POP Anca Lucia1, DIACONESCU Nicoleta 1, UDEANU Denisa1, VARLAS Valentin2*, NASUI Bogdana Adriana4, TARGOVISTE Constantin Ionescu3 ZETU Cornelia3, MOROSAN Elena1
1Clinical Laboratory and Food Safety Department, Faculty of Pharmacy, ”Carol Davila” University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956, Bucharest (ROMANIA)
2 “Filantropia” Clinical Hospital, Bucharest, (ROMANIA)
3National Institute of Diabetes, Nutrition and Metabolic Diseases “Prof. Dr. N. Paulescu” Romania
4 University of Medicine and Pharmacy, Cluj-Napoca, Department of Community Health
*corresponding author: email@example.com
This paper aims to investigate what metabolic syndrome means and the complications generated by it based on a retrospective clinical study on 50 patients diagnosed with diabetes, presenting multiple risk factors for inclusion in metabolic syndrome. Through this study we emphasize the importance of adjusting the lifestyle of patients with increased health risks through lifestyle and nutritional behaviour to the parameters recommended by medical treatment standards, to prevent complications of metabolic syndrome and obesity, dyslipidemia, insulin resistance, cardiovascular disease by highlighting the extent of metabolic pathology with extremely varied manifestations of the metabolic syndrome and impressive costs for the health system and especially for the quality of life of the population.
Keywords: metabolic syndrome, obesity, diabetes, nutritional behavior
Metabolic syndrome (MetS) is an association of clinical manifestations / pathologies with no apparent link between them, practically a cluster of risk factors for cardiovascular disease. Since 1988, Dr. Gerald Reaven has described X syndrome or dysmetabolic syndrome characterized by: insulin resistance, hyperglycemia, hypertension, low HDL-cholesterol and high VLDL triglycerides. His remarks are still valid today, but they have undergone some additions [1,2].
The major components of the metabolic syndrome are: diabetes, cardiovascular disease, dyslipidemia and obesity. Abdominal obesity and insulin resistance are seen as major defects related to the pathophysiology of metabolic syndrome. These two risk factors are strongly interdependent, so it is very difficult to say which of them plays a predominant role in the pathogenesis and progression of metabolic syndrome [3,4].
The physiopathology of the metabolic syndrome is complicated by factors such as: adipose tissue irregularity, inflammation, genetic factors, race / ethnicity, physical inactivity, inadequate diet, hormonal imbalances, psychological status [10, 11] medications and old age. Given all these factors, it is unrealistic to believe that metabolic syndrome can be caused by a single underlying defect. This is actually a combination of many risk factors, primarily obesity and insulin resistance that give rise to this group of metabolic health risks [5 – 9, 12].
The aim of this study was to make correlations between diabetic pathology at presentation and the degree of association with the components of metabolic syndrome (obesity, dyslipidemia, hypertension, insulin resistance) in a group of 50 patients with diabetes followed in the Outpatient Clinic of the Institute of Diabetes, Nutrition and Metabolic Diseases “Nicolae Constantin Paulescu”, from UMF Carol Davila, Bucharest. The lifestyle and nutritional behavior at the parameters recommended by medical treatment standards, comorbidities and complications of metabolic syndrome, respectively obesity, dyslipidemia, insulin resistance, cardiovascular pathology were investigated by highlighting the extent of metabolic pathology with extremely varied manifestations of metabolic syndrome.
A retrospective analysis of routine medical records was performed, from the institution’s archive, on known patients with diabetes presented at the specialized routine control, dispensed at the Specialty Clinic N. Pavel (Bucharest), for a period of 30 days during year 2019. Correlations of the main presentation pathology (diabetes) were made with elements from the metabolic syndrome. According to the legislation in force, this retrospective study complied with the rules of confidentiality and data protection, was approved by the management of the unit and did not require the opinion of the ethics committee. The criterion for including patients in the study was: patients with diabetes, dispensaries, with a minimum age of 18 years, presented to the specialized medical examination, randomly, for a period of 30 days. Data from the medical file, results of laboratory tests, paraclinical tests, medical records, other data from the medical file were processed. Biostatistical data processing and analysis was performed in Microsoft Excel, QX calculated, MDRD eGFR.
The recordings for a number of 50 patients of both sexes (72% women and 18% men) aged between 18 and 79 years were studied, with an average age of 49 years (of which women with a mean age of 46). years and men 54 years) recorded in the order of presentation (chronological). They were diagnosed in a proportion of 28% with insulin-dependent type I diabetes and 72% with type II diabetes (fig.1).
Figure 1. Distribution of the group by sex
An individual sheet was completed for each of the 50 participants in the study, which included data on: age, sex, lifestyle elements (smoker status, alcohol consumption, type of diet, diet), personal pathological history (hypertension, AMI, stroke, obesity, diabetes), anthropometric parameters (weight, height, BMI, abdominal circumference), biochemical parameters (fasting blood glucose, HbA1c, total cholesterol, LDL, HDL, TG). The data were recorded in the electronic worksheet without patient identification data, in compliance with the rules of confidentiality.
Results and Discussions
The degree of heredity in diabetes was 18% of which 100% in women and 0% in men. Out of a total of 50 patients, the degree of diabetic heredity was more pronounced in patients with type II diabetes (36 patients, respectively 72%) and only 28% (14 patients) in type I diabetes. In the studied group, the majority of patients (26) and 52% were smokers and 11 patients with a history of chronic alcohol consumption (respectively 22%). Of the total patients in the study group, 36% had a history of obesity and another 10% overweight and only 44% were normal weight. Of these, 16 patients, respectively 44% of patients with type II diabetes were obese, 7 (19.4%) overweight, and only 2 patients with type I diabetes and 14% were obese and 3 patients, respectively 20% overweight in antecedent (fig.2).
Figure 2. Distribution of patients according to type of diabetes and body weight
22 patients in the study group had hypertensive disease (hypertension) of different degrees, respectively 44%, of which only four patients with type I diabetes (28.5%) and 18 patients with type II diabetes had associated hypertension (50%). Out of the total of 15 patients known to have hypertension, 11 (73.3%) had exceeded blood pressure values and uncontrolled hypertensive disease at the regular medical consultation. Seven of the total number of patients presented increased blood pressure values since the last control (newly diagnosed), respectively 31.8% new cases of hypertension in the group of patients with hypertension, respectively 14% of the total number of patients in the studied group. Half of the patients with type II diabetes are hypertensive, the majority (73%) having uncontrolled blood pressure values either by improper treatment or by new onset of the disease (1/3) (fig.3).
We tracked the history of cardiovascular disease in patients in the study group, namely myocardial infarction, chronic coronary heart disease, vascular brain disease, peripheral vascular disease and systemic atheromatosis. Out of the total number of patients in the studied group, a number of five patients presented in the pathological antecedent acute coronary events (acute myocardial infarction) respectively 10% of the total patients, all in the category of patients with DZTII, five patients out of 50 (10%) presented events acute cerebral or carotid atheromatosis all patients with this type of complication being among patients with type II diabetes. The history of familial hypercholesterolemia type II (with LDL) was found in 2 patients, respectively in 4% of the studied group, also in patients with type II diabetes (fig. 3). They presented an associated autoimmune disease, in the form of autoimmune hypothyroidism (Hashimoto) a number of 7 patients (14%) distributed equally as a proportion in the two categories of diabetes (fig.3).
Figure 3. Type of DM and distribution of associated comorbidities (A. obesity, B. high blood pressure, C. AMI, D. Acute cerebrovascular events, E. Familial hypercholesterolemia, F. associated autoimmune disease)
It is easy to see that patients with type II diabetes are more at risk of developing associated comorbidities. The proportion of developing obesity, hypertension, AMI, acute brain events, type II familial hypercholesterolemia and autoimmune diseases such as hypothyroidism is much higher in patients with type II diabetes, compared to those with type I diabetes.
The average weight of the patients in the study group was 84 kg, with a minimum of 46 and a maximum of 125 kg. Of these, 15 had a weight over 100 kg (30%), their average age being 51 years, predominantly women (60%) and 10 smokers (66.66%), all with grade II obesity (BMI 35-40) and only two with type I diabetes (13%), the majority being in the category of patients with type II diabetes (87%). According to the data presented, patients weighing> 100 kg (30%) are mostly women, smokers, with type II diabetes and grade II obesity. The average BMI, on the sample taken in the study, was 30.17 kg/m2, which places the population observed at the first degree of obesity. The distribution by sex was uniform. Out of a total of 50 patients, 10 had a BMI> 30 kg/m2, also 10 a BMI> 35 kg/m2 and 4 a BMI> 40 kg/m2. Of these, only 3 patients had type I diabetes, meaning 12%, which indicates a prevalence increased obesity among patients with type II diabetes (87.5%). The percentage of smokers was 45.83% (11 patients) and that of alcohol consumers was 20.83% (6 patients) (fig.4).
The patients included in the study were subjected to laboratory tests in order to obtain the lipid profile. Thus, the values of triglycerides, total cholesterol, HDL and LDL cholesterol were determined. The studied population has an average TG of 164.44 mg / dl, of which the average for women was 179.93 mg / dl and for men 146 mg / dl. It is clear that males are at the optimal limit of TG, while females are in the increased borderline.
The optimal level of TG was recorded in 42% (21 people of which 12 women and 9 men), an increased borderline was observed in 32% of cases (16 people of which 10 women and 6 men) and increased values were registered in a percentage of 26% (13 people of which 11 women and 2 men). Out of a total of 50 patients, 13 (26%) have elevated TG values (> 200 mg / dl). Of these, 11 are women (33.33%) and 2 are men (11.76%). The increase in the serum level of TG occurs in the case of genetic hypelipidemias, gout, pancreatitis, liver disease, alcoholism, kidney disease, acute disease (AMI), hypothyroidism, diabetes (fig.5).
For the correlation between the BMI value and that of the lipid profile parameters, the values> 150 mg / dl for TG,> 200 mg / dl for total cholesterol,> 130 mg / dl for LDL and <40 mg / dl were taken into account for HDL in men and <50 mg / dl for HDL in women. Following the analysis, it was found that of the patients with a BMI> 30 kg/m2, 24.13% (n=7) had a high level of TG, 20% (n=6) had a high level of cholesterol, 15.15% (n=5) had a high level of LDL and 26.66% (n=8) had a low level of HDL.
Figure 5. Percentage of pathologies and causes associated with increased TG levels among the patients analysed (A. Type 1 DM, B. Type 2 DM, C. AMI, D. gout, E. renal pathology, F. hypothyroidism, G. alcoholism)
Patients with BMI> 35 kg/m2 had a similar percentage of 24.13% (n=7) of increased TG, 20% (n=6) had high total cholesterol, 15.15% (n=5) had elevated LDL and 16, 66% (n=5) had low HDL values. In patients with a BMI> 40 kg/m2, 6.89 (n=2) had high TG values, 10% (n=3) had high total cholesterol, 12.12% (n=4) had high LDL values, and 3.33% (n=1) low HDL values (fig.6).
Figure 6. Correlation of BMIs with lipid profile disorders
After correlating all the high values of the lipid profile, a number of 4 patients (8%) were observed that presented values well above the allowed limit both in terms of TG, total cholesterol, LDL and very low values for HDL. All of these patients had a BMI> 30 kg/m2, one had stage I obesity, two had stage II obesity and one had morbid obesity. Regarding comorbidities, two people have obliterating arteriopathy of the lower limbs (50%), three have hypertension (75%) and one person has had an AMI (25%). Analysing the data, a low degree of compliance with the diet recommended by the nutritionist was found, a degree between 30% and 50%. Of the total of 50 patients included in the study, only 4% (n=2) met the optimal values for TG, total cholesterol, LDL, HDL and BMI. The degree of compliance with the recommended diet was in this case 70% and 90%, respectively, with an average of 80% (fig.7).
Figure 7. Comparison of the degree of compliance with the diet with the lipid profile and the value of BMI. A. patients with optimal BMI and lipid profile
The degree of obesity of the patients was also associated with their degree of adherence to the recommended diet. From this association it emerged that the patients enrolled in the lowest degree of compliance with the diet have mostly morbid obesity (50%), patients in the middle group are predominantly overweight and those with the highest percentage of compliance with the diet has a proportion of 30% type II obesity (fig.8). The results obtained were expected in the first two groups, but surprisingly in the group with the highest degree of compliance with the diet. It is noted that in the first two groups there are patients with morbid obesity in a percentage of 50% and 5.55%, respectively, and in the last group (over 80% degree of compliance with diet) are missing.
Figure 8. Correlation of various degrees of diet compliance with overweight or type of obesity presented
Changing the lifestyle of patients with many risk factors involves establishing a daily or weekly exercise plan of varying degrees of difficulty and an individualized diet according to the needs of each individual.
All patients who were the subject of the study were advised on the diet to be followed by the specialist in diabetes, nutrition and metabolic diseases. Patients are advised to follow a diet with a certain number of carbohydrates daily, plus other recommendations when the situation requires. In the study, there was a better compliance for compliance with dietary recommendations among males, 65.88% than for females 64.54%, the difference being 1.34 percent. Thus, it is necessary to involve the health staff, the community pharmacist, in patient advice with diabetes with metabolic syndrome both in adherence to the drug treatment prescribed by the specialist and adherence to the dietary recommendations made by the specialist in diabetes, nutrition and metabolic diseases.
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