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Cardiometabolic Risk Factors and Incident Cardiovascular Disease Events in Women vs Men With Type 1 Diabetes.
Braffett, BH, Bebu, I, El Ghormli, L, Cowie, CC, Sivitz, WI, Pop-Busui, R, Larkin, ME, Gubitosi-Klug, RA, Nathan, DM, Lachin, JM, et al
JAMA network open. 2022;5(9):e2230710
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In the general population, women have a lower absolute risk of cardiovascular disease (CVD) compared with men. However, among individuals with type 1 or type 2 diabetes, the relative risk of CVD is similar or higher in women compared with men. The aim of this study was to assess sex differences in achieving recommended CVD risk management targets and associations with CVD events. This is a cohort study which included a total of 1441 (men n= 736) participants with type 1 diabetes. Results show that the prevalence and mean levels of most cardiometabolic risk factors (except for pulse rate and haemoglobin A1c) were consistent with a less atherogenic profile among women compared with men. Furthermore, achieving treatment targets for blood pressure, lipids, and glucose was associated with significantly decreased risk of CVD in both women and men. Authors conclude that their findings argue for a recalibration of CVD risk factor stratification in revised clinical care guidelines and therapeutic recommendations by sex for individuals with type 1 diabetes.
Abstract
IMPORTANCE The lower risk of cardiovascular disease (CVD) among women compared with men in the general population may be diminished among those with diabetes. OBJECTIVE To evaluate cardiometabolic risk factors and their management in association with CVD events in women vs men with type 1 diabetes enrolled in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data obtained during the combined DCCT (randomized clinical trial, conducted 1983-1993) and EDIC (observational study, conducted 1994 to present) studies through April 30, 2018 (mean [SD] follow-up, 28.8 [5.8] years), at 27 clinical centers in the US and Canada. Data analyses were performed between July 2021 and April 2022. EXPOSURE During the DCCT phase, patients were randomized to intensive vs conventional diabetes therapy. MAIN OUTCOMES AND MEASURES Cardiometabolic risk factors and CVD events were assessed via detailed medical history and focused physical examinations. Blood and urine samples were assayed centrally. CVD events were adjudicated by a review committee. Linear mixed models and Cox proportional hazards models evaluated sex differences in cardiometabolic risk factors and CVD risk over follow-up. RESULTS A total of 1441 participants with type 1 diabetes (mean [SD] age at DCCT baseline, 26.8 [7.1] years; 761 [52.8%] men; 1390 [96.5%] non-Hispanic White) were included. Over the duration of the study, compared with men, women had significantly lower body mass index (BMI, calculated as weight in kilograms divided by height in meters squared; β = -0.43 [SE, 0.16]; P = .006), waist circumference (β = -10.56 cm [SE, 0.52 cm]; P < .001), blood pressure (systolic: β = -5.77 mm Hg [SE, 0.35 mm Hg]; P < .001; diastolic: β = -3.23 mm Hg [SE, 0.26 mm Hg]; P < .001), and triglyceride levels (β = -10.10 mg/dL [SE, 1.98 mg/dL]; P < .001); higher HDL cholesterol levels (β = 9.36 mg/dL [SE, 0.57 mg/dL]; P < .001); and similar LDL cholesterol levels (β = -0.76 mg/dL [SE, 1.22 mg/dL]; P = .53). Women, compared with men, achieved recommended targets more frequently for blood pressure (ie, <130/80 mm Hg: 90.0% vs 77.4%; P < .001) and triglycerides (ie, <150 mg/dL: 97.3% vs 90.5%; P < .001). However, sex-specific HDL cholesterol targets (ie, ≥50 mg/dL for women, ≥40 mg/dL for men) were achieved less often (74.3% vs 86.6%; P < .001) and cardioprotective medications were used less frequently in women than men (ie, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker: 29.6% [95% CI, 25.7%-33.9%] vs 40.0% [95% CI, 36.1%-44.0%]; P = .001; lipid-lowering medication: 25.3% [95% CI, 22.1%-28.7%] vs 39.6% [95% CI, 36.1%-43.2%]; P < .001). Women also had significantly higher pulse rates (mean [SD], 75.2 [6.8] beats per minute vs 71.8 [6.9] beats per minute; P < .001) and hemoglobin A1c levels (mean [SD], 8.3% [1.0%] vs 8.1% [1.0%]; P = .01) and achieved targets for tighter glycemic control less often than men (ie, hemoglobin A1c <7%: 11.2% [95% CI, 9.3%-13.3%] vs 14.0% [95% CI, 12.0%-16.3%]; P = .03). CONCLUSIONS AND RELEVANCE These findings suggest that despite a more favorable cardiometabolic risk factor profile, women with type 1 diabetes did not have a significantly lower CVD event burden than men, suggesting a greater clinical impact of cardiometabolic risk factors in women vs men with diabetes. These findings call for conscientious optimization of the control of CVD risk factors in women with type 1 diabetes.
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Relationship of age at menarche and serum leptin with the metabolically unhealthy phenotype in adolescents.
Magalhaes, ACL, Pierucci, AP, Oliveira, MN, Campos, ABF, Jesus, PC, Ramalho, A
Nutricion hospitalaria. 2021;38(1):29-35
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Carrying excess weight during childhood and adolescence is believed to be a major risk factor for the development of cardiometabolic diseases in adulthood. Furthermore, high serum leptin concentrations are strictly related to pubertal development, and therefore have an impact on the age at which menarche occurs. The aim of this study was to analyse the relationship between age at menarche and healthy/unhealthy metabolic profiles, relating them to different body mass index categories, waist circumference, and serum leptin concentrations in female adolescents. This study is a cross-sectional study which investigated one hundred and thirty-nine, girls aged 10 to 19 years, who had gone through menarche. Results show that there is a relationship between early menarche and high serum leptin concentrations particularly in the metabolically unhealthy phenotype adolescent girls who have different body mass indices. Authors conclude that it is important that age of menarche, serum leptin levels and metabolic phenotypes of children and adolescents are analysed during clinical practice, in order to formulate strategies to prevent the development of cardiometabolic diseases in adulthood.
Abstract
Objective: to analyze the relationship of age at menarche and leptin with the metabolically healthy (MH) and metabolically unhealthy (MUH) phenotypes in adolescent girls in different body mass index (BMI) categories. Method: an observational and cross-sectional study consisting of 139 female adolescents attended to at the Adolescent Reference Center in Macaé, Rio de Janeiro. Menarche was classified as early (EM) when the first menstruation occurred at or before 11 years of age; normal menarche (NM) was categorized at ages 12 to 14; menarche was considered late (LM) when it occurred at age 15 or older. The factors required to ascertain the subjects' phenotype, as well as their leptin levels, weight, and height, were measured and their BMIs were calculated. The girls were classified as MH or MUH based on the NCEP-ATP III criteria as adapted for children and adolescents. Results: 82 % (n = 114) of the girls were classified as MH and 18 % (n = 25) as MUH. Mean age at menarche was 11.79 ± 1.39 years. There was a higher prevalence of MUH amongst the girls who had EM (p = 0.04). A higher inadequacy of serum leptin concentrations was found in girls who had EM (p = 0.05) and in those classified as MUH (p = 0.01). The adolescents who were severely obese exhibited inadequate leptin levels (p < 0.01) and had gone through EM (p = 0.02). A total of 8.1 % (n = 7) of the normal-weight girls were classified as MUH, and 29.4 % (n = 5) of those who were severely obese were classified as MH (p < 0.01). Conclusion: early menarche and high serum leptin concentrations are related with the MUH phenotype in adolescent girls in different BMI categories. Objetivo: analizar la relación de la edad de la menarquia y los niveles de leptina con los fenotipos metabólicamente saludables (MS) y metabólicamente no saludables (MNS) en adolescentes de diferentes categorías de índice de masa corporal (IMC). Método: estudio observacional y transversal compuesto por 139 adolescentes de sexo feminino, atendidas en el Centro de Referencia para Adolescentes de Macaé, Río de Janeiro. La menarquia se clasificó como precoz (MP) cuando se produjo la primera menstruación a o antes de los 11 años de edad; la menarquia normal (MN) se clasificó como aquella sucedida a la edad de 12 a 14 años; la menarquia se consideró tardía (MT) cuando ocurrió a los 15 años o más. Se midieron los factores necesarios para determinar el fenotipo de los sujetos, y se midieron sus niveles de leptina, peso y altura, y se calculó su IMC. Las adolescentes se clasificaron como MS y MNS según los criterios de NCEP-ATP III, adaptados para niños y adolescentes. Resultados: el 82 % (n = 114) de las adolescentes se clasificaron como MH y el 18 % (n = 25) como MUH. La edad media de la menarquia fue de 11,79 ± 1,39 años. Hubo una mayor prevalencia de MUH entre las adolescentes que tenían MP (p = 0,04). Se encontró una mayor insuficiencia de las concentraciones séricas de leptina en las adolescentes que tenían MP (p = 0,05) y en aquellas clasificadas como MNS (p = 0,01). Las adolescentes que eran severamente obesas exhibieron niveles inadecuados de leptina (p < 0,01) y habían pasado por una MP (p = 0,02). El 8,1 % (n = 7) de las adolescentes de peso normal se clasificaron como MNS y el 29,4 % (n = 5) de las que eran severamente obesas se clasificaron como MS (p < 0,01). Conclusión: la menarquia temprana y las altas concentraciones séricas de leptina están relacionadas con el fenotipo MNS en las adolescentes de diferentes categorías de IMC.
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The Influence of Reducing Diets on Changes in Thyroid Parameters in Women Suffering from Obesity and Hashimoto's Disease.
Ostrowska, L, Gier, D, Zyśk, B
Nutrients. 2021;13(3)
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Hashimoto’s disease is also known as autoimmune thyroiditis or chronic lymphocytic thyroiditis. It is the most common type of thyroiditis and autoimmune endocrinopathy. Weight gain is frequently the first symptom of hypothyroidism. The treatment of hypothyroidism (including autoimmune disorders) is based mainly on pharmacological treatment aimed at supplementing the deficiency of thyroid hormones. The aim of this study was to evaluate the effectiveness of two different reducing diets and their influence on changes in thyroid parameters in female patients. This study is an interventional/observational study of 100 women aged 18–65 years with previously diagnosed Hashimoto’s disease and obesity. The women were randomly assigned to group A (the test group, n = 50) or group B (the control group). Results show that: - the elimination diets enabled an average weight loss of 21.17 kg, and the reducing diets a weight loss of 17.03 kg. - effective weight reduction led to improvement of thyroid parameters in patients suffering from obesity and Hashimoto’s disease. - an individually adjusted elimination diet may lead to better therapeutic results. Authors conclude that elimination diets are a more effective tool in reducing body fat mass in women with Hashimoto’s disease compared to standard balanced reducing diets with the same energy value and main nutrient content.
Abstract
Hashimoto's disease is listed among the most common endocrine causes of obesity. As treatment of obesity in women with Hashimoto's disease is frequently unsuccessful, the aim of this study was to evaluate the effectiveness of two different reducing diets and their influence on changes in thyroid parameters in female patients. A six-month observational/interventional study was performed on 100 women aged 18-65 years, previously diagnosed with Hashimoto's disease and obesity and receiving L-thyroxine. The women were randomly assigned to the test group (group A, n = 50) following elimination/reducing diets, and the control group (group B, n = 50) following reducing diets with the same caloric content (without elimination). Anthropometric and thyroid parameters were evaluated at the beginning, after 3 months and after 6 months of treatment. In both groups a significant decrease in BMI and body fat percentage was achieved, but in test group A the decrease in BMI and body fat percentage was significantly greater than in control group B (p < 0.002 and p = 0.026, respectively). Serum TSH (thyroid stimulating hormon) levels decreased significantly more in group A than in group B (p < 0.001). Group A exhibited significantly greater increases in fT4 and fT3 levels than the control group (p < 0.001) as well as significantly greater decreases in the levels anti-TPO (thyroid peroxidase) (p < 0.001) and anti-TG (thyreoglobulin) antibodies (p = 0.048). The application of reducing diets with product elimination was found to be a more beneficial tool for changing anthropometric and thyroid parameters in women suffering from obesity and Hashimoto's disease than classic reducing diets with the same energy values and macronutrient content.
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Changes in Weight and Nutritional Habits in Adults with Obesity during the "Lockdown" Period Caused by the COVID-19 Virus Emergency.
Pellegrini, M, Ponzo, V, Rosato, R, Scumaci, E, Goitre, I, Benso, A, Belcastro, S, Crespi, C, De Michieli, F, Ghigo, E, et al
Nutrients. 2020;12(7)
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The pandemic of the coronavirus SARS-CoV-2 (COVID-19) has caused significant disruption in everyday lifestyle. The aim if this study was to evaluate the changes in weight and dietary habits in a sample of individuals with obesity attending the Obesity Unit after 1 month of enforced lockdown. This is an observational retrospective study were patients followed a 12-month multidisciplinary weight loss program. Results showed that patients with obesity attending an Obesity Unit in Northern Italy showed a ≈1.5 kg self-reported weight gain after the first month of lockdown. Lower education level, self-reported anxiety/depression, and not paying attention to the healthiness of food choices were significantly associated with weight and body mass index increase. Authors conclude that the adverse mental burden linked to the COVID-19 pandemic might be associated with their increased weight.
Abstract
Our aim is evaluating the changes in weight and dietary habits in a sample of outpatients with obesity after 1 month of enforced lockdown during the COVID-19 pandemic in Northern Italy. In this observational retrospective study, the patients of our Obesity Unit were invited to answer to a 12-question multiple-choice questionnaire relative to weight changes, working activity, exercise, dietary habits, and conditions potentially impacting on nutritional choices. A multivariate regression analysis was performed to evaluate the associations among weight/BMI changes and the analyzed variables. A total of 150 subjects (91.5%) completed the questionnaire. Mean self-reported weight gain was ≈1.5 kg (p < 0.001). Lower exercise, self-reported boredom/solitude, anxiety/depression, enhanced eating, consumption of snacks, unhealthy foods, cereals, and sweets were correlated with a significantly higher weight gain. Multiple regression analyses showed that increased education (inversely, β = -1.15; 95%CI -2.13, -0.17, p = 0.022), self-reported anxiety/depression (β = 1.61; 0.53, 2.69, p = 0.004), and not consuming healthy foods (β = 1.48; 0.19, 2.77, p = 0.026) were significantly associated with increased weight gain. The estimated direct effect of self-reported anxiety/depression on weight was 2.07 kg (1.07, 3.07, p < 0.001). Individuals with obesity significantly gained weight 1 month after the beginning of the quarantine. The adverse mental burden linked to the COVID-19 pandemic was greatly associated with increased weight gain.
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The Risks of Cardiovascular Disease and Mortality Following Weight Change in Adults with Diabetes: Results from ADVANCE.
Lee, AK, Woodward, M, Wang, D, Ohkuma, T, Warren, B, Sharrett, AR, Williams, B, Marre, M, Hamet, P, Harrap, S, et al
The Journal of clinical endocrinology and metabolism. 2020;105(1)
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Type 2 diabetes is characterized by metabolic dysregulation resulting in an increased risk of cardiovascular disease The objectives of this study were: a. to determine whether weight change over 2 years was associated with subsequent cardiovascular outcomes and death in adults with diabetes, and b. to examine whether this association was modified by baseline body mass index (BMI), age, or type of glucose-lowering medications. This study is a large prospective study of adults with type 2 diabetes. One arm tested the effects of intensive glucose lowering versus standard glucose control. Whereas the second arm tested the effects of blood pressure-lowering medication versus a placebo. Results showed that that >10% weight loss was associated with >2 times higher risk of cardiovascular and all-cause mortality and was associated with 75% greater risk of major macrovascular events, compared with adults with stable weight. These associations were not significantly modified by metformin use, age, or baseline BMI. Authors conclude that unless patients specifically report lifestyle changes to lose weight, even modest weight loss may be a marker of declining health for which further clinical investigation is merited.
Abstract
CONTEXT Weight loss is strongly recommended for overweight and obese adults with type 2 diabetes. Unintentional weight loss is associated with increased risk of all-cause mortality, but few studies have examined its association with cardiovascular outcomes in patients with diabetes. OBJECTIVE To evaluate 2-year weight change and subsequent risk of cardiovascular events and mortality in established type 2 diabetes. DESIGN AND SETTING The Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation was an international, multisite 2×2 factorial trial of intensive glucose control and blood pressure control. We examined 5 categories of 2-year weight change: >10% loss, 4% to 10% loss, stable (±<4%), 4% to 10% gain, and >10% gain. We used Cox regression with follow-up time starting at 2 years, adjusting for intervention arm, demographics, cardiovascular risk factors, and diabetes medication use from the 2-year visit. RESULTS Among 10 081 participants with valid weight measurements, average age was 66 years. By the 2-year examination, 4.3% had >10% weight loss, 18.4% had 4% to 10% weight loss, and 5.3% had >10% weight gain. Over the following 3 years of the trial, >10% weight loss was strongly associated with major macrovascular events (hazard ratio [HR], 1.75; 95% confidence interval [CI], 1.26-2.44), cardiovascular mortality (HR, 2.76; 95% CI, 1.87-4.09), all-cause mortality (HR, 2.79; 95% CI, 2.10-3.71), but not major microvascular events (HR, 0.91; 95% CI, 0.61-1.36), compared with stable weight. There was no evidence of effect modification by baseline body mass index, age, or type of diabetes medication. CONCLUSIONS In the absence of substantial lifestyle changes, weight loss may be a warning sign of poor health meriting further workup in patients with type 2 diabetes.
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Assessment of sleep and obesity in adults and children: Observational study.
Bonanno, L, Metro, D, Papa, M, Finzi, G, Maviglia, A, Sottile, F, Corallo, F, Manasseri, L
Medicine. 2019;98(46):e17642
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Sleep is essential to support the functions and health of the entire body. The aim of this study was to investigate the association between sleep duration and quality, and overweight risk and obesity in children and adults. The study was conducted on secondary school children. It involved 199 subjects of which 71 were adults (29 males and 42 females) with age between 29 and 65 years, and 128 children (73 males and 55 females) with age between 10 and 13 years. Results indicate that the duration and quality of sleep can represent a risk factor of overweight and obesity in examined subjects (both adults and children irrespective of their gender). Authors conclude that sufficient sleep is required to maintain a normal weight.
Abstract
The sleep allows many psychological processes, such as immune system activity, body metabolism and hormonal balance, emotional and mental health, learning, mnemonic processes. The lack of sleep could undermine mental and physical purposes, causing an alteration in cognitive functions or metabolic disorders. In our study, we have examined the irregular sleep effects with the overweight and obesity risk in children and adults.The sample was composed of 199 subjects, of which 71 adults, (29 males and 42 females), and 128 children (73 males and 55 females). We have measured the weight and height with standard techniques; we also have measured the body mass index dividing the weight in kg with the height square expressed in meters (kg/m). Subjects were divided into underweight, normal weight, overweight, and obese. Were administered some questionnaires to measure the quantity and quality of sleep, and eating habits and individual consumption of food.Analysis of demographic variables not showed significant differences between male and female groups but highlighted a significant trend differences in normal-weight score. The clinical condition has a substantial impact on body mass index score and sleep hours were significant predictor on this.Quantity and quality sleep can also represent a risk factor of overweight and obesity, so sufficient sleep is a factor that influence a normal weight. Adults and children that sleep less, have an increase in obesity and overweight risk with dysfunctional eating behaviors, decreased physical activity, and metabolic changes.
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Vitamin D nutritional status and its relationship with metabolic changes in adolescents and adults with severe obesity.
Teixeira, JS, Bull Ferreira Campos, A, Cordeiro, A, Pereira, SE, Saboya, CJ, Ramalho, A
Nutricion hospitalaria. 2018;35(4):847-853
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In adolescents, severe obesity may lead to a high risk of premature mortality and morbidity in adult life. Increased vitamin D deficiency (VDD) occurs together with obesity. The main aim of this study was to assess the nutritional status of vitamin D and metabolic profile in adolescents and adults with obesity. The study is a comparative observational study which included 128 individuals. A total of 60 participants comprised the adolescent group (G1), (63.3% female) whereas 68 participants comprised the adult group (G2), (75% female). Results indicate: - a high prevalence of inadequacy of Vitamin D in both groups. - a trend of association of elevated blood glucose with the inadequacy of Vitamin D in the adolescent group. - a high prevalence of VDD and non-alcoholic fatty liver disease in both groups. - no relationship between Vitamin D and high blood pressure or metabolic syndrome in any of the groups evaluated. Authors conclude that strategies for the prevention and control of obesity and for the fight against the inadequacy of the nutritional status of vitamin D should be developed.
Abstract
INTRODUCTION increased vitamin D deficiency occurs together with obesity and the association between these conditions has been observed. OBJECTIVE to assess the nutritional status of vitamin D and metabolic profile in adolescents and adults with obesity, and the relationship between complications arising from severe class of obesity with vitamin D nutritional status, and to compare the differences between these groups. METHODS observational comparative study. Population comprises adolescents and adults with severe obesity. Waist circumference (WC) and body mass index (BMI) were measured. Analysis of vitamin D (25(OH)D), lipid profile, C-reactive protein (CRP), blood glucose, fasting insulinemia, insulin sensitivity, blood pressure and diagnoses of nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome (MS) were performed. RESULTS a total of 60 adolescents (G1) and 68 adults (G2) were evaluated. The percentage of vitamin D inadequacy was observed in 90% in G1 and 79.4% in G2. There was a negative and significant correlation of BMI with the values of 25(OH)D in the group of adults (r = -0.244; p = 0.045). Individuals with inadequacy of vitamin D showed higher values of CRP in both groups (p = 0.000). HOMA-IR showed a negative correlation with 25(OH)D in G1 (r = -0.832; p = 0.000) and G2 (r = -0.589; p = 0.000). The inadequacy of this vitamin showed association with high total cholesterol in G1 (p = 0.029) and higher values of LDL-c in G2 (p = 0.003). CONCLUSION high prevalence of deficiency and insufficiency of vitamin D were observed, associated with metabolic changes both in obese adults and adolescents. It is necessary to develop strategies for the prevention and control of obesity and vitamin D deficiency.
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The Association between Mediterranean Diet and the Risk of Falls and Physical Function Indices in Older Type 2 Diabetic People Varies by Age.
Tepper, S, Alter Sivashensky, A, Rivkah Shahar, D, Geva, D, Cukierman-Yaffe, T
Nutrients. 2018;10(6)
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Diabetes is associated with high risk for disability, and accelerated rate of decline in physical capacity. The aim of the study is to examine whether a higher adherence to a Mediterranean Diet in a Mediterranean country is associated with walking speed, better physical function and decreased risk for falls. This cross-sectional study includes data of 117 individuals, of which 40% were females, with Type 2 diabetes aged over 60 years. Results indicate that those individuals with a higher adherence to the Mediterranean Diet were at lower risk for falls and had greater muscle strength. The relationship between physical performance measured by walking speed, walking distance and Mediterranean Diet differed by age. Authors conclude that there is an association between the balances indices, risk for falls, muscle strength, aerobic capacity, and Mediterranean Diet among 60+ individuals with diabetes.
Abstract
BACKGROUND AND AIMS Diabetes and dysglycemia increase the risk of frailty and decreased physical abilities. Adherence to the Mediterranean Diet (MD) may reduce this risk. We hypothesized that adherence to the MD is associated with physical function in older type-2 diabetic patients and that the association is stratified by age. METHODS AND RESULTS We recruited type-2 diabetes patients aged >60 years at the Center for Successful Aging with Diabetes at Sheba Medical Center. Health status and demographic data were obtained from medical records. Food Frequency Questionnaire was used for nutritional assessment and calculation of MD score. Physical function indices were determined by a physiotherapist and included: Berg Balance test, Timed Get-Up-and-Go, 6-min walk (6 MW), 10-m walk (10 MW), Four Square Step Test, 30-s chair stand and Grip strength, and activities and instrumental activities of daily living. Among 117 participants (age 70.6 ± 6.5), high adherence to MD was associated with better score on functional tests (low vs. high MD adherence: 9.7% vs. 25%, ANOVA p = 0.02). A significant age by MD interaction was found: a higher adherence to MD was associated with a better 6 MW (low vs. high: 387 ± 35 m vs. 483 ± 26 m; p = 0.001) and higher 10 MW (low vs. high: 1.8 ± 0.16 m/s vs. 2.0 ± 0.13 m/s; p = 0.02) in participants aged >75 years. These associations remained significant after controlling for gender, age, BMI, and physical activity. CONCLUSION In the current study, we showed relationships between strength, physical performance, and MD among older diabetic patients. Future studies are needed to confirm this association and establish temporal relationships.