مجله دیابت و متابولیسم ایران
سال هفتم شماره 2 (پیاپی 23، زمستان 1386)

Diabetes among Eastern Mediterranean (EM) population above age of 20 years is around 10.5% and is ranked among the leading causes of blindness, renal failure and lower limb amputation. While 50% of EM people with diabetes will die of cardiovascular diseases. This means that in our region, there are pandemic trends in prevalence of diabetes and associated complications. Globally, people with diabetes are 25 times more likely to have a leg amputated than those without the condition, and up to 70% of all leg amputations happen to people with diabetes. Somewhere in the world, a leg is lost to diabetes every 30 seconds. Foot ulcer is the most common single precursor to lower extremity amputations among diabetics. Hyperglycemia, impaired immunologic responses, neuropathy, and peripheral arterial disease are the major predisposing factors leading to limb-threatening diabetic foot infections. Diabetic foot represents a health problem and economic burden among majority of EM Countries. Infection in a diabetic foot is limb-threatening and must be treated empirically and aggressively. Treatment of infected foot wounds is the most common reason for diabetes- related hospitalization. The good news is that up to 85 percent of diabetic amputations can be prevented. As to above challenge, the best approach for EMR is education, community awareness and prevention of diabetic foot. The public approach and education that emphasize on proper footwear and foot care are best preventive and cost-effective modalities that can be easily implemented among EM Countries. EM Countries need to strengthen national health services that promote the concept of prevention and tight control of diabetes in order to prevention diabetes complications. This also necessitates building/strengthening diabetes registry and complications.

High plasma homocysteine is identified as an important risk factor for cardiovascular disease. Epidemiological studies have shown that increased plasma homocysteine is related to a higher risk of coronary heart disease, stroke and peripheral vascular disease. Homocysteine may have an effect on atherosclerosis by damaging the inner lining of arteries and promoting blood clots. Folic acid and other B group vitamins help break down homocysteine in the body and folate fortification of foods reduces the average homocysteine level in the population. Low blood levels of folate are also linked with a higher risk of fatal coronary heart disease and stroke. Homocysteine levels are strongly influenced via diet, as well as via genetic factors. Many common genetic disorders and problems (such as vitamin deficiency) adversely affect the metabolism of homocysteine. Common causes of a high homocysteine level include dietary deficiency of folate and B group vitamins, hypothyroidism, kidney disease, psoriasis, and some medicines. Clinical trials to date have not provided consistent evidence that lowering homocysteine levels reduce strokes, heart attacks and other cardiovascular events; notwithstanding it is recommended to lower a high homocysteine level because it is a risk factor for heart disease. Homocysteine abnormalities also contribute to birth defects and dementia and folic acid supplementation in the pre-conceptual period is effective in preventing recurrent and primary neural tube defects.

Use of medicinal plants for attenuation of hyperglycemia and restoration of lipids to normal levels is very important. The effect of oral administration of Vaccinium myrtillus (VM) on serum glucose and lipids in diabetic rats was investigated. Female Wistar rats were divided into 4 groups: control, VM-treated control, diabetic, and VM-treated diabetic groups. The treatment groups received oral administration of plant-mixed food (6.25%) for 4 weeks. Serum glucose, triglyceride, total cholesterol, LDL- and HDL- cholesterol levels were determined before the study, and at 2nd and 4th weeks after the study. Serum glucose level in diabetic group increased 2 and 4 weeks after the experiment as compared to data one week before the study (P<0.001) and VM treatment of diabetic rats did have a significant hypoglycemic effect (P<0.01). In addition, triglyceride level in diabetic group increased 4 weeks after the experiment in comparison with related data one week before the study (P<0.05) and there was a significant lower level of triglyceride in VM-treated diabetic rats (P<0.05). Furthermore, there was no significant changes regarding serum total cholesterol, HDL- and LDL- cholesterol levels in treated diabetic group as compared to untreated diabetic group. Oral administration of VM has a significant hypoglycemic effects and leads to an appropriate changes only in triglyceride level.

Type 2 diabetes mellitus is the most common type of diabetes which is triggered by various factors such as obesity, hyperlipidemia, hypertension, dietary habits and inheritance. With respect to geographic variation of diabetes prevalence, it is important to know the risk factors regionally. As a case-control study, we looked for important risk factors of diabetes in our region. This study consisted of 400 individuals in case group and 400 individuals in control group. All these anthropometric measurements were calculated by standard methods. Blood samples taken from two groups were studied for TG, FBS, Cholesterol and HbA1c. Data are reported as the Mean±SD. P<0.05 was considered as statistically significant. There was no significant difference between two groups about mean age and sex ratio. Statistically significant difference were found for central obesity, hyperlipidemia, hypertension, polycystic ovarian syndrome (PCOS) and positive family history of diabetes in both groups (P<0.05). The results showed that central obesity, hyperlipidemia, hypertension, PCOS and positive family history of diabetes are important risk factors of diabetes mellitus in Shiraz. In concordance with the results of this study, screening programme for that risk factor of diabetes in this region is suggested.

Non- alcoholic fatty liver disease (NAFLD) is a pathogenic factor of insulin resistance and type 2 diabetes. On the other hand, the circulating liver enzymes including Aspartate aminotransferase (AST), Alanin aminotranferase (ALT) and Gamma glutamyl transferase (GGT) are commonly elevated in asymptomatic patients with NAFLD. As a nested case-control study, AST, ALT, GGT as well as classic diabetes risk factors, homeostatic model assessment of insulin resistance(HOMA- IR) and C-reactive protein (CRP) were measured in 133 non-diabetic subjects at baseline (68 cases and 65 controls). Conditional logistic regression was used to calculate the odds ratio (OR) of diabetes associated with different hepatic markers. We used factor analysis for clustering of classic diabetes risk factors. In Univariate analysis, both ALT and GGT were associated with diabetes with ORs of 3.07(1.21-7.79) and 2.91(1.29-6.53), respectively. After adjustment for CRP and insulin, ALT and GGT were still predictive of incident diabetes. When the model was further adjusted for anthropometric, blood pressure and metabolic factors resulted from factor analysis (full model), only ALT was independently associated with diabetes [OR=3.06 (1.01-9.26)]. No difference was found between the area under the receiver operating characteristic curves of the models with and without ALT (0.820 and 0.802 respectively, P=0.4) ALT is associated with incident type 2 diabetes independent of classic risk factors. However, its addition to the classic risk factors does not improve the prediction of diabetes.

Adiponectin is an adipose tissue-derived hormone that low levels of this hormone are associated with obesity, insulin resistance, and type 2 diabetes. The aim of this study was to compare the serum levels of adiponectin in diabetic and non-diabetic obese individuals. As a cross-sectional study 35 obese individuals with type 2 diabetes mellitus and 35 non-diabetic obese subjects were enrolled. Two groups were matched for age, gender and body mass index. Fasting lipid profile was measured via the enzymatic methods. The NycoCard HbA1c Kit was used to measure HbA1c.The Serum Adiponectin, insulin and glucose levels were measured via an enzyme immunoassay, using a commercially available kit and glucose oxidase methods, respectively. The HOMA and QUICKI indices were used to determine insulin resistance and insulin sensitivity, respectively. The mean of insulin resistance index (HOMA-IR), HbA1c, diastolic blood pressure, triglyceride and fasting glucose in diabetes were significantly higher than non-diabetics (P<0.05). The serum Adiponectin levels was significantly lower in diabetes than non-diabetics (15.74±6.70 vs. 21.52 ± 9.35) and was significantly higher in women than men (19.38 ± 7.33 vs. 12.68 ± 4.28) among diabetic and (24.63 ± 10.52 vs. 17.83 ± 6.21) among non-diabetics groups. type 2 diabetes mellitus is associated with low serum adiponectin concentrations and probably adiponectin involved in the pathophysiology linking obesity to type 2 diabetes.

The relationship between diabetes and serum insulin and Zinc (Zn) levels is complex with no clear cause and effect relationships. Since Zn plays a clear role in the synthesis, storage and secretion of insulin as well as conformational integrity of insulin in the hexametric form, the decreased Zn, which affects the ability of the islet cell to produce and secrete insulin, might then compound the problem, particularly in type 2 diabetes. The aim of this study was to determine the changes of plasma Zn in patients with type 2 diabetes mellitus and healthy control in Shiraz city. As a case-control study, we determined the serum Zn levels by atomic absorption spectrophotometer, blood HbA1c levels with columnar chromatographic method and Glucose, by enzymatic colorimetric method in auto analyzer. Data are reported as the Mean±SD and P<0.05 was considered as statistically significant Results of this study revealed that levels of Zn in serum of diabetic patients is lower than in the healthy control in Shiraz city (P<0.05). With respect to the result of this study, dietary educations about consuming enriched Zn foods such as sea foods and corn in diabetic patients is necessitated.

The prevalence of depression in diabetic patients is 2-3 times more than general population. The quality of life (QOL) and glycemic control are two important outcome measures of diabetes management. The aim of this research is to study the relationship between depression, glycemic control and QOL in a sample of Iranian diabetic patients. One hundred diabetic patients who were referred to diabetes clinic of Dr. Shariati Hospital were included in the study consecutively. The depression subscale of Hospital Anxiety and Depression Scale (HADS-D) were used to determine depression. The World Health Organization Quality of life brief version questionnaire (WHOQOL-BREF) was used to measure QOL. The status of glycemic control was evaluated through measuring HbA1c. Other measured variables included: demographic variables, smoking, diabetes type, body mass index, duration and complications of diabetes and previous history of depression. The linear regression method was implemented to analyze the data. Depression was observed in 28% of the patients. Glycemic control had a reverse significant correlation with diabetes complications. No significant relationship was found between HbA1c and scores of HADS-D. WHOQOL-BREF subscales scores had no significant relationship with glycemic control. There was a significant relation between scores of HADS-D and WHOQOL-BREF subscales. Improving quality of life (QOL) is one of the main outcomes in the management of diabetes. According to the result of this study, depression had a prominent relationship with QOL. Thus, careful management of depression may be necessary to improve QOL of diabetic patients.

Obesity is the most common cause of insulin resistance and metabolic syndrome (MS). These are the most important risk factors for CHD. The present study aims to evaluate the prevalence of obesity and metabolic syndrome, the two most important risk factors for CHD, in adolescent girls in Rafsanjan In this cross sectional study 1221 respondents were randomly selected using a multiphase sampling method. The individual questionnaire was completed after receiving a written consent form. The weight, height, waist circumference (WC) and blood pressure were measured using standard equipments. Five ml blood sample were taken for measuring TG, HDL-C and FBS of the obese volunteer after detecting obese subjects (n=76). We determined MS according to the latest ATP3 criteria. Mean age of respondents was 14.3 ± 1.7 years, and 11.2 % (95 % CI = 9.4% -12.9 %) and 2.4 % (95 % CI = 1.5 % - 3.3 %) of subjects were overweight and obese respectively. Based on our findings about 1.2% (95% CI= 0.6%-1.8%) of respondents counted as abdominal obesity. According to ATPIII criteria 3.9 %(CI95 % = 2.8 % -5 %) of respondents encounter with MS. This study showed high prevalence obesity and metabolic syndrome among adolescent girls of Rafsanjan. Therefore researchers suggest screening test also for children aged 6-11 years. The results will help with planning to control the problem in the future.

Although hypertriglyceridemic waist (HW) phenotype has received much attention over recent years for its association with other metabolic abnormalities, it remains unknown whether its effects are mediated through changes in plasma concentrations of inflammatory markers. We aimed to evaluate the association between hypertriglyceridemic waist (HW) phenotype and markers of systemic inflammation and endothelial dysfunction among women. Anthropometric and biochemical measurements were assessed in a cross-sectional study of 507 Iranian women aged 40-60 years. HW phenotype was defined as serum triacylglycerol concentration ≥150 mg/dl and concurrent waist circumference ≥89. The prevalence of hypertriglyceridemic waist (HW) phenotype was 32.2% (95% CI: 28.7, 35.7) among women. Individuals with HW phenotype had higher anthropometric measures, were older and less physically active. After control for potential confounding variables, women in different categories of WC had significantly different levels of CRP (WC main effect: P=0.001), TNF-α (P=0.01), IL-6 (P=0.001), E-selectin (P=0.007), sICAM-1 (P=0.01) and sVCAM-1 (P=0.02, 2-factor ANOVA for all). When the models were further adjusted for BMI, the difference in sICAM-1 and sVCAM-1 ceased to be significant. Significant differences in CRP (TG main effect: P=0.01), TNF-α (P=0.008), SAA (P=0.03), IL-6 (P=0.01), E-selectin (P=0.02) and sICAM-1 (P=0.01, 2-factor ANOVA for all) were found between categories of TG concentration after control for confounders. Most of these differences remained significant even after additional adjustments for BMI, except for E-selectin. There was a significant interaction between WC and TG concentration with regard to CRP, IL-6, SAA, and E-selectin. This study provides evidence showing a positive association between HW phenotype and markers of systemic inflammation and endothelial dysfunction.

Fortification of corn with folic acid has beneficial effects on hyperhomocysteinemia and heart disease. Folate fortification was contributed to an increase in average folate status and a reduction in serum homocysteine concentration. In this randomized clinical trial 17 men and women aged 61±5 years old with hyperhomocysteinemia with mean homocysteine concentration of 15/32±6/13 µmol/L were recruited. Subjects received fortified bread which contained 100µg folic acid daily for 8 weeks. Three-day food record, food frequency questionnaire and BMI (Body Mass Index) data at baseline and week 8 were completed. Plasma homocysteine and serum folate at baseline and week 8 were measured. All dietary and statistical analyses were undertaken using Nutritionist III and SPSS release 15.0 software with paired t-test. Mean plasma homocysteine concentration decreased significantly in hyperhomocysteinemic subjects after daily consumption of folate fortified bread for 8 weeks (P<0.001).After 8 weeks serum folate concentration increased %26 (P=0.06). Mean BMI, energy and other components of dietary intake did not change significantly. Dietary vitamin C decreased significantly (P<0.001). Daily consumption of folic acid fortified bread, with 100 µg folic acid, in hyperhomocysteinemic subjects for 8 weeks led to significant decrease in plasma homocysteine and an increase in serum folate.

Milk and fermented milk products have been known as foods with possible hypocholesterolemic effects. In this study we compared the effects of milk replacement with regular and probiotic yogurt in normocholesterolemic (N) and hypercholesterolemic (H) subjects. Twenty eight subjects with total serum cholesterol 160-280 mg/dl were included. They did not consume yogurt for 2 weeks after that 300 g/day of milk was added to their diet. Then, blood lipids were measured and they were randomly allocated to 2 groups to receive either 300g/day of ordinary yogurt or probiotic yogurt for 6 weeks as a substitution for milk. Blood lipid tests were repeated at the end of the study. Subjects in both groups were divided into these two subgroups according to their baseline blood cholesterol level: subgroup N (cholesterol<220mg/dl) and H (cholesterol≥220mg/dl). Blood lipid changes were compared between these subgroups in each experimental group. Total cholesterol and LDL-C levels reduced in the H as compared to N subgroup after regular yogurt consumption instead of milk and the reduction of LDL-C was significant (P=0.033). The effect of milk replacement with probiotic yogurt on total cholesterol and LDL-C reduction in H compared to N subgroup was higher than regular yogurt consumption (P=0.028 and P=0.014 for total cholesterol and LDL-C respectively). The higher the baseline blood cholesterol level, the more beneficial effects of milk replacement with yogurt, especially probiotic yogurt. So, it is suggested for hypercholesterolemic individuals to consume more yogurt as the source of dairy products in their diet.