RESUMEN
En esta revisión valoraremos el tema en cuatro fases: 1) Prevención primaria Factores de riesgo no modificables: 1) Edad, 2) Sexo, 3) Bajo peso al nacer, 4) Raza, 5) Factores genéticos. Factores de riesgo modificables: 1) Enfermedad aterosclerótica, 2) Hipertensión arterial, 3) Diabetes mellitus, 4) Dislipemia, 5) Hábito tabáquico, 6) Consumo abusivo de alcohol, 7) Actividad física, 8) Dieta y nutrición: Las sociedades científicas recomiendan la dieta DASH (fruta, vegetales, pobre en grasas totales y saturadas) para reducir la presión arterial. La dieta rica solamente en fruta y vegetales puede disminuir el riesgo de ictus. Se recomienda reducir el consumo de sodio (≤ 2,3 g 100 mmol/día) y aumentar el de potasio (≥ 4,7 g . 120 mmol/día). para reducir la presión arterial. 9) Obesidad y distribución de la grasa corporal, 10) Hiperhomocisteinemia. 2) Tratamiento de la fase aguda La incidencia de malnutrición varían entre un 7-15% al ingreso. Después del ictus el estado nutricional se deteriora, generalmente por disfagia y déficit motores que dificultan la alimentación autónoma estando ya desnutridos el 22-35%. La presencia de malnutrición en estos pacientes condiciona de forma desfavorable su pronóstico. En caso de presentar alguna dificultad para la ingesta normal y siempre que el riesgo de aspiración sea mínimo, estar. indicado realizar modificaciones en la textura de la dieta. Si el paciente presenta fatiga o saciedad precoz será útil hacer tomas de poca cantidad pero muy frecuentes. Con mucha frecuencia nos encontramos disfagia para líquidos y deberemos espesar éstos con productos de nutrición enteral como los módulos de espesante. En pacientes con un estado nutricional deficitario o que no cubren sus requerimientos nutricionales con dieta oral los suplementos de nutrición enteral son un recurso eficaz. En pacientes con disfagia persistente, las vías para la administración de nutrición enteral m.s frecuentes son la sonda nasogástrica (SNG) y la gastrostomía endoscópica percutánea (PEG). La fórmula de elección es una polimérica, normoproteica y normocalórica y con fibra, salvo que alguna otra situación haga recomendable otro tipo diferente. En los casos de pacientes con desnutrición al ingreso o con úlceras de decúbito se recomienda una fórmula hiperprotéica. Es frecuente la hiperglucemia de estrés, que con fórmulas específicas para la diabetes mellitus se consigue controlar sin requerir tratamiento farmacológico hipoglucemiante ni control glucémico intensivo. 3) Cuidados tras el alta El desarrollo de malnutrición en este grupo de pacientes puede ser muy frecuente y se debe a míltiples factores. Si aparece disfagia, se favorece el desarrollo de infecciones por aspiración. Se debe realizar un seguimiento nutricional de los pacientes que han requerido soporte nutricional durante la fase aguda del ictus hasta su completa recuperación y un aporte de nutrientes adecuado. La nutrición enteral domiciliaria ha demostrado ser coste efectiva en este grupo de pacientes. 4) Prevención secundaria. Manejo óptimo de los factores de riesgo vascular: 1) Hipertensión arterial, 2) Diabetes mellitus, 3) Dislipemia, 4) Hábito tabáquico, 5) Sobrepeso, 6) Vitaminas (AU)
In this review we will approach the topic in four stages: 1) Primary prevention Non-modifiable risk factors: 1) Age, 2) Gender, 3) Low birth weight, 4) Ethnicity, 5) Genetic factors. Modifiable risk factors: 1) Atherosclerotic disease, 2) Arterial hypertension, 3) Diabetes mellitus, 4) Dyslipidemia, 5) Cigarette smoking, 6) Alcohol abuse, 7) Physical activity, 8) Diet and nutrition: the scientific societies recommend the DASH diet (fruits, vegetables, and low in total fat and saturated fat) in order to reduce the blood pressure. The diet rich only in fruits and vegetables may decrease the risk of ictus. Reduction in sodium intake (£ 2.3 g or 100 mmol/day) and increase of potassium (4.7 g or 120 mmol/day) are recommended to reduce arterial blood pressure. 9) Obesity and distribution of body fat, 10) Hyperhomocysteinemia. 2) Managing the acute phase The incidence of malnourishment ranges 7%-15% at admission. After the CVA the nutritional status worsens, generally due to dysphagia and motor deficits that impair autonomous feeding, 22%-35% of the patients being already malnourished. The presence of malnourishment in these patients unfavourably affects their prognosis. In the case of having some difficulty for normal feeding and whenever the risk for aspiration is low, modifying the texture of the diet is indicated. If the patient presents fatigue or early satiety, having small but frequent intakes will be useful. It is common to encounter dysphagia for liquids so that beverages should be thicken with enteral nutrition products such as thickeners. In patients with a deficient nutritional status or not meeting the nutritional requirements with an oral diet, the enteral nutrition supplements are an effective resource. In patients with persistent dysphagia, the most common routes for administrating enteral nutrition are the nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG). The first choice formula should be polymeric, normo-proteinic and normocaloric, with fibre, unless the recommendation is changed by some other condition. In the case of patients with hyponutrition at admission or with decubitus ulcers a hyperproteinic diet is recommended. Stress-induced hyperglycaemia is common, which may be controlled with specific diabetes mellitus formulas without needing pharmacological therapy for lowering glucose levels or intensive glycemic monitoring. 3) Care at discharge The development of malnourishment in this group of patients may be very common and is due to multiple factors. If dysphagia ensues, the occurrence of aspiration induced infections is facilitated. A nutritional follow-up should be done in the patients having required nutritional support during the acute phase of a CVA until complete recovery and appropriate nutrients intake are achieved. Home-based enteral nutrition has been shown to be cost effective in this group of patients. 4) Secondary prevention. Optimal management of vascular risk factors: 1) Arterial hypertension, 2) Diabetes mellitus, 3) Dyslipidemia, 4) Cigarette smoking, 5) Overweight, 6) Vitamins (AU)
Asunto(s)
Humanos , Accidente Cerebrovascular/dietoterapia , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/complicaciones , Desnutrición/dietoterapia , Desnutrición/etiología , Recuperación Nutricional , Apoyo Nutricional , Factores de Riesgo , PronósticoRESUMEN
Introducción: El objetivo del trabajo es valorar diferentes variables clínicas y bioquímicas con la finalidad de identificar posibles factores predictivos de insulinización, de tal manera que podamos seleccionar desde el momento del diagnóstico de diabetes gestacional (DG), grupos de pacientes con mayor predisposición para insulinización y así poder realizar un seguimiento más estrecho intentando minimizar la probabilidad de complicaciones mater-no-fetales. Sujetos: Estudiamos a 101 pacientes con DG de raza caucásica con las siguientes características globales: edad media de 33,6 ± 4,6 años, índice de masa corporal (IMC) de 25,8 ± 4,9 kg/m2, ganancia ponderal durante la gestación de 7,3 ± 4,2 kg. Antecedentes familiares de primer grado de DM 2 en el 52,6 %. El porcentaje de mujeres fumadoras durante el embarazo fue de un 30,5% y el porcentaje de insulinización global fue del 45%. Método: Identificar en primer lugar las variables con asociación estadística para posteriormente confirmarlas o descartarlas como predictoras de insulinización. Resultados: En nuestro grupo de pacientes diagnosticadas de DG se han identificado como factores predictivos de insulinización: el peso previo a la gestación (tanto el sobrepeso como la obesidad), la presencia de glucemia basal en el TSOG con 100 g superior a 85 mg/dl y tras una hora superior a 200 mg/dl y los antecedentes familiares de DM 2
ntroduction: The aim of this project is to value different clinical and biochemical variables in order to identify possible predictive factors for initiating insulin therapy in gestational diabetes, so we can select from the initial moment of the diagnosis those groups of patients with most possibilities of being treated on insulin and therefore carry out a closer follow up on them, trying to minimize the incidence of maternal and foetal complications. Subjects: 101 women with gestational diabetes of caucasian race with a medium age of 33.6 ± 4.6 years, a body mass index (BMI) of 25.8 ± 4.9 kg/m2, a weight increase during pregnancy of 7.3 ± 4.2 kg. A 52.6% of them presented a first degree familiar history of type two diabetes mellitus. A 30.5% of women smoked during pregnancy and 45% of all the group required insulin. Material and methods: To identify, in first place, the variables with statistic association as predictive of insulin treatment and thereafter confirm them or rule them out. Results: In our group of gestational diabetes diagnosed patients, we have identified as predictive factors of insulin requirement: Previous weight before pregnancy (obesity and overweight), a basal glucose level greater than 85 mg/dl in the TTOG and a 1 hour value greater than 200 mg/dl and a familiar history of type two diabetes mellitus
Asunto(s)
Femenino , Embarazo , Humanos , Diabetes Gestacional/tratamiento farmacológico , Insulina/administración & dosificación , Factores de Riesgo , Obesidad/complicaciones , Valor Predictivo de las PruebasRESUMEN
No disponible
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Humanos , Neuralgia/etiología , Diabetes Mellitus Tipo 2/complicacionesRESUMEN
No disponible
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Humanos , Diagnóstico Diferencial , Hipoglucemia , Árboles de DecisiónRESUMEN
The article summarizes the endocrinology axis in relation to leptin in the obesity. There is a glucocorticoid hypothesis in the obesity origin. Human plasma leptin levels are elevated in Cushing's syndrome and there is a robust leptin secretory responses to dexamethasone. Obesity impacts on reproductive function in man and women. Leptin levels are higher in women than in men and a critical blood leptin level is necessary to trigger reproductive ability in women. The relationship between body mass index and circulating leptin varies during the course of spontaneous cycles in women, the best correlation occurring during the luteal phase when progesterone and leptin concentrations are highest. Obesity is associated with a decrease in growth hormone (GH) and reversible with weight loss. The influence of body composition on GH secretion in the obesity may be mediated through leptin, acting as a peripheral signal from adipose tissue. Thyroid dysfunction appear not associated with alterations in serum leptin levels. There is a significant relationship between insulin and leptin, but it is not immediate, since type 2 diabetics show similar leptin levels to those of nondiabetic humans of the same body mass index.
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Leptina/fisiología , Obesidad/fisiopatología , Adulto , Animales , Índice de Masa Corporal , Síndrome de Cushing/sangre , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 2/sangre , Femenino , Hormona de Crecimiento Humana/sangre , Humanos , Hiperinsulinismo/fisiopatología , Hipertensión/sangre , Sistema Hipotálamo-Hipofisario/fisiología , Insulina/sangre , Leptina/sangre , Leptina/metabolismo , Masculino , Ciclo Menstrual/fisiología , Ratones , Ratones Obesos , Persona de Mediana Edad , Obesidad/sangre , Obesidad/etiología , Sistema Hipófiso-Suprarrenal/fisiología , Progesterona/sangre , Ratas , Reproducción/fisiología , Factores SexualesRESUMEN
El artículo revisa los diferentes ejes endocrinológicos en relación con los niveles plasmáticos de leptina del paciente obeso. Existe una hipótesis glucocorticoidea como causa de obesidad. Los niveles plasmáticos en humanos de leptina están elevados en el síndrome de Cushing y hay una respuesta secretora franca de leptina a la dexametasona. La obesidad altera la función reproductora tanto en el hombre como en la mujer. Los niveles de leptina son mayores en la mujer que en el hombre y se requiere un nivel crítico de leptina en plasma para desarrollar la capacidad reproductora femenina. La interrelación entre el índice de masa corporal y los niveles circulantes de leptina varían en el curso de los ciclos ováricos, la mejor correlación aparece en la fase luteal, cuando los niveles de leptina y progesterona están mas altos. La obesidad se asocia a disminución de los niveles plasmáticos de GH, situación que revierte con la pérdida de peso. La infuliencia de la composición corporal sobre la secreción de GH en la obesidad puede estar relacionada con la leptina, que acutaría como una señal periférica del tejido adiposo. La disfución tiroidea no parece producir alteraciones en los niveles de leptina. Existe una interrelación significativa entre los niveles de insulina y leptina, pero ésta no está clara ya que en el paciente con diabetes tipo 2 encontramos niveles similares de leptina a los de los controles con similar indice de masa corporal (AU)
Asunto(s)
Adulto , Animales , Femenino , Masculino , Persona de Mediana Edad , Ratas , Humanos , Ratones , Índice de Masa Corporal , Síndrome de Cushing/sangre , Hiperinsulinismo/fisiopatología , Hipertensión/sangre , Sistema Hipotálamo-Hipofisario/fisiología , Insulina/sangre , Leptina/sangre , Leptina , Ciclo Menstrual/fisiología , Ratones Obesos , Obesidad/etiología , Obesidad/sangre , Progesterona/sangre , Reproducción/fisiología , Factores Sexuales , Sistema Hipófiso-Suprarrenal , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 2/sangre , Hormona de Crecimiento Humana/sangre , Leptina/fisiología , Obesidad/fisiopatologíaRESUMEN
OBJECTIVES: In uremic patients with diabetes mellitus, morbi-mortality on maintenance hemodialysis is considerably higher than in nondiabetic patients. This is mainly due to age, seniority and quality of the hemodialysis therapy, nutritional status, plasmatic lipid levels and associated pathology. We compare all these factors in the uremic patients under hemodialysis in diabetics and non-diabetics. METHODS: We have studied 307 uremic patients under hemodialysis therapy during 199 and 1996. Sixty of them had been diagnosticated of diabetes mellitus (19.6%), 17 were type I (DM-I) and 27 were type II (DM-II). We selected two control groups no-diabetics, one for each subgroup of diabetics with similar characteristics in age, sex and hemodialysis seniority. The control group for DM-I were 34 patients and for DM-II were 54 patients. RESULTS: Ideal body weight percentage, body mass index, mid-arm muscle circumference percentil, serum albumin and prealbumin are subnormal for DM-I. By considering whole nutritional date, a moderate to severe malnutrition was observed in 79% of DM-I patients, 50.4% of all non diabetics and only in 30.6% of patients included in the DM-II group. However, DM-II patients present hypertrigliceridemia and a decrease in HDL cholesterol and apolipoprotein A levels with a high atherogenic index. Significantly higher rates of associated pathology were observed among both types of diabetic patients than their control groups and especially referred to cardiovascular and neurological diseases. CONCLUSIONS: In conclusion, diabetes mellitus is an increasing incidence pathology in hemodialysis programs, that is associated to a higher morbi-mortality because vascular disease. Undernutrition is the main factor in DM-II whereas hyperlipidemia is in DM-II.
Asunto(s)
Diabetes Mellitus/terapia , Morbilidad , Diálisis Renal , Uremia/terapia , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana EdadAsunto(s)
Conducta Alimentaria , Trastornos de Alimentación y de la Ingestión de Alimentos/diagnóstico , Parasitosis Intestinales/diagnóstico , Teniasis/diagnóstico , Adulto , Enfermedad Crónica , Diagnóstico Diferencial , Trastornos de Alimentación y de la Ingestión de Alimentos/etiología , Femenino , Humanos , Parasitosis Intestinales/complicaciones , Teniasis/complicacionesRESUMEN
Protein catabolic rate (PCR) has been proposed as a indirect index of dietary protein intake, but its sensitivity has been discussed. In a group of 140 chronic uremic patients undergoing maintenance hemodialysis, we evaluated the nutritional status (body mas index: BMI, triceps skinfold thickness: TST, arm muscle circumference: AMC, serum total proteins, albumin and lymphocytes) and its relation with dietary survey and PCR levels. PCR was correlated positively with Kt/V (p: 0.0001, r: 0.45) and with seric albumin (p: 0.01, r: 0.22), whereas dietary protein intake by dietary survey (g/Prot/Kg/day) was correlated strongly with anthropometric measurements like BMI, AMC (p: 0.0001) and less with Kt/V (p: 0.01), but not with serum albumin. PCR was correlated with dietary survey results: g Prot/Kg/day (p: 0.04, r: 0.18) and Kcal/Kg/day (p: 0.03, r:0.2). The results suggest that nutritional parameters with slow evolution as anthropometric measurements could be related with usual dietary intake (dietary survey), whereas serum albumin (that vary early with recent changes of dietary intake) could be related better with a biochemical index like PCR, in these way both determinations are complementary.
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Proteínas en la Dieta/administración & dosificación , Proteínas/metabolismo , Diálisis Renal , Uremia/terapia , Adulto , Anciano , Enfermedad Crónica , Encuestas sobre Dietas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estado Nutricional , Desnutrición Proteico-Calórica/metabolismo , Uremia/dietoterapia , Uremia/metabolismoRESUMEN
Hypoparathyroidism can exist due to one or more of the following pathogenic mechanisms: 1) Parathyroid Hormone (PTH) deficit, b) biologically inactive PTH, c) PTH antagonists and d) target tissues defects. Biologically inactive PTH secretion, also named pseudo-idiopathic hypoparathyroidism, is an exceptional cause of hypoparathyroidism. We report a case of a patient with this illness. A 71-year-old male with a past history of cataracts since he was 48 was admitted to our hospital. Laboratory data showed a total calcium of 4.82 mg/dl, ionized calcium of 2.72 mg/dl, serum phosphate 5.30 mg/dl, intact PTH 83 pg/ml (N 15-60), osteocalcin 2,4 ng/ml (N 9-30), tubular resorption of phosphate 96% and 1.25 di-hydroxycholecalciferol 7 pg/ml (N 18-78); creatinine and magnesium values were between normal limits. The Ellsworth-Howard test showed a normal response of both urinary c-AMP excretion and phosphaturia to PTH. We review the diagnostic clues of hypoparathyroidism and the value of the Ellsworth-Howard test in order to enable distinction between the several variants of the syndrome.
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Catarata/etiología , Hipocalcemia/etiología , Hipoparatiroidismo/etiología , Hormona Paratiroidea/sangre , Anciano , Calcitriol/uso terapéutico , Calcio/sangre , AMP Cíclico/orina , Humanos , Hipoparatiroidismo/diagnóstico , Masculino , Osteocalcina/sangre , Hormona Paratiroidea/química , Fosfatos/sangre , Fosfatos/orinaRESUMEN
Abnormalities of plasma lipids are highly prevalent in both types of diabetes, but there are important quantitative and qualitative differences that this paper reviews. The importance of abnormalities in lipoprotein metabolism as determinant of vascular risk in general population is similar in diabetes, where there is chronic hyperglycemia associated, but it is considered as an independent vascular risk factor. People with IDDM in adequate glycemic control generally have plasma lipid concentrations in normal levels, but in NIDDM, even in good glycemic control, there are another factors associated and usually there are hypertriglyceridemia and total hypercholesterolemia with reduced HDL fraction. Carbohydrate-rich diet increase plasma triglyceride levels and low HDL-cholesterol levels in the majority of studies. Substitute monounsaturated fats in the diet to replace saturated fats lowers total cholesterol and LDL fraction and increase HDL, in addition it acts over others vascular risk factors. These findings were taken into account by ADA and recently revises their 1986 dietary recommendations with the same goals of medical nutrition therapy but with individualized approach appropriate for the personal life style to facilitate adherence to achieve the glycemic, lipid body weight and blood pressure aims with a good quality of live.
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Diabetes Mellitus/metabolismo , Dieta para Diabéticos , Metabolismo de los Lípidos , Colesterol/metabolismo , LDL-Colesterol/metabolismo , Diabetes Mellitus Tipo 1/metabolismo , Diabetes Mellitus Tipo 2/metabolismo , Ácidos Grasos/administración & dosificación , Humanos , Lipoproteínas HDL/metabolismo , Lipoproteínas LDL/metabolismo , Lipoproteínas VLDL/metabolismo , Triglicéridos/metabolismoRESUMEN
When the supply of energetic substrates is insufficient to slow the development of the catabolism, the next step is to focus on the neuro-endocrine mechanism which regulates the anabolism-catabolism balance. In this work, we review the endocrine response to stress and its implications in protein metabolism, in order to evaluate the different therapeutic possibilities available. Pharmacological blocking of the secretion of catabolic hormones (glucagon and catecholamines) has been unsuccessful up to now. Insulin is the only hormone which produces anabolism in all energetic substrates, but the results published about its administration with glucose and amino acids and its effects upon the nitrogen balance are controversial. The administration of anabolic steroids such as nandrolone, stanolone, and methenolone are usually associated with protein anabolism with minimum androgenizing action. The most recent works lead to the study of the effects of the use of GH and IGF-1 with clearly hopeful results. We have not yet acquired enough experience to use these methods in the habitual clinical practice. At the moment, the clinical studies are in the experimental stage and their application in nutrition is not accepted by the official authorities.
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Hormonas/uso terapéutico , Fenómenos Fisiológicos de la Nutrición/fisiología , Metabolismo Energético/efectos de los fármacos , Hormonas/fisiología , Humanos , Apoyo Nutricional , Cuidados Posoperatorios , Proteínas/efectos de los fármacos , Proteínas/metabolismo , Estrés Fisiológico/metabolismo , Estrés Fisiológico/terapiaRESUMEN
The objective of this paper is to examine the usefulness of plasmatic fructosamine finding as an indicator of glycemic control in patients with hypocaloric parenteral nutrition with glycerol. Thirty abdominal surgery patients were studied. None displayed malnutrition, diabetes mellitus, hepatopathy, nephropathy or hyperlipemia in the preoperative stage or during the five days of postoperative recovery they were administered hypocaloric parenteral nutrition with glycerol. Their plasma levels of glucose, fructosamine, triglycerides, albumin and total proteins were found in the preoperative stage and on the first and fourth day of postoperative recovery. Following surgery, findings showed an increase in triglycerides and a decrease in the protein compartment, while glycemia levels remained steady. Furthermore there was a positive correlation between the figures for glycemia and later fructosamine figures. The conclusion was that providing hypocaloric nutrition with glycerol does not increase fructosamine levels. This confirmed prior observations on the slightness of its effect on hydrocarbonic metabolisms.