabetes and 152 with arterial hypertension. Time zero (T0) was the date in which the diabetes or the hypertension were established. The time in years from T0 up to diagnosis of hypertension in diabetics or diabetes in hypertensives was determined. The cumulative probability was calculated with the method of Kaplan and Meier.

RESULTS

The incidence of hypertension in the diabetics was 4.36 patient-year, and that of diabetes in hypertensives of 1.23 patient-year (p = < 0.00001; Cl95% 4.8-14.7). After the first 5 years, 40% of the diabetics had hypertension and 12% of the hypertensives developed diabetes; at 15-years follow-up, these figures were 71% and 21% respectively (p < 0.001).

CONCLUSIONS

The probability of essential arterial hypertension in type 2 diabetes was significantly higher than the incidence of diabetes in hypertensive subjects. In both instances, the risk was greater for men than for women.

[Prevalence of arterial hypertension and related factors in a marginated rural population]

OBJECTIVE

To determine the prevalence and risk factors related to systemic arterial hypertension (SAH) in the rural marginated population of Durango, Mexico.

MATERIAL AND METHODS

A comparative cross-sectional study was performed in 627 rural communities, approximately 90% of which have 250 inhabitants or less. The arterial pressure and sociodemographic variables were determined.

RESULTS

A total of 5,802 subjects were studied, 4,452 women (76.7%) and 1,350 men (23.3%). SAH was found in 1,271 individuals (21.9%; CI 95% 20.8-23.0) of which 1,011 were women (22.71%; CI 95% 21.5-23.9) and 260 were men (19.26%; CI 95% 17.2-21.4). Of the target population, 3,018 individuals (52.0%) live in communities of less than 250 inhabitants, 2,080 (60.9%) women and 938 (31.1%) men. In this group, SAH was identified in 445 cases (14.74%; CI 95% 13.5-16.0) of which 326 are women (15.7%; CI 95% 14.1-17.3) and 119, men (12.7%; CI 95% 10.6-14.9). The main risk factors related to SAH were obesity, type 2 diabetes, alcohol and tobacco consumption.

CONCLUSIONS

The prevalence of SAH in the rural marginated population is apparently related to the degree of development of the communities.

[Postoperative analgesia using epidural administration of bupivacaine plus lidocaine]

OBJECTIVE

To compare the postoperative analgesia of bupivacaine + lidocaine versus lidocaine in lower abdominal surgery.

DESIGN

Randomized clinical trial.

METHODS

Thirty patients, scheduled for lower abdominal surgery and epidural anesthesia (EA) were randomly assigned to receive EA with 30 mg of bupivacaine plus 240 mg of lidocaine (group A) or 300 mg of lidocaine (group B). A lumbar epidural catheter in L1-L2 or L2-L3 was inserted, and a bolus with total dose was given. The periods of latency and postoperative analgesia, the hemodynamic variable and the preoperative, intraoperative and postoperative data were recorded.

RESULTS

Fifteen patients per group were included. There were no differences intergroup in age, height, weight, hemodynamic variables and surgical data. The period of latency was similar in the groups but postoperative analgesia was longer in group A and the postoperative pain scores were higher in group B in the first 120 minutes after surgery. There were no serious complications. In newborns of cesarean section, the Apgar scores at 1 and 5 minutes after delivery were similar in both groups.

CONCLUSIONS

The mixture of bupivacaine + lidocaine proved be an effective alternative for epidural use in lower abdominal surgery.

[Serum cholesterol levels and their relation to ischemic cardiopathy in patients with non-insulin-dependent diabetes]

OBJECTIVE

Determine the frequency and relationship between ischemic heart disease (IHD) and serum cholesterol levels (SCL) in non insulin dependent diabetes mellitus (NIDDM) of the primary medical care level.

MATERIAL AND METHODS

A total of 411 patients from the first medical care level were studied. The sociodemographic profile, SCL and glycemia were determined and conventional ECG was taken. The ST uneveness, ischemic T or pathological Q waves in two or more tappings was considered as IHD. Patients with history of IHD were not included.

RESULTS

The male:female ratio was 1.5:1. Mean SCL was 225 mg/dl (in females 240.8 +/- 56 mg/dl and 220.7 +/- 50.7 in males). In 90 patients we identified IHD (22%), with male predominance (0.85:1, F:M). In the stratified statistical analysis the SCL > or = 200 mg/dl and IHD were significantly associated. The frequency of IHD by SCL levels of 200-239 mg/dl was 24.6% (OR 2.04; CI 95% 1.03-4.07, p = 0.04) and 24.2% (OR 1.99; CI 95% 1.02-3.96, p = 0.04) for SCL of 240-300 mg/dl; in patients with SCL > 300 mg/dl, an increase of IHD to 38.7% was observed (OR 3.95; CI 95% 1.52-10.30, p = 0.002).

CONCLUSIONS

The hypercholesterolemia was one of the most important cardiovascular risk factors in NIDDM, in which SCL > or = 200 mg/dl must be considered strongly associated to IHD.

Low prevalence of non-insulin-dependent diabetes mellitus in indigenous communities of Durango, Mexico

To determine the prevalence and associated risk factors of non-insulin-dependent diabetes mellitus (NIDDM) in inhabitants of traditional indigenous communities from Durango, Mexico, a transversal descriptive study was conducted. Tepehuano, Huichol and Mexicanero tribe members without racial admixture and a minimal Western influence on lifestyle were studied. One hundred and ninety-three subjects were included, this figure corresponding to approximately 20% of subjects aged from 30 to 64 years of the target population. Glycemia was determined in capillary blood after an overnight fast of 10-12 h, and 2 h after a 75 g oral glucose load using a Glucometer II device; NIDDM diagnosis was established according to the WHO criteria. Personal risk factors of NIDDM were determined. The average glucose level was 87.5 +/- 19.3 mg/dl. There were no NIDDM cases, hence the prevalence was 0.0%. The personal risk factors profile for NIDDM were as follows: 0.0% of cases with family history of NIDDM and with residency in urban areas > 40% of their lifetime, 7.2% of obese subjects and 15.5% of subjects with alcohol intake > or = 8 g/day. The absence of NIDDM suggests that this disease may be rare in traditional indigenous communities of Mexico and may be associated with less exposure to risk factors or genetic differences.

[Importance of family support in the control of glycemia]

OBJECTIVE

To determine the importance of family support in the control of glucemia in non-insulin-dependent diabetes mellitus patients.

MATERIAL AND METHODS

A case and control study was designed where cases were patients with glycemia < 140 mg/dl and controls, patients with glycemia > or = 140 mg/dl. Family support was determined using the questionnaire Environmental Barriers to Adherence Scales which estimates the support lent by the family to the patient to follow therapeutic indications. The study consisted of 32 cases and 50 controls.

RESULTS

Family support received by the patient is significantly associated to the presence of glycemia < 140 mg/dl (OR = 3.9; 95% C.I. 1.4-11.1). Other variables did not show significant association.

CONCLUSIONS

Family support lent to patients influences the control of glycemia.

[Survival analysis in cirrhotic patients]

BACKGROUND

Hepatic cirrhosis (HC) is a chronic and progressive disease that, independently of its etiology, favors the presence of some complications that impair the survival of patients.

AIMS

To determine the frequency, etiology, and main decompensation factors, as well as analyse survival curves in HC of a population of Durango, México.

METHODS

Cirrhotic patients of both sexes from the Hospital General del IMSS in Durango were included. The etiology of cirrhosis, the factors of decompensation and the grade of portal hypertension (PHT) were determined. A 39 month follow-up was done, registering complications and cause of death.

STATISTICAL ANALYSIS

Fisher's exact test, Friedman's variance analysis, Mantel-Haenzsel chi-square test and Kaplan-Meier methods were used.

RESULTS

Fifty patients were studied, 30 female and 20 male. The mean age was 54.3 years old (range 32-74 years). The more frequent etiology was alcoholic in 42% patients (19 male and 2 female). Forty three patients (86%) had decompensation by ascitis; 19 (38%) had variceal bleeding, 18(36%) had encephalopathy and 16(32%) were icteric. Twenty six patients (52%) had PHT III, and 30 (60%) were Child-Pugh class B.

CONCLUSIONS

Survival in the decompensated group at 19.8 months follow-up was 62% and 73% in the total group, 20% died. Statistical significance (p < 0.05) was found between PHT grade and Child-Pugh functional class; hepatic reserve correlated inversely with bleeding (p < 0.05) and encephalopathy (p < 0.05) probability. The advanced grade of PHT directly correlated with bleeding encephalopathy and mortality (p < 0.05). We did not find any association between the etiology of cirrhosis and the incidence of complications.

[Prevalence of risk factors associated with hepatitis C in blood donors in the municipality of Durango, Mexico]

OBJECTIVE

To determine the prevalence of anti-viral hepatitis C antibodies (HCV-Ab+) in voluntary blood donors and to identify the main risk factors associated with it.

MATERIAL AND METHODS

A case-control study was conducted over a 20-month period beginning in June 1993. A clinical history was obtained from all blood donors seen at the Centro Estatal de la Transfusión Sanguínea (State Blood Transfusion Center) and the Instituto Mexicano del Seguro Social in Durango, Mexico. HCV-Ab+ was determined in 5 915 serum assays using the second generation enzymatic immunoassay (UBI HCV EIA).

RESULTS

The prevalence of HCV-Ab+ was 1.47 per 100 donors. The HCV-Ab+ prevalence was similar for urban and rural donors (1.54% and 1.34%) with no history of work migration. The main risk factors associated with HCV were a history of transfusions, (odds ratio -OR- 14.80, 95% confidence interval -CI-4.97-47.17) and sexual promiscuity or intercourse with prostitutes, (OR 6.53, 95% CI 2.61-16.54).

CONCLUSIONS

The high prevalence of HCV-Ab+ may be explained by the lack of epidemiological surveillance of the population at risk. These data underscore the need for routine screening of HCV-Ab among voluntary blood donors and male or female prostitutes.

Consumption of soft drinks with phosphoric acid as a risk factor for the development of hypocalcemia in children: a case-control study

A comparison of 57 cases (in children with serum calcium concentration < 2.2 mmol/L) and 171 controls (in children with serum calcium level > or = 2.2 mmol/L) was carried out to assess whether the intake of at least 1.5 L/wk of soft drinks containing phosphoric acid is a risk factor for the development of hypocalcemia. A significant association was found: odds ratio = 5.27; 95% confidence interval, 3.17 to 8.75; p < 0.001. The hypothesis of a causal relationship between intake of phosphoric acid-containing soft drinks and hypocalcemia warrants further investigation.