Miscelnea de diabetes y

nutricin
Gonzalo Ruiz-Esquide
 Objetivo de control 140 180 (200) mg/dL

1. Diabetes Res Clin Pract. 2013 Oct;102(1):8-15. Intensity of peri-operative glycemic control and postoperative outcomes in
patients with diabetes: a meta-analysis. Sathya B
2. Ann Intern Med. 2011 Feb 15;154(4):268-82. Intensive insulin therapy in hospitalized patients: a systematic review. Kansagara D,
Fu R, Freeman M, Wolf F, Helfand M.
Conceptos de control periop
EL DIABTICO TIPO 1 NO PUEDE QUEDAR SIN INSULINA
Programar a 1 hora
Procedimientos largos: susp trat previos e iniciar BIC de insulina
Proc cortos:
Tipo 2, bien controlados, saltarse la dosis de la maana
Tipo 1:
avisar
saltarse la dosis de rpida de la maana
Lacteos y riesgo de diabetes

Nutr Metab Cardiovasc Dis. 2014 Aug 7. pii: S0939-4753(14)00258-0

PLoS One. 2013 Sep 27;8(9):e73965.
Am J Clin Nutr. 2013 Oct;98(4):1066-83
Lacteos y enfermedad cardiovascular

J Clin Hypertens (Greenwich). 2013 Jul;15(7):503-10

Lcteos y cncer gstrico

FIG. 2. Forest plots showing estimated relative risks (highest vs. lowest category) of gastric cancer associated with total dairy consumption.
Published in: Yanjun Guo; Zhilei Shan; Hongyu Ren; Weihong Chen; Nutrition and Cancer 2015, 67, 555-568.
DOI: 10.1080/01635581.2015.1019634
Copyright 2015 Taylor & Francis Group, LLC
 Intake of total dairy products and prostate cancer risk.

Dagfinn Aune et al. Am J Clin Nutr 2015;101:87-117

2015 by American Society for Nutrition

 Intake of milk and prostate cancer risk.

Dagfinn Aune et al. Am J Clin Nutr 2015;101:87-117

2015 by American Society for Nutrition

 Definiciones
Sensibilidad o respuesta
disminuidas a las
acciones de la Insulina:
50% Utilizacin de glucosa mediada
por insulina
Inhibicin de produccin
heptica de glucosa

Sensibilidad

Am J Physiol Endocrinol Metab. 2008 Jan;294(1):E15-26. Current approaches for assessing

insulin sensitivity and resistance in vivo: advantages, limitations, and appropriate usage.
 Medicin
Clamp Euglicmico Hiperinsulinmico
Ayuno
Infusin de Insulina en dosis altas
Infusin de Glucosa para euglicemia
Estado estable => infusin = disposicin
Disposicin + insulinemia = sensibilidad

Am J Physiol Endocrinol Metab. 2008 Jan;294(1):E15-26. Current approaches for assessing

insulin sensitivity and resistance in vivo: advantages, limitations, and appropriate usage.
 Medicin en ayunas
HOMA
=Insulina (U/mL)*glicemia (mg/dL)/405
Estado estable en ayunas
Glicemia= PHG-C cerebral
Sensibilidad heptica a la insulina
Tres (dos) tomas de insulinemia

QUICKI, otros
1. Am J Physiol Endocrinol Metab. 2008 Jan;294(1):E15-26. Current approaches for assessing
insulin sensitivity and resistance in vivo: advantages, limitations, and appropriate usage.
2. Diabetes Care. 2004 Jun;27(6):1487-95. Use and abuse of HOMA modeling
3. Rev. chil. endocrinol. diabetes 1 (4), 2008: 272 281. Consenso SOCHED
J Clin Invest. 2000 Jul;106(2):171-6.
Mecanismos celulares de resistencia
Insulnica: Msculo

Physiol Rev. 2007 Apr;87(2):507-20. Disordered lipid metabolism and the pathogenesis of insulin
resistance. Savage DB, et al.
Curr Opin Pharmacol. 2009 Dec;9(6):753-62
Circulation. 2009;120:1640-1645. Consenso IDF, AHA, NHLBI, WHF, IAS, IASO.
 Criterios diagnsticos de consenso
MEDIDA PUNTO DE CORTE
Circunferencia de cintura
Europeos >94 cm (h) / >80 cm (m)
Sudamericanos >90 cm (h) / >80 cm (m)
>102 cm (h) / >88 cm (m) SOCHED, 2008

Trigliceridos elevados >150 mg/dL

c-HDL reducido <40 mg/dL (h)
<50 mg/dL (m)
Presin arterial elevada > 130 mmHg sistlica
> 85 mmHg diastlica
Glicemia alterada de ayunas >100 mg/dL
O tratamientos para cualquiera de las condiciones

1. Circulation. 2009 Oct 20;120(16):1640-5. Harmonizing the metabolic syndrome...

2. Rev. chil. endocrinol. diabetes 1 (4), 2008: 272 281. Consenso SOCHED
Diabetes Prevention Program-2002
n=3234
IFG+IGT
IMC=34
68% mujeres
51 aos
F/U= 2,8 a

RRR de Diabetes
EV= 59%
MTF= 31%

NNT x 3 aos
EV=7
MTF=14

N Engl J Med. 2002 Feb 7;346(6):393-403. Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin.
Prevencin de Diabetes y Eventos

Incidencia de diabetes

Eur J Cardiovasc Prev Rehabil. 2011 Dec;18(6):813-23. Prevention of diabetes and reduction in
major cardiovascular events in studies of subjects with prediabetes: meta-analysis of randomised
controlled clinical trials. Hopper I, et al
Prevencin de Diabetes y Eventos

MORTALIDAD TOTAL

Eur J Cardiovasc Prev Rehabil. 2011 Dec;18(6):813-23. Prevention of diabetes and reduction in
major cardiovascular events in studies of subjects with prediabetes: meta-analysis of randomised
controlled clinical trials. Hopper I, et al
Prevencin de Diabetes y Eventos
INFARTO NO FATAL AVE FATAL Y NO FATAL

Eur J Cardiovasc Prev Rehabil. 2011 Dec;18(6):813-23. Prevention of diabetes and reduction in
major cardiovascular events in studies of subjects with prediabetes: meta-analysis of randomised
controlled clinical trials. Hopper I, et al
 Prevalencias costos
Hiperglicemia de ayunas (100 mg/dL)
Talca, 2005 = 26%
EEUU, 2010 = 37%
Sndrome metablico:
Chile, 2009 = 35%
EEUU, 2009 = 34%

1. Rev Med Chil. 2007 Jul;135(7):904-12. Prevalence of cardiovascular risk factors in adult from Talca, Chile. Palomo G I, et al.
2. Diabetes Care. 2014 Apr;37(4):943-9. The reality of type 2 diabetes prevention. Kahn R1, Davidson MB.
3. Ervin RB. Prevalence of metabolic syndrome among adults 20 years of age and over, by sex, age, race and ethnicity, and body
mass index: United States, 20032006. National health statistics reports; no 13. Hyattsville, MD: National Center for Health
Statistics. 2009.
 Resistencia Insulnica
y ganancia de peso

1. Greenspan's Basic ; Clinical Endocrinology: Eighth Edition, 2007

2. J Clin Endocrinol Metab. 1995 May;80(5):1571-6. Reduced insulin secretion: an independent
predictor of body weight gain
3. Int J Obes Relat Metab Disord. 1999 Feb;23 Suppl 1:37-41. Metabolic predictors of weight gain
4. Int J Obes (Lond). 2011 Dec;35(12):1495-501. Higher incremental insulin area under the curve
during oral glucose tolerance test predicts less food intake and weight gain
5. J Clin Invest. 1991 Jul;88(1):168-73. Insulin resistance associated with lower rates of weight gain
in Pima Indians
 Peso corporal v/s placebo

Cochrane Database Syst Rev. 2005 Jul 20;(3):CD002966.

Metformin monotherapy for type 2 diabetes mellitus.
 DPP, Peso corporal v/s placebo

1. N Engl J Med. 2002 Feb 7;346(6):393-403. Reduction in the incidence of type 2

diabetes with lifestyle intervention or metformin.
2. Lancet. 2009 Nov 14;374(9702):1677-86. 10-year follow-up of diabetes incidence and
weight loss in the Diabetes Prevention Program Outcomes Study.
Efectos cardiovasculares de
hiperinsulinemia farmacolgica:
El estudio ORIGIN

N Engl J Med. 2012 Jul 26;367(4):319-28. Basal insulin and

cardiovascular and other outcomes in dysglycemia.
 Schematic overview on the predominant distribution of SGLT1 and SGLT2 receptors along the
nephron.

George Vlotides, and Peter R. Mertens Nephrol. Dial.

Transplant. 2014;ndt.gfu299

The Author 2014. Published by Oxford University Press on behalf of ERA-EDTA. All rights
reserved.
Inhibidores SGLT2
Reduccin A1c = 0,5-0,9%
Reduccin de peso = 3-5 % -- 4-8 kg
Reduccin de PA = 1-10 mmHg

Aumentan:
Infecciones urinarias
Infecciones vulvovaginales
CETOACIDOSIS? (no slo en tipo 1)
 Mean percent change from baseline at day 7 for basal daily insulin dose (A), bolus daily insulin
dose (B), and total daily insulin dose (C). , placebo plus insulin; , dapagliflozin 1 mg plus
insulin; , dapagliflozin 2.5 mg plus insulin; , dapagliflozin 5 mg plus insulin; and ,
dapagliflozin 10 mg plus insulin.

Robert R. Henry et al. Dia Care 2015;38:412-419

2015 by American Diabetes Association

Inhibidores DPP4
Januvia (Sitagliptina) (R)
Trayenta (Linagliptina) (R)
Onglyza (Saxagliptina)
Galvus (Vildagliptina)
Inhibidores DPP4
Reducen A1c 0,5 - 1%
No hipoglicemias
Neutros en peso
Seguros: (?)
RR=1,2 de nasofaringitis
ITU?
Pancreatitis, ca de pncreas??
Guas ACC/AHA 2013
Tpicos actuales en el tratamiento de la dislipidemia
Grupos que se benefician de Estatinas
para la reduccin de Riesgo ECV Aterotrombticos
1. Portadores de ECVAE clnica
2. Elevaciones primarias de cLDL 190mg/dL
3. Diabticos
40-75 aos
cLDL 70 189 (si el cLDL de inicio 70mg/dL)
4. Prevencin primaria
RCV a 10 aos 7,5%

J Am Coll Cardiol. 2013 Nov 7. pii: S0735-1097(13)06028-2. 2013 ACC/AHA Guideline on the
Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A
Report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines.
 Resumen de las recomendaciones para iniciar
estatinas: AHA/ACC 2013
No= Estatinas alta potencia ALTA POTENCIA
ECVAC >75a
Si= Estatinas de potencia moderadas cLDL > 50%
No ATORVASTATINA 40-80mg
ROSUVASTATINA 20-40mg
cLDL
Estatinas alta potencia
190 POTENCIA MODERADA
No
cLDL 30 - 50%
ATORVASTATINA 10-20mg
DM RCV No= Estatinas de potencia moderada
40-75a 7,5% ROSUVASTATINA 5-10mg
Si= Estatinas alta potencia SIMVASATINA 20-40mg
No

CALCULE RCV a 10 AOS LOVASTATINA 40mg

Si= Estatinas de potencia

RCV moderada/alta
7,5%
5-7,5% Considerar Estatinas de
potencia moderada
Las estatinas son el tratamiento ms efectivo
MORTALIDAD TOTAL, EN GENERAL: EVENTOS EN PACIENTES RCV BAJO (<10%):
REDUCCION 10% x 38mg/dL de cLDL REDUCCIN 36%

Metaanlisis CTT : Lancet. 2012 Aug 11;380(9841):581-90.

Metaanlisis CTT: Lancet. 2010;376:1670-81 Tonelli et al: CMAJ. 2011 Nov 8;183(16):E1189-202.
 Reacciones adversas de estatinas v/s placebo
1.4

1.2

0.8
OR

0.6

0.4

0.2

1.07 1.03 1.13 1 0.96 1.01 1.09 1.18 0.95 0.86

0
Mialgia Elevaciones de CK Cncer Diabetes Suspensin por cualquier EA

Naci et al. COCHRANE

1. Circ Cardiovasc Qual Outcomes. 2013 Jul 1;6(4):390-9. Comparative tolerability and harms of individual statins: a study-
level network meta-analysis of 246 955 participants from 135 randomized, controlled trials. Naci H
2. Cochrane Database Syst Rev. 2013 Jan 31;1:CD004816. Statins for the primary prevention of cardiovascular disease.
Taylor F, et al.
Miscelnea de diabetes y
nutricin
Gonzalo Ruiz-Esquide