Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 1 - Jan/Mar - 2018

Original Article Imprimir 

Páginas 26 a 33


Prevalence of cardiovascular risk factors in adolescents with type 1 diabetes mellitus

Prevalencia de factores de riesgo cardiovasculares en adolescentes portadores de diabetes mellitus tipo 1

Prevalência de fatores de risco cardiovasculares em adolescentes portadores de diabetes mellitus tipo 1

Autores: Carolina Scherer Golle1; Simone Bernardes2; Leandro Meirelles Nunes3

1. Graduation in Nutrition by the Institute of Health Sciences, Feevale University (FEEVALE). New Hamburg, RS, Brazil
2. Master in Health Sciences: Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul (UFRGS). Porto Alegre, RS, Brazil. Professor at the Institute of Health Sciences, Feevale University (FEEVALE). New Hamburg, RS, Brazil
3. Doctorate in Child and Adolescent Health at the Federal University of Rio Grande do Sul (UFRGS). Porto Alegre, RS, Brazil. Associate Professor, Institute of Health Sciences, Feevale University (FEEVALE). New Hamburg, RS, Brazil

Correspondência:
Leandro Meirelles Nunes
Rua Cristóvão Colombo, 603/201, Vila Rosa
Novo Hamburgo, RS, Brasil CEP: 93310-320
(lmnunes@hcpa.edu.br)

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Keywords: Diabetes mellitus, Type 1, adolescent, cardiovascular diseases, risk factors.
Palabra Clave: Diabetes mellitus Tipo 1, adolescente, enfermedades cardiovasculares, factores de riesgo.
Descritores: Diabetes mellitus Tipo 1, adolescente, doenças cardiovasculares, fatores de risco.

Abstract:
OBJECTIVE: Determine and analyze the prevalence of cardiovascular risk factors in adolescents with type 1 diabetes mellitus (DM1) in specialized outpatient follow-up.
METHODS: A retrospective cross-sectional study was carried out from the medical records of adolescents with DM1 in a referral outpatient clinic in the city of Porto Alegre (RS), during the follow-up period between 2005 and 2014. Demographic information, clinical history of diabetes, Body Mass Index, lipid profile and glycated hemoglobin (HbA1c) were analyzed, and the sample was stratified by gender.
RESULTS: A total of 79 adolescents with DM1 (51.8% male) were included, with mean age of 17.2 ± 2.4 years and mean duration of diabetes of 9.9 ± 4.8 years. The most prevalent cardiovascular risk factors (CVRF) were HbA1c values greater than 7.5% (81%), total cholesterol and plasma HDL cholesterol greater than or equal to 150 mg / dL (62%) and lower than 45 mg / dL (38, 5%), respectively. In general, 93.7% of adolescents had one or more CVRF, with a frequency of two (29.1%), four or more (26.6%) and three (25.3%).
CONCLUSION: The prevalence of cardiovascular risk factors is high in the population of adolescents with DM1 studied, and in order to prevent future cardiovascular events, one must seek the best possible glycemic control, early detection of cardiovascular risk factors, as well as adequate medical and nutritional interventions.

Resumen:
OBJETIVO:Determinar y analizar la prevalencia de factores de riesgo cardiovasculares en adolescentes portadores de diabetes mellitus tipo 1 (DM1) en cuidado ambulatorio especializado.
MÉTODOS: Estudio transversal retrospectivo desde los datos de prontuarios de adolescentes con DM1 en cuidado ambulatorio de referencia en la ciudad de Porto Alegre (Rs), en el período de cuidado entre 2005 a 2014. Fueron analizadas informaciones demográficas, historia clínica de diabetes, niveles de presión, Índice de Masa Corporal, perfil lipídico y hemoglobina glicosilada (HbA1c), siendo la muestra estratificada por género.
RESULTADOS: Fueron incluidos 79 adolescentes con DM1 (51,8% masculinos), con edad media de 17,2 ± 2,4 años, y tiempo medio de duración de diabetes de 9,9 ± 4,8 años. Los factores de riesgo cardiovasculares (FRCV) más prevalentes fueron valores de HbA1c superiores a 7,5% (81%), colesterol total y colesterol HDL plasmáticos mayores o iguales a 150 mg/dL (62%) e inferiores a 45 mg/dL (38,5%), respectivamente. En general, 93,7% de los adolescentes presentaban uno o más FRCV, siendo que la simultaneidad de ellos fue más frecuente para dos (29,1%), cuatro o más (26,6%) y tres (25,3%) factores de riesgo.
CONCLUSIÓN: Las prevalencias de factores de riesgo cardiovasculares son elevadas en la población de adolescentes con DM1 estudiada, y para prever futuros eventos cardiovasculares se debe buscar el mejor control de glicemia posible, la precoz detección de factores de riesgos cardiovasculares, así como adecuadas intervenciones médicas y nutricionales.

Resumo:
OBJETIVO: Determinar e analisar a prevalência de fatores de risco cardiovasculares em adolescentes portadores de diabetes mellitus tipo 1 (DM1) em seguimento ambulatorial especializado.
MÉTODOS: Estudo transversal retrospectivo a partir dos dados de prontuários de adolescentes com DM1 em seguimento ambulatorial de referência na cidade de Porto Alegre (RS), no período de acompanhamento entre 2005 a 2014. Foram analisadas informações demográficas, história clínica de diabetes, níveis pressóricos, Índice de Massa Corporal, perfil lipídico e hemoglobina glicada (HbA1c), sendo a amostra estratificada por gênero.
RESULTADOS: Foram incluídos 79 adolescentes com DM1 (51,8% masculinos), com idade média de 17,2 ± 2,4 anos, e tempo médio de duração do diabetes de 9,9 ± 4,8 anos. Os fatores de risco cardiovasculares (FRCV) mais prevalentes foram valores de HbA1c superiores a 7,5% (81%), colesterol total e colesterol HDL plasmáticos maiores ou iguais a 150 mg/dL (62%) e inferiores a 45 mg/dL (38,5%), respectivamente. Em geral, 93,7% dos adolescentes apresentavam um ou mais FRCV, sendo que a simultaneidade desses foi mais frequente para dois (29,1%), quatro ou mais (26,6%) e três (25,3%) fatores de risco.
CONCLUSÃO: As prevalências de fatores de risco cardiovasculares são elevadas na população de adolescentes com DM1 estudada, e para prevenir futuros eventos cardiovasculares deve-se buscar o melhor controle glicêmico possível, a precoce detecção de fatores de riscos cardiovasculares, bem como adequadas intervenções médicas e nutricionais.

INTRODUCTION

Diabetes mellitus (DM) is one of the most prevalent endocrine diseases in the world, affecting about 382 million people, of which 24 million are from South America and Central America1. In Brazil, from 1999 to 2014, more than 495 thousand new cases were diagnosed, 31 thousand of them in children or adolescents2.

DM is a condition that doubles the chances of cardiovascular events in men and triples in women. The most frequent events in diabetics compared to the non-diabetic group are coronary artery disease and sudden death, making it the main independent cardiovascular risk factor3 and the main cause of death due to cardiovascular disease in the age group between 20 and 39 years of age. age4.

The prevalence of cardiovascular risk factors (CVRF), especially obesity and dyslipidemias, is quite high in the general population, not only in adults, but also in children. There is evidence that the atherosclerotic process begins in childhood and progresses during adolescence and adulthood5. It is also known that CVRF influences each other in its appearance and progression, just as a longer duration of DM seems to be related to a higher frequency of cardiovascular risk6.

Despite the magnitude of this problem, studies in our country investigating CVRF in the population of diabetic adolescents are scarce. This situation is in line with the comments of Maftei and collaborators (2014)7 that point out the need to carry out studies evaluating cardiovascular risk in younger groups with type 1 diabetes mellitus (DM1), due to the high frequency of children and adolescents with potential atherogenic risk.

Thus, the objective of this study was to determine the prevalence of the number of CVRF in adolescents with DM1, as well as to investigate the existence of possible differences between the male and female genders.


METHOD

A cross-sectional study was carried out in which adolescents with a diagnosis of DM1 who underwent follow-up at an outpatient clinic of Endocrinology specialized in the treatment of DM, located in southern Brazil, were enrolled.

The data were collected retrospectively for the period between January 2005 and December 2014. The year chosen to be the initial milestone was due to the introduction of the electronic medical record in the institution where the study was conducted. Patients who were under investigation, yet without a proven diagnosis, who had a diagnosis of type II diabetes mellitus or whose medical records were incomplete were excluded from the study.

The sample size calculation was performed in the Programs for Epidemiologists (PEPI) version 4.0. A total of 62 adolescents were obtained for a 95% confidence level, a prevalence of systemic arterial hypertension (SAH), elevated LDL cholesterol levels and triglyceride elevation (TG) of around 20%, with a margin of error of 10%. To minimize possible losses and the need for multivariate analysis, 20% of the final value of the sample was added, totaling a minimum of 74 adolescents.

Data from the survey were collected in April and May 2015. The following information from the last query was obtained from electronic medical records, according to the routine of the service: sex, chronological age, age at diagnosis, time of diagnosis, daily prescription of insulin, blood pressure levels, use of antihypertensive medications, oral hypoglycemic drugs and carbohydrate counting. Weight (kg) and height (m) were also recorded for later determination of the Body Mass Index (BMI), calculated by weight (in kg) / height (in m), as well as the most recent biochemical data of total cholesterol (TC), LDL cholesterol, HDL cholesterol, TG and glycated hemoglobin (HbA1C).

The analysis of CVRF data considered the following variables and their respective cutoff points: inadequate glycemic control, by measuring HbA1c > 7.5%1, presence of SAH (systolic blood pressure > 120 mmHg and / or blood pressure diastolic > 80 mmHg), obesity (BMI / I score values Z +2), lipid profile, this is, TC > 170 mg / dL, HDL cholesterol < 45 mg / dL, TG > 130 mg / dL and LDL cholesterol > 130mg / dL8.

It is important to note that in order to confirm the diagnosis of hypertension ideally three isolated measures or 24-hour ambulatory blood pressure monitoring are used, however in our analysis we considered two consecutive measures altered in the same consultation as SAH, a method that has already been used in another study as a form of screening9.

Each subject was categorized for the presence of CVRF in absence, presence of a risk factor, presence of two CVRF, presence of three risk factors, and presence of four or more CVRF.

The database was double-typed in the Microsoft Excel program with later validate and the analyzes were performed in the Statistical Package for the Social Sciences (SPSS) program for Windows version 21.0. Quantitative variables were described by mean and standard deviation and categorical variables by absolute and relative frequencies. To compare means between genders, Student's t-test was applied. In the comparison of proportions, Pearson's chi-square or Fisher's exact tests were performed. The level of statistical significance was set at 5% (p0.05).

The research protocol met the ethical criteria of Resolution 466/2012 of the National Health Council and was submitted to the Research Ethics Committee (CEP) of the Feevale University. It was approved under opinion number 1,025,612.


RESULTS

The clinical and demographic characterization of the sample is presented in Table 1. The study included 79 electronic medical records of adolescents with DM1 (51.8% males), mean ± standard deviation of 17.2 ± 2, 4 years and mean ± standard deviation of the duration of diabetes of 9.9 ± 4.8 years. The fast, rapid and ultra fast dose of insulin prescribed to adolescents was 41.3 ± 18.2 IU, 18.0 ± 13.7 IU and 19.3 ± 8.5 IU, respectively. There was a statistically significant difference between genders only for the slow-acting insulin dose, which was higher among male adolescents (p = 0.024), and a trend towards significance in the use of antihypertensive treatment in the female group (p = 0.051).




The most prevalent risk factors were elevated HbA1c (81%), plasma levels of CT ≥ 170 mg / dL (62%) and HDL cholesterol < 45 mg / dL ( 38.5%). There was a statistically significant difference for the female gender regarding CT ≥ 170 mg / dL (86.8% with p < 0.001); TG > 130 (26.3% with p = 0.049); and LDL > 130 (44.7% with p = 0.030).




The mean plasma levels of CT, TG and LDL cholesterol were significantly different between genders, as they were higher in female adolescents (p < 0.001, p = 0.004 and p = 0.007, respectively).




Figure 1 shows the simultaneity of CVRF according to the gender of adolescents, where only 6.3% didn´t present any risk factor, being this characteristic verified only in the male gender. The presence of two CVRF was the highest prevalence category (29.1%), followed by the four categories (26.6%) and three risk factors (25.3%). On the other hand, the distribution of the number of CVRF by gender showed differences, with most of the adolescent boys presenting two CVRF (46.8%), while in the female gender most of the adolescents (73.6%) had ≥ three CVRF.


Figure 1. Simultaneity of cardiovascular risk factors stratified by gender and expressed in frequencies.



DISCUSSION

The present study identified a high prevalence of CVRF among adolescents with DM1, followed up at an outpatient clinic to monitor this specific population. 81% of our adolescents were found to have two or more risk factors: high levels of HbA1c (81%), CT (62%), and low HDL cholesterol concentrations (38.5% ).

The poor glycemic control of our sample, evidenced by the average HbA1c of 10.2%, was superior to that observed in similar national investigations, in which the average HbA1c was 9.4%10 and 9.7%11. Elevated levels of HbA1c may result from insufficient self-monitoring of blood glucose, hypoinsulinization, inadequate correction of hyperglycaemia, sedentary lifestyle, dietary transgressions, intercurrent diseases, interindividual variability and a longer diagnosis of diabetes1,12-13. Glycemic control is essential in reducing cardiovascular risk, since it exerts a decisive influence on the atherogenic process of diabetic children and adolescents, since it is established early and progresses more intensely in this population1.

In relation to the lipid profile, it was verified that the majority of our sample had high serum levels of total cholesterol ( ≥ 170 mg / dL), with significant differences for the female gender in relation to the male (187 ± 48.4 mg / dL and 162 ± 50.2, p <0.001), a result that is similar to those found by Steigleder-Schweiger et al6. This intergenerational discrepancy may be due to the higher production of estrogen that occurs in the female organism during adolescence, contributing in a temporary way to a higher plasma concentration of CT and its fractions. In addition, poor glycemic control in DM1 is associated with an increase in serum lipid levels, a higher prevalence of lipid abnormalities and, consequently, the onset of the atherogenesis process14-16.

In the present study, the prevalence of BMI classified as obesity, although not elevated in the sample as a whole, was twice as frequent in females. A similar finding was found in the studies by Dobrolwoskienè and collaborators (2013) who also observed this value twice as high in females. The same authors also found that 100% of overweight adolescents presented elevated HbA1c, indicating a direct correlation between body weight and metabolic control17.

The prevalence of increased systolic blood pressure in this study was similar to that of the study by Dobrolwoskiene et al. (2013)17 and the study by Steigleder-Schweiger et al. (2012)6, and neither found any significant difference between the sexes. The administration of oral antihypertensive was superior to that found in other studies6,18, indicating hypertension even with drug control in a higher number of adolescents. This finding is relevant because regardless of age, the presence of systolic hypertension is considered an isolated risk factor for cardiovascular events. This becomes even more important inasmuch as hypertension is frequently seen in diabetic patients, and is an important risk factor for cardiovascular and microvascular complications, such as ischemic heart disease, retinopathy, and especially nephropathy19.

The prevalence of hypertriglyceridemia found in our sample was similar to that observed in the study by Steigleder-Schweiger and collaborators (2012)6 and above that found in the study by Valerio et al. (2012)19. The mean TG value was similar to that found in other studies, while the prevalence of low HDL was higher5,6. With regard to the prevalence of high LDL cholesterol, this was higher than that found in the study by Steigleder-Schweiger and collaborators (2012)6 and may be related to the high prevalence of elevated HbA1c, since this lipoprotein is more susceptible to oxidation in a patient with DM1 due to the contribution of hyperglycemia in the oxidation process of LDL. Hyperglycemia appears to be associated with reduced activity and affinity of LDL receptors, promoting increased susceptibility to LDL oxidation20.

As for the time of diagnosis, there was correlation with the increase in blood pressure, CT and LDL cholesterol levels. Dobrolwoskiene et al. (2013)6 also observed correlation with CT and LDL levels with the time of diagnosis.

This study has the merit of proposing, from its conception, to concomitantly analyze several CVRF in diabetic adolescents, in addition to seeking possible associations with the male and female genders. As limitations, we can mention the lack of a non - diabetic control group to compare the prevalence and lack of information on family history, physical activity practice, abdominal circumference measurement, adherence to drug and nutritional treatment, since such information was not available in the medical records.

It is concluded that the prevalence of CVRF in the studied population was high and seems to be related to poor metabolic control. The female sex is the most affected and due to the hormonal interactions of this population, especially during the puberty phase, may represent a greater susceptibility to early cardiovascular disease. Because hyperglycemia causes macro and microvascular complications, maintaining glucose values as close to normal as possible should be a priority in the care of children and adolescents. In addition, it is essential to search for possible CVRF from childhood for early intervention, including nutritional guidelines and lifestyle modifications.

In this context, the multidisciplinary team that works with adolescents with DM1 should work through food education, dietary guidelines and plans, and may or may not use carbohydrate counting in order to ensure good metabolic control and, consequently, improvement in quality of life of this population.


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