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PURPOSE: Patients with severe obesity submitted to Roux-en-Y gastric bypass (RYGB) are at risk of developing long-term hypovitaminosis D and secondary hyperparathyroidism (SHPT) as well as osteometabolic disease. This study aimed to evaluate calcium-vitamin D-PTH axis and bone mineral density (BMD) changes from post-RYGB patients who were followed-up until a median of 5 years. MATERIALS AND METHODS: Vitamin D deficiency was defined as 25-hydroxyvitamin D <20 ng/mL and SHPT as PTH >68 pg/mL, in patients with normal serum creatinine and calcium. BMD was estimated by dual-energy X-ray absorptiometry (DXA, g/cm2). RESULTS: We included 127 post-RYGB patients (51±10.6 years, 87.4% self-declared White, 91.3% female, 52.8% postmenopausal). Vitamin D deficiency prevalence was the highest (41.5%) in the second year and the lowest (21.2%) in the third year (p<0.05). SHPT prevalence was 65.4% in the second year and increased to 83.7% in the sixth year (p<0.05). Patients with low BMD in lumbar, femoral neck, and total proximal femur were older and presented menopausal status more frequently than normal BMD group (p<0.05). Older age was a risk marker for altered BMD in femoral neck (OR=1.185; 95% CI 1.118-1.256) and in total proximal femur (OR=1.158; 95% CI 1.066-1.258), both after adjusting for follow-up and excess weight loss. CONCLUSION: After 5 years, most bariatric patients presented calcium-vitamin D-PTH axis disruption, in which SHPT was more frequent than hypovitaminosis D. Older patients and menopausal women presented higher rates of low BMD, and older age was a risk marker, especially for low BMD in femoral sites.

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OBJECTIVES: The aim of this study was to establish the prevalence of sarcopenia and associated factors in elderly patients with type 2 diabetes mellitus (DM) according to 2010 (EWGSOP1) and 2018 (EWGSOP2) European consensus. DESIGN: Cross-sectional study. PARTICIPANTS: Elderly outpatients ≥60 years with type 2 DM and able to walk were recruited at the DM ambulatory care center of a public hospital in Porto Alegre from 2017 to 2018. MATERIALS AND METHODS: The diagnosis of sarcopenia was performed according to EWGSOP1 and EWGSOP2. Muscle mass (MM) was assessed using bioelectrical impedance (BIA). Muscle strength (MS) was assessed using the handgrip strength (HS) test and physical performance (PP) by timed-up-and-go (TUG) test. RESULTS: We included 242 patients with 68.3 ± 5.6 years, 54% women, 78% white, DM duration 14(8-22) years, BMI 29.5 ± 4.5 kg/m2, and HbA1c 7.8 ± 1.5%. Overall prevalence of sarcopenia was 21%. In EWGSOP1 it was 16.9%. The GLM Poisson model was used to assess sarcopenia. Male sex increased the prevalence of sarcopenia by 33% (3.330 [1.747-6.350]; p < .001), and walking >5401 steps/day had a protective effect of 70% for the prevalence of sarcopenia (0.306 [0.127-0.739]; p = .029). Finally, age had an impact of 6% on prevalence of sarcopenia (1.06 [1.015-1.108]; p = .009) according to EWGSOP1. On the other hand, the prevalence was 7%, women had more sarcopenia (88%), and BMI was lower in the sarcopenic group when defined according to EWGSOP2. CONCLUSIONS: The prevalence of sarcopenia was more than double when comparing EWGSOP1 (16.9%) and EWGSOP2 (7%). We believe that the difference in prevalence is due to modifications in MM and MS criteria. According to EWGSOP1, walking may have protective role in the prevalence of sarcopenia in elderly type 2 DM individuals.

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OBJECTIVES: The aims of this study are to investigate which of the seven selected predictive equation for estimating basal metabolic rate (BMR) is the best alternative to indirect calorimetry (IC) and to evaluate the dietary energy intake in patients with type 2 diabetes. SUBJECTS AND METHODS: Twenty-one patients with type 2 diabetes participated in this diagnostic test study. Clinical and laboratorial variables were evaluated as well as body composition by absorptiometry dual X-ray emission (DXA) and BMR measured by IC and estimated by prediction equations. Dietary intake was evaluated by a quantitative food frequency questionnaire. Data were analyzed using Bland-Altman plots, paired t-tests, and Pearson's correlation coefficients. RESULTS: Patients were 62 (48-70) years old, have had diabetes for 8 (2-36) yeas, and 52.4% were females. The mean body composition comprised a fat-free mass of 49.8 ± 9.4 kg and a fat mass of 28.3 ± 7.2 kg. The energy intake was 2134.3 ± 730.2 kcal/day and the BMR by IC was 1745 ± 315 kcal/day. There was a wide variation in the accuracy of BMR values predicted by equations when compared to IC BMR measurement. Harris-Benedict, Oxford, FAO/WHO/UNO equations produced the smallest differences to IC, with a general bias of < 8%. The FAO/WHO/UNO equation provided the best BMR prediction in comparison to measured BMR. CONCLUSION: In patients with type 2 diabetes, the equation of the FAO/WHO/UNO was the one closest to the BMR values as measured by IC.

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Fiber intake is associated with better glycemic control being an important nonpharmacologicaltreatment for diabetes (DM). We hypothesize that a dietary fiber intake can bringbenefits to diabetic kidney disease (DKD), improving renal outcomes. This systematic review aimedto evaluate the effect of dietary fiber (supplemental or dietary pattern rich in fiber) on DKD. Wesearched six databases to identify clinical trials that reported fiber intake and renal outcomes(albuminuria, proteinuria, estimated glomerular filtration rate (eGFR) dialysis) in patients with DM.From 1814 studies, 48 papers were fully evaluated. In the end, seven trials (161 patients, aged 58.3years, 49% females) were included. The studies were organized into three categories (vegetarian,Dietary Approaches to Stop Hypertension (DASH) diet, and fiber supplement), two evaluatedsupplements and five dietary patterns. Vegetarian diet reduced albuminuria in three trials, two inpatients with type 1 DM and one in patients with type 2 DM; and one study demonstrated a change inthe eGFR in type 1 DM. The individual quality of the studies was low/uncertain. A vegetarian dietarypattern may have a beneficial effect on these renal outcomes. However, the individual effect of theintake of fiber on DKD not was possible to be evaluated.

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ABSTRACT Objectives: The aims of this study are to investigate which of the seven selected predictive equation for estimating basal metabolic rate (BMR) is the best alternative to indirect calorimetry (IC) and to evaluate the dietary energy intake in patients with type 2 diabetes. Subjects and methods: Twenty-one patients with type 2 diabetes participated in this diagnostic test study. Clinical and laboratorial variables were evaluated as well as body composition by absorptiometry dual X-ray emission (DXA) and BMR measured by IC and estimated by prediction equations. Dietary intake was evaluated by a quantitative food frequency questionnaire. Data were analyzed using Bland-Altman plots, paired t-tests, and Pearson's correlation coefficients. Results: Patients were 62 (48-70) years old, have had diabetes for 8 (2-36) yeas, and 52.4% were females. The mean body composition comprised a fat-free mass of 49.8 ± 9.4 kg and a fat mass of 28.3 ± 7.2 kg. The energy intake was 2134.3 ± 730.2 kcal/day and the BMR by IC was 1745 ± 315 kcal/day. There was a wide variation in the accuracy of BMR values predicted by equations when compared to IC BMR measurement. Harris-Benedict, Oxford, FAO/WHO/UNO equations produced the smallest differences to IC, with a general bias of < 8%. The FAO/WHO/UNO equation provided the best BMR prediction in comparison to measured BMR. Conclusion: In patients with type 2 diabetes, the equation of the FAO/WHO/UNO was the one closest to the BMR values as measured by IC.

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AIM: This cross-sectional study aimed to assess the association of the fat content in the diet with Diabetic Kidney Disease (DKD) in patients with type 2 diabetes. METHODOLOGY: Patients from the Diabetes research clinic at Hospital de Clínicas de Porto Alegre (Brazil) were consecutively recruited. The inclusion criterion was the diagnosis of type 2 diabetes. The exclusion criteria were as follows: body mass index >40 kg/m2, heart failure, gastroparesis, diabetic diarrhea, dietary counseling by a registered dietitian during the previous 12 months, and inability to perform the weighed diet records (WDR). The dietary fatty acids (saturated, monounsaturated and polyunsaturated) consumption was estimated by 3-day WDR. Compliance with the WDR technique was assessed by comparison of protein intake estimated from the 3-day WDR and from the 24-h urinary nitrogen output performed on the third day of the WDR period. The presence of DKD was defined as urinary albumin excretion (UAE) ≥ 30 mg / 24 h or/and glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Urinary albumin was measured twice and eGFR was estimated by using the CKD-EPI equation. RESULTS: A total of 366 patients were evaluated; of these, 33% (n = 121) had DKD. Multivariate analysis showed that the intake of linolenic acid was negatively associated with DKD (OR = 0.57; 95% CI 0.35-0.93; P = 0.024), adjusted for gender, smoking, cardiovascular disease, ACE inhibitors and/or angiotensin receptor blocker use, systolic blood pressure, fasting plasma glucose and HDL cholesterol. In a separate model, similar results were observed for linoleic acid, adjusting to the same co-variables (OR = 0.95; 95% CI 0.91-0.99; P = 0.006). CONCLUSION: The lower intake of polyunsaturated fatty acids, especially linolenic and linoleic acid, is associated with chronic kidney disease in patients with type 2 diabetes.

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The aim of this study is to evaluate the association between usual physical activity and 24 h blood pressure (BP) profile in people with type 2 diabetes mellitus (DM). This is a cross-sectional study of 151 participants with type 2 DM. Usual physical activity was assessed by step counting and self-reported questionnaire. BP was measured in office and by 24 h ambulatory BP monitoring (ABPM; 24 h, daytime and nighttime). Mean participant age was 61.1 ± 8.4 years, 64% was women, and mean duration of diabetes was 14.3 ± 8.5 years. Ninety-two percent of participants had hypertension, and office BP was 138 ± 18/78 ± 10 mmHg. Inverse correlations were observed between step count and 24 h BP (systolic, r = -0.186; p = 0.022), daytime BP (systolic, r = -0.198; p = 0.015), and nighttime BP (pulse pressure, r = -0.190; p = 0.019). People were categorized into tertiles of daily step count, and the 1st tertile had higher 24 h systolic BP, daytime systolic BP, daytime mean BP, and daytime systolic BP load than those in the other tertiles, even after adjusting for age and HbA1c. Participants with type 2 DM and low levels of physical activity exhibit higher 24 h and daytime systolic ambulatory BP values as compared with those who performed more steps per day, even after adjustments for confounding factors.

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BACKGROUND: The best insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support (NS) is unclear. METHODS: We searched electronic databases to identify cohort studies or randomized clinical trials in order to evaluate the efficacy of different insulin regimens used to treat hyperglycemia in hospitalized patients on NS on diverse outcomes: mean blood glucose (MBG), hypoglycemia, length of stay in hospital, and mortality. RESULTS: Seventeen studies from a total of 5,030 were included. Enteral Group included 8 studies; 1,203 patients using rapid, glargine, NPH, or Premix insulin; MBG 108-225 mg/dL; hypoglycemia 0-13%. In indirect meta-analyses, NPH insulin ranked best for glucose control (MD 95% CI -2.50 mg/dL [2.65 to -2.35]). Parenteral Group included 4 studies; 228 patients using regular and glargine or NPH insulin; MBG 137-202 mg/dL; hypoglycemia 0-40%. In meta-analyses comparing regular insulin added to parenteral nutrition bag with glargine, MBG (MD 95% CI -3.78 mg/dL [-11.93 to 4.37]; I2 = 0%) or hypoglycemia frequency (RR 95% CI 1.37 [0.43-4.32]; I2 = 70.7%) did not differ. The description related to hospital length of stay and mortality was inconsistent between groups. CONCLUSIONS: The best insulin regimen to treat hyperglycemia in hospitalized patients on NS has not been established; best results using insulin regimens with NPH in enteral nutrition do not seem to be clinically relevant.

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To investigate the effects of micronutrients on blood pressure (BP) in patients with type 2 diabetes through a systematic review and meta-analysis, randomized clinical trials (RCTs) of the effects of individual micronutrients on BP in patients with type 2 diabetes were searched in the Medline, Embase, Cochrane, and Clinical Trials.gov databases through April 2016. From the 28,164 studies, 11 RCTs (13 interventions, 723 patients, 54% males) with 3 to 52 weeks of follow-up were classified according to the type of micronutrient intervention: sodium (n = 1), vitamin C (n = 2), vitamin D (n = 7), and magnesium (n = 1). The available data enabled us to perform meta-analyses of vitamins C and D. Vitamin C reduced diastolic BP [WMD -2.88 mmHg (95%CI -5.31, -0.46; P = 0.020)] but not systolic BP [WMD -3.93 mmHg (95%CI -14.78, 6.92; P = 0.478)]. Vitamin D caused a reduction of 4.56 mmHg (WMD; 95%CI -7.65, -1.47; P = 0.004) for systolic BP and 2.44 mm Hg (WMD; 95%CI -3.49, -1.39; P < 0.001) for diastolic BP. In conclusion, vitamin D and possibly vitamin C have beneficial effects on BP in patients with type 2 diabetes. These interventions might represent a novel approach to the treatment of hypertension in these patients.

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BACKGROUND: Brazilian records on glycemic control in patients with type 1 diabetes show treatment efficacy. Poor patient adherence to therapeutic proposals influences these results and can be associated with social, psychological, and economic aspects, besides others factors. The aim of this study was to evaluate the efficacy of psychological, telecare, and educational interventions to improve treatment compliance among patients with type 1 diabetes. Compliance was assessed indirectly using reduction of glycated hemoglobin (HbA1c) as the principal outcome measure. METHODS: Systematic review and meta-analyses of randomized controlled clinical trials (RCTs) were performed using Medline, Embase, Cochrane and Scopus databases up to April 2015. The following medical subject headings were used: Diabetes Mellitus, Type 1, Patient Compliance or Adherence, Hemoglobin A, glycated, and Randomized Controlled Trial. The principal outcome was change in HbA1c between baseline and follow-up. Where appropriate, trials were combined in meta-analysis using fixed effects models. RESULTS: From 191 articles initially identified, 57 were full text reviewed, and 19 articles met the inclusion criteria providing data from 1782 patients (49.4 % males, age 18 years). The RCTs (2 to 24 months in duration) were divided into four groups according to type of intervention: psychology (seven studies; 818 patients), telecare (six studies; 494 patients); education (five studies; 349 patients), and psychoeducation (one study; 153 patients). All studies reported some type of adherence measurement of the interventions. Decrease in HbA1c was observed after psychology (MD -0.310; 95 % CI, -0.599 to -0.0210, P = 0.035) but not after telecare (MD -0.124 %; 95 % CI, -0.268, 0.020; P = 0.090) or educational (MD -0.001; 95 % CI, -0.202, 0.200; P = 0.990) interventions. CONCLUSION: Psychological approaches to improve adherence to diabetes care treatment modestly reduced HbA1c in patients with type 1 diabetes; telecare and education interventions did not change glycemic control. However, the limited number of studies included as well as their methodological quality should be taken into account.

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BACKGROUND: In type 1 diabetes mellitus (T1DM) management, enhancing health-related quality of life (HRQoL) is as important as good metabolic control and prevention of secondary complications. This study aims to evaluate possible regional differences in HRQoL, demographic features and clinical characteristics of patients with T1DM in Brazil, a country of continental proportions, as well as investigate which variables could influence the HRQoL of these individuals and contribute to these regional disparities. METHODS: This was a retrospective, cross-sectional, multicenter study performed by the Brazilian Type 1 Diabetes Study Group (BrazDiab1SG), by analyzing EuroQol scores from 3005 participants with T1DM, in 28 public clinics, among all geographical regions of Brazil. Data on demography, economic status, chronic complications, glycemic control and lipid profile were also collected. RESULTS: We have found that the North-Northeast region presents a higher index in the assessment of the overall health status (EQ-VAS) compared to the Southeast (74.6 ± 30 and 70.4 ± 19, respectively; p < 0.05). In addition, North-Northeast presented a lower frequency of self-reported anxiety-depression compared to all regions of the country (North-Northeast: 1.53 ± 0.6; Southeast: 1.65 ± 0.7; South: 1.72 ± 0.7; Midwest: 1.67 ± 0.7; p < 0.05). These findings could not be entirely explained by the HbA1c levels or the other variables examined. CONCLUSIONS: Our study points to the existence of additional factors not yet evaluated that could be determinant in the HRQoL of people with T1DM and contribute to these regional disparities.

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Objective:This study sought to develop a dietary index for assessment of diet quality aiming for compliance with dietary recommendations for diabetes: The Diabetes Healthy Eating Index.Methods:Cross-sectional study with 201 outpatients with type 2 diabetes (61.4±9.7 years of age; 72.1% were overweight; 12.1±7.7 years of diagnosis; 7.3±1.3% mean HbA1c). Clinical and laboratory evaluations were performed together with 3-day weight diet records. The dietary index developed included 10 components: "diet variety", "fresh fruits", "vegetables", "carbohydrates and fiber sources", "meats and eggs", "dairy products and saturated fatty acids", "oils and fats", "total lipids", "cholesterol", and "transunsaturated fatty acids". The performance of each component was evaluated using the Item Response Theory, and diet quality was scored from 0-100%.Results:Overall, diet quality in this sample was 39.8±14.3% (95%CI=37.8-41.8%), and only 55 patients had a total diet quality score >50%. Good compliance was observed in only four index components: "total lipids", "variety", "fiber sources", and "dairy and saturated fatty acids". The components that differentiated patients with poor dietary quality from those with good dietary quality were "vegetables", "diet variety", "dairy and saturated fatty acids" and "total lipids". The greatest determinants of dietary quality were the components "diet variety", "vegetables", and "total lipids".Conclusion:This dietary index proposed assesses diet quality in compliance with the specific nutritional recommendations for diabetes. In clinical practice, this novel index may be a useful tool for the assessment and management of diet of patients with type 2 diabetes.

Objetivo:Desenvolver índice dietético para avaliar a qualidade da dieta considerando a adesão às recomendações nutricionais específicas para diabetes: Índice de Alimentação Saudável para o Diabetes.Métodos:Estudo transversal com 201 pacientes ambulatoriais com diabetes tipo 2 (idade=61,4±9,7 anos; 72,1% com excesso de peso; duração do diabetes=12,1±7,7 anos; HbA1c=7,3±1,3%) que realizaram 3 dias de registros com pesagem de alimentos, avaliação clínica e laboratorial. O índice foi elaborado com 10 componentes: "variedade da dieta", "frutas frescas", "vegetais", "carboidratos e fontes de fibra", "carnes e ovos", "laticínios e ácidos graxos saturados", "óleos e gorduras", "lipídeos totais", "colesterol" e "ácidos graxos trans-insaturados". O desempenho dos componentes foi avaliado pela análise de Teoria de Resposta ao Item e a qualidade da dieta foi convertida em escala de 0-100%.Resultados:Nessa amostra, a qualidade da dieta foi de 39,8±14,3% (IC95%=37,8-41,8%) e somente 55 pacientes apresentaram pontuação total >50%. Boa adesão foi observada para apenas quatro componentes: "lipídeos totais", "variedade", "fontes de fibra" e "laticínios e ácidos graxos saturados". Os componentes que diferenciaram pacientes com baixa qualidade daqueles com boa qualidade foram "vegetais", "variedade", "laticínios e ácidos graxos saturados" e "lipídeos totais". Os maiores determinantes da qualidade da dieta foram os componentes "variedade", "vegetais" e "lipídeos totais".Conclusão:O índice proposto avalia a qualidade da dieta de acordo com a adesão às recomendações nutricionais específicas do diabetes. Na prática clínica, esse novo instrumento pode ser uma ferramenta útil para a avaliação e manejo da dieta em pacientes com diabetes tipo 2.

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Data on the potential beneficial effects of combining diet and exercise on blood pressure (BP) are still scarce. A 4-week randomized controlled clinical trial was undertaken in 40 hypertensive patients with type 2 diabetes with uncontrolled blood pressure (BP) in office and daytime ambulatory BP monitoring (ABPM). Patients were assigned to follow a Dietary Approaches to Stop Hypertension (DASH) diet associated with advice to increase walking using a pedometer (intervention group) or a diet based on the American Diabetes Association recommendations (control group). The lifestyle intervention caused a greater ABPM (mm Hg) reduction in systolic 24-hour, diastolic 24-hour, nighttime systolic, daytime systolic, and daytime diastolic measurements than observed in the control group. In the intervention group there was a decrease in urinary sodium and an increase in urinary potassium, plasma aldosterone, and the number of steps per day (P<.05). The DASH diet and increased walking were associated with clinically significant reductions in ABPM values in hypertensive patients with type 2 diabetes.

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Type 1 diabetes mellitus (T1DM) is associated with chronic complications that lead to high morbidity and mortality rates in young adults of productive age. Intensive insulin therapy has been able to reduce the likelihood of the development of chronic diabetes complications. However, this treatment is still associated with an increased incidence of hypoglycemia. In patients with "brittle T1DM", who have severe hypoglycemia without adrenergic symptoms (hypoglycemia unawareness), islet transplantation may be a therapeutic option to restore both insulin secretion and hypoglycemic perception. The Edmonton group demonstrated that most patients who received islet infusions from more than one donor and were treated with steroid-free immunosuppressive drugs displayed a considerable decline in the initial insulin independence rates at eight years following the transplantation, but showed permanent C-peptide secretion, which facilitated glycemic control and protected patients against hypoglycemic episodes. Recently, data published by the Collaborative Islet Transplant Registry (CITR) has revealed that approximately 50% of the patients who undergo islet transplantation are insulin independent after a 3-year follow-up. Therefore, islet transplantation is able to successfully decrease plasma glucose and HbA1c levels, the occurrence of severe hypoglycemia, and improve patient quality of life. The goal of this paper was to review the human islet isolation and transplantation processes, and to describe the establishment of a human islet isolation laboratory at the Endocrine Division of the Hospital de Clínicas de Porto Alegre - Rio Grande do Sul, Brazil.

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BACKGROUND: A functional variant in the promoter region of the gene encoding tumor necrosis factor (TNF; rs1800629, -308G>A) showed to confer susceptibility to T1D. However, TNF rs1800629 was found, in several populations, to be in linkage disequilibrium with HLA susceptibility haplotypes to T1D. We evaluated the association of TNF rs1800629 with T1D in a cohort of Brazilian subjects, and assessed the impact of HLA susceptibility haplotypes in this association. METHODS: 659 subjects with T1D and 539 control subjects were genotyped for TNF-308G>A variant. HLA-DRB1 and HLA-DQB1 genes were genotyped in a subset of 313 subjects with T1D and 139 control subjects. RESULTS: Associations with T1D were observed for the A-allele of rs1800629 (OR 1.69, 95% CI 1.33-2.15, p<0.0001, in a codominant model) and for 3 HLA haplotypes: DRB1*03:01-DQB1*02:01 (OR 5.37, 95% CI 3.23-8.59, p<0.0001), DRB1*04:01-DQB1*03:02 (OR 2.95, 95% CI 1.21-7.21, p=0.01) and DRB1*04:02-DQB1*03:02 (OR 2.14, 95% CI 1.02-4.50, p=0.04). Linkage disequilibrium was observed between TNF rs1800629 and HLA-DRB1 and HLA-DQB1 alleles. In a stepwise regression analysis HLA haplotypes, but not TNF rs1800629, remained independently associated with T1D. CONCLUSION: Our results do not support an independent effect of allelic variations of TNF in the genetic susceptibility to T1D.

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BACKGROUND: Meals with a low glycemic index (GI) and rich in fiber could be beneficial with regard to postprandial metabolic profile and satiety. OBJECTIVE: The aim of this study was to investigate the effect of 4 breakfasts with a different GI and amount of fiber on postprandial plasma glucose, insulin, and appetite in patients with type 2 diabetes. METHODS: This randomized 4-intervention crossover trial included 14 patients [7 men; ages 65.8 ± 5.2 y; glycated hemoglobin: 6.6 ± 0.9%; BMI (in kg/m(2)): 27.2 ± 3.1]. Dietary interventions were as follows: breakfasts with a high GI (60.4 ± 0.1%) and high fiber (6.0 ± 0.3 g) (HGI-HF), a high GI (60.9 ± 1.7%) and low fiber (2.5 ± 0.4 g) (HGI-LF), a low GI (37.7 ± 0.1%) and high fiber (6.2 ± 0.3 g) (LGI-HF), and a low GI (39.8 ± 1.3%) and low fiber (2.0 ± 0.1 g) (LGI-LF). Plasma glucose, insulin, and total ghrelin were evaluated postprandially (0-180 min). A visual analog scale was used to assess appetite. Data were analyzed by generalized estimating equations and post hoc least significant difference (LSD) tests. Data are reported as means ± SDs. RESULTS: The area under the curve (AUC) [mean (95% CI); P for LSD tests] for plasma glucose (mmol/L × min) was higher after patients consumed the HGI-LF breakfast [9.62 (8.39, 10.84)] than after the LGI-HF breakfast [8.95 (7.71, 10.18)] (P ≤ 0.05). Insulin AUC (µIU/mL × min) after patients consumed the HGI-LF meal [65.72 (38.24, 93.19)] was higher than after the HGI-HF meal [57.24 (32.44, 82.04)] (P ≤ 0.05). The other observed difference was higher insulin AUC after the consumption of the LGI-LF breakfast [61.54 (36.61, 86.48)] compared with the AUC after the LGI-HF breakfast [54.16 (31.43, 76.88)] (P ≤ 0.05). Plasma ghrelin decreased in comparison with baseline only after patients consumed the LGI-HF and LGI-LF breakfasts (P ≤ 0.05). Subjective satiety did not differ between breakfasts. CONCLUSIONS: Plasma glucose, insulin, and ghrelin responses were least favorable when patients with type 2 diabetes consumed a breakfast with a high GI and low fiber, which suggests that reducing the GI or increasing the fiber content or both of breakfasts may be a useful strategy to improve the postprandial metabolic profile of these patients. This trial was registered at clinicaltrials.gov as NCT01410292.

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Type 1 diabetes mellitus (T1DM) is associated with chronic complications that lead to high morbidity and mortality rates in young adults of productive age. Intensive insulin therapy has been able to reduce the likelihood of the development of chronic diabetes complications. However, this treatment is still associated with an increased incidence of hypoglycemia. In patients with “brittle T1DM”, who have severe hypoglycemia without adrenergic symptoms (hypoglycemia unawareness), islet transplantation may be a therapeutic option to restore both insulin secretion and hypoglycemic perception. The Edmonton group demonstrated that most patients who received islet infusions from more than one donor and were treated with steroid-free immunosuppressive drugs displayed a considerable decline in the initial insulin independence rates at eight years following the transplantation, but showed permanent C-peptide secretion, which facilitated glycemic control and protected patients against hypoglycemic episodes. Recently, data published by the Collaborative Islet Transplant Registry (CITR) has revealed that approximately 50% of the patients who undergo islet transplantation are insulin independent after a 3-year follow-up. Therefore, islet transplantation is able to successfully decrease plasma glucose and HbA1c levels, the occurrence of severe hypoglycemia, and improve patient quality of life. The goal of this paper was to review the human islet isolation and transplantation processes, and to describe the establishment of a human islet isolation laboratory at the Endocrine Division of the Hospital de Clínicas de Porto Alegre – Rio Grande do Sul, Brazil.

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OBJECTIVE: To analyze possible associations of dietary components, especially protein intake, with blood pressure (BP) during ambulatory BP monitoring (ABPM) in patients with type 2 diabetes. METHODS: In this cross-sectional study, BP of outpatients with type 2 diabetes was evaluated by 24-hour ABPM (Spacelabs 90207) and usual diet by 3-day weighed diet records. Patients were divided into 2 groups according to their daytime ABPM: uncontrolled BP (systolic BP ≥ 135 mmHg or diastolic BP ≥ 85 mmHg) and controlled BP (systolic BP < 135 mmHg and diastolic BP < 85 mmHg). Logistic regression models unadjusted and adjusted for possible confounders (covariates) were used to analyze the association of protein and uncontrolled BP. RESULTS: A total of 121 patients with type 2 diabetes aged 62.3 years, 54.5% of whom were women, were studied. The uncontrolled BP group had higher glycated hemoglobin (HbA1C) values (8.4 ± 2.0 vs 7.6 ± 1.3%; p = 0.04) and consumed more protein (20.0 ± 3.8 vs 18.2 ± 3.6% of energy; p = 0.01) and meat, (2.6 [1.45, 2.95] vs 2.0 [1.49, 2.90] g/kg weight; p = 0.04) than the controlled BP group. In a multivariate analysis, protein intake (% of energy) increased the chance for uncontrolled BP (odds ratio [OR] = 1.16; 95% confidence interval [CI], 1.02, 1.30; p = 0.02), adjusted for body mass index (BMI), HbA1C, low-density lipoprotein (LDL) cholesterol, number of antihypertensive medications, and ethnicity. Meat consumption higher than 3.08 g/kg weight/day more than doubled the chance for uncontrolled BP (OR = 2.53; 95% CI, 1.01, 7.60; p = 0.03). CONCLUSION: High protein intake and meat consumption were associated with high daytime ABPM values in patients with type 2 diabetes. Reducing meat intake might represent an additional dietary intervention in hypertensive patients with type 2 diabetes.

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OBJECTIVE: Diet is the cornerstone treatment of patients with gestational diabetes mellitus (GDM), but its role in maternal and newborn outcomes has been scarcely studied. The purpose of this study was to analyze the efficacy of dietary interventions on maternal or newborn outcomes in patients with GDM. RESEARCH DESIGN AND METHODS: A systematic review and meta-analysis of randomized clinical trials (RCTs) of dietary intervention in GDM or pregnancy with hyperglycemia was performed. MEDLINE, Embase, ClinicalTrials.gov, Cochrane, and Scopus were searched through to March 2014. The main evaluated maternal outcomes were proportion of patients using insulin and proportion of cesarean delivery; the newborn outcomes were proportion of macrosomia and hypoglycemia and newborn weight. RESULTS: From 1,170 studies, nine RCTs, including 884 women aged 31.5 years (28.7-33.2) with 27.4 weeks (24.1-30.3) of gestation, were eligible. We divided the RCTs according to the type of dietary intervention: low glycemic index (GI) (n = 4; 257 patients), total energy restriction (n = 2; 425 patients), low carbohydrates (n = 2; 182 patients), and others (n = 1; 20 patients). Diet with low GI reduced the proportion of patients who used insulin (relative risk 0.767 [95% CI 0.597, 0.986]; P = 0.039) and the newborn birth weight (weight mean differences -161.9 g [95% CI -246.4, -77.4]; P = 0.000) as compared with control diet. Total restriction and low carbohydrate diets did not change either maternal or newborn outcomes. CONCLUSIONS: A low GI diet was associated with less frequent insulin use and lower birth weight than control diets, suggesting that it is the most appropriate dietary intervention to be prescribed to patients with GDM.

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Different dietary interventions have been identified as potential modifiers of adiponectin concentrations, and they may be influenced by lipid intake. We identified studies investigating the effect of dietary lipids (type/amount) on adiponectin concentrations in a systematic review with meta-analysis. A literature search was conducted until July 2013 using databases such as Medline, Embase and Scopus (MeSH terms: 'adiponectin', 'dietary lipid', 'randomized controlled trials (RCT)'). Inclusion criteria were RCT in adults analysing adiponectin concentrations with modification of dietary lipids. Among the 4930 studies retrieved, fifty-three fulfilled the inclusion criteria and were grouped as follows: (1) total dietary lipid intake; (2) dietary/supplementary n-3 PUFA; (3) conjugated linoleic acid (CLA) supplementation; (4) other dietary lipid interventions. Diets with a low fat content in comparison to diets with a high-fat content were not associated with positive changes in adiponectin concentrations (twelve studies; pooled estimate of the difference in means: -0·04 (95% CI -0·82, 0·74) µg/ml). A modest increase in adiponectin concentrations with n-3 PUFA supplementation was observed (thirteen studies; 0·27 (95% CI 0·07, 0·47) µg/ml). Publication bias was found by using Egger's test (P= 0·01) and funnel plot asymmetry. In contrast, CLA supplementation reduced the circulating concentrations of adiponectin compared with unsaturated fat supplementation (seven studies; -0·74 (95% CI -1·38, -0·10) µg/ml). However, important sources of heterogeneity were found as revealed by the meta-regression analyses of both n-3 PUFA and CLA supplementation. Results of new RCT would be necessary to confirm these findings.

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