Lupine Publishers| Archives of Diabetes & Obesity (ADO)
Summary
Background and objective: The dislipidemia are one of the main factors of risk of
cardiovascular illness in patients with diabetes mellitus type 2 (DM2). The aim
of this study is to evaluate the prevalence and factors of risk associated to
the dislipidemia in the population with DM2 of the Community of Castile-La
Mancha.
Material and methods: It are a longitudinal study made in centers of Attention
Primaria of the Service of Health of Castilla- La Mancha (n=70). It selected a
representative sample of the population with DM2 of 18 to 85 years by means of
a procedure polyetapic. They obtained the clinical history and by means of
interview the data of the factors of risk to study. It analyzed the association
with the dislipidemia by means of linear regression.
Results: 52.1% were men, the half age was of 69-84 years, the
evolution of the diabetes of 999 years, 84.3% had HTA, 76.6%
sobrepeso/obesigive and the HbA1c half was of 69.6%. The prevalence of
dislipidemia was of 85.3% and in the analysis bivariado associated with
antecedent of peripheral vascular illness, diabetes controlled, treatment
antihypertensive, filtered glomerular, HbA1c>7%, grasto corporal estimated
in sobrepeso and obesity, antecedent of cardiovascular illness, age and HbA1c.
In the univariant analysis the independent factors were the feminine sex and
the antecedent of cardiovascular illness.
Conclusion: The prevalence of dislipidemia in our study was of 85.3%.
The factors of risk associated of independent form were the feminine sex and
the personal antecedent of cardiovascular illness.
Keywords: Dislipidemia; Diabetes mellitus Type 2; Prevalence; Factors
of risk
Introduction
The diabetes mellitus type 2 (DM2)
is an illness that has purchased a character pandemic because of the increase
of the hope of life, that supposes an increase of the aging of the population,
to the increase of the obesity and to the change in the lifestyles to some
habits no cardiosaludables (sedentarism and bad feeding) [1].
The prevalence of DM2, according to the study diabetes, emplaza in 13.79% of
the Spanish population elder of age. According to data of the Organization
Mundial of the Health (2016), in Spain the DM finds between the causes of death
more frequent. The proportional mortality that attributes to this illness is of
3% of the total of deaths for all the groups etarios. The DM comports notable
costs socioeconomics. Crespo Et al. They signaled that, in 2013, the annual
cost of the DM was of 5. 890 million euros: 8.2% of the sanitary cost total
[2].
In the patients with diabetes, the complications microvascular are the main
cause of morbimortalidad to level mundial. Near of 3/4 parts die by cardiac
illness or cerebrovascular. Likewise, the frequency of deaths by cardiovascular
reasons in adult’s diabetes in comparison with the no diabetes is of 2 to 4
greater times [3]. The importance of the quilomicrones for the reduction of the
cardiovascular risk in the DM2 has been showed in different studies and
metanalysis [4]. The association between dislipidemia and cardiovascular
illness (ECV) remained showed in the “United Kingdom Prospective Diabetes Study
(UKPDS 23)”, where observed that an increase of 38.5 mg/dl in the concentration
of quilomicrones associates to an increase of 15.7% to present coronary
arterial illness and that an increase of 4 mg/dl of the cHDL associates to a
descent of 15% of events cardiovascular [3]; like this then , the factor of
risk of greater weight to develop coronary illness were the quilomicrones,
followed of the levels of cHDL. It is necessary to diagnose and treat
temperamental the dislipidemia of effective form for like this reduce the risk
of cardiovascular events futures [1].
In Spain, diverse studies epidemiological have analyzed the prevalence of the
alterations lipidic, that oscillate between 56.2% in the one of Domínguez and
92.6% in the study OBEDIA8; however, it is scarce the information on the
prevalence and the factors associated to the dislipidemia in patients with DM2
in Castile-La Mancha [5].
The present study has like aims:
a. Estimate the prevalence of the dislipidemia.
b. Investigate the factors of risk associated to the dislipidemia and
c. Investigate the factors of risk associated of independent form to the
dislipidemia.
Material and Methods
Longitudinal study of populational
base on a sample of 70 patients with DM2, between November of the 2019 and
February of the 2020. It made a procedure polyetapic by means of the employment
of a sample of the conglomerates of some centers of health. Of the 60 centers
of health registered in the Service of Castile-La Mancha of Health, selected
30. The greater part of this in the province of Albacete (where selected 20),
in Cuenca selected 4, in Ciudad Real 3 and in Toledo other 3. Later there was a
second selection of a submaster of the contingents of patients of the doctors
of each center of health elegido. If any of the centers of health rejected to
participate in the study, was replaced by another inside the same stratum.
Of each included patient in the study collected information of the following
variables: age, sex, year of diagnostic of DM2, habitat, level of education,
familiar economic level, labor situation, habit tobacco, weight, size,
perimeter abdominal waist, corporal fat estimated, index of corporal mass
(IMC), arterial systolic pressure, arterial diastolic pressure, abdominal
obesity, antecedents of ECV, arterial hypertension (HTA), antihypertensive
treatment, dislipidemia, hypolipidemia treatment, renal insufficiency and
retinopathy.
Besides, they collected the analytical parameters of quotient
albumin/creatinine, filtered glomerular (FG), hemoglobin glycosylate (HbA1c),
plasmatic glycemia, total cholesterol (CT), cLDL, cHDL, triglycerides (TG) and
creatinine. For the register of the periarterial ion made 2 measurements of
arterial pressure systolic and diastolic in 2 successive visits and with
monitor of validated arterial pressure. For the analysis, the average of the
two measurements is used.
For the analysis of data used the
program statistician SPSS V23.0.0.0. The qualitative variables expressed like
absolute value and percentage, with the estimate of the interval of confidence
to 90% (IC 90%). The quantitative variables expressed like half ± typical
deviation and IC 90%. For the relation of the quantitative and qualitative
variables between himself employed an analysis bivariado with t of Student. It
made the analysis multivariate of binary linear regression no conditional with
the dislipidemia like dependent variable, having in unit the variables that in
the analysis bivariado associated with the presence of the dislipidemia or were
clinically notable, that were the following: age, sex, HTA, personal antecedent
of peripheral vascular illness, diabetes controlled, antidiabetic treatment,
HbA1c≥7%, quotient albumin/creatinine, FG, personal antecedent of ECV, years of
evolution of DM, glycemia basal, creatinine and retinopathy. All the statistical
analyses were of 1 tail and considered estimated signification a value of <
p 0.05.
Results
Of the 70 patients, 68.9% were 65
years old or more, with average of age of 69-84 years and average of years of
evolution of the diabetes of 999 years. 68.2% of the participants were of urban
habitat, 50% had primary studies, 74% were jubilates and 75% had annual income
<18.000 D. There was a light predominance of men (52.1%) and the women were
of greater age (70.8 years). The tabaquismo active and the obesity according to
the IMC was significantly greater in men; the abdominal obesity was significant
and greater in women. The prevalence of dislipidemia was of 85.3%; the one of
HTA, of 84.3%; renal insufficiency, of 22.9%; sedentarism, of 48.2%; logo
albuminuria and proteinuria, 31.3%; sobrepeso and obesity according to IMC, of
76.6%; obesity according to the corporal fat estimated by means of CUN-BAE, of
93%; abdominal obesity, of 67.6% and the retinopathy was of 29.3%. The
prevalence of dislipidemia was similar in women and men (87.7% in women in
front of 83.1% in men; p = 0.085). Of the subjects dilapidations, 79.5% were
dilapidations for receiving hypolipidemic treatment and 20.5%, dilapidations
that did not receive hypolipidemic treatment and that presented values of
cLDL>160mg/dl, cHDL < 40mg/dl in men or <50mg/dl in women, or
TG≥150mg/dl. The 75.3% received hypolipidemic treatment; 71.1%, statins; 5.4%,
ezetimibe; 3.3%, fibrates; 0.8%, resins of ionic exchange and 0.5%, esters
etarios of sour grass omega 3. 69.6% received treatment in monotherapy and 5.7%
in bitherapy. In the subject’s dilapidations for receiving hypolipidemic
treatment, 96.5% received statins or ezetimibe; 4.3%, fibrates and 2%, statins
and fibrates. In the subjects with diagnostic of dislipidemia and without
hypolipidemic treatment, the 14.3% had the cLDL > 160mg/dl; 79%, cHDL <
40mg/ dl in men or <50mg/dl in women and 51.3% had TG>150mg/dl. The
average of glycemia plasmatic basal was of 137.85 ± 46.59mg/ dl, of CT
178.17±38.18mg/dl, of cHDL. 47.09±12.10mg/dl, of cLDL 108,10±36.44mg/dl, of TG
136.6±66.3mg/dl and of creatinine 0.96±0.55mg/dl.
68.7% of the patients had
normoalbuminuric; 23.8%, logo albuminuria and 7.5%, self-evident proteinuria.
77.1% of the patients had a tax of filtered glomerular (MDRD) TFGe>60ml/
min/1.73m2 and 22.9%, renal insufficiency (TFGe<60ml/ min/1.73m2). Of the
patients with renal insufficiency, 19.1% had TFGe of 30-59 ml/min/1.73m2; 2.9%,
of 15-29ml/min/1.73m2 and 0.9%, <15ml/min/1.73m2. The average of leukemia
plasmatic basal, TG and creatinine was significantly greater in men and, the
average of CT, cHDL and cLDL was significantly greater in the women. To his
time, the logo albuminuria and proteinuria was significantly more prevalent in
the men. They obtained the parameters lipidic complete of 70 patients that had
registered one or more parameters. Of them, 26.6% did not reach the aims of CT
(<200mg/ dl) neither 54.9% the ones of cLDL (<100mg/dl). They documented
TG high (≥150mg/dl) in 33.7% and cHDL low (<40mg/dl in men and <50mg/dl
in women) in 46%. With regard to the alterations combined, cLDL out of aims and
cHDL low detected in 23.7%; cLDL out of aims, cHDL low or TG elevated in 14%
and cLDL and CT future of aims, cHDL low or TG elevated in 6.6%. In the
analysis bivariado, the variables associated to the presence of dislipidemia
are: antecedent of peripheral vascular illness, diabetes controlled,
pharmacological treatment for HTA, HbA1c ≥ 7%, FG, corporal fat estimated in
sobrepeso and obesity, personal antecedent of ECV, age and HbA1c (Table 1). The
antecedent of peripheral vascular illness is included in the variable
antecedent of ECV.
Clinical diagnostic of dislipidemia*
*Dislipidemia: In treatment of hypolipidemia or those that do not follow
treatment hypolipidemia and present figures of cLDL > 160 mg/dl; cHDL <
40 mg/dl in men and <50 mg/dl in women or TG > 150 mg/dl. cHDL:
Cholesterol joined to lipoproteins of high density; cLDL: cholesterol joined to
lipoproteins of low density; CT: total cholesterol; DM: diabetes mellitus;
HbA1c: hemoglobin glycosylate; IC: interval of confidence; OR: odds ratio; TG:
triglycerides.
We have not found significant
differences in the presence of dislipidemia with the following variables: sex,
familiar economic level, level of education, labor situation, habitat, habit tobacco,
HTA, HTA controlled, pharmacological treatment DM, quotient albumin/
creatinine, IMC, obesity abdominal, retinopathy diabetic, years of evolution,
glycemia basal neither creatinine. In spite of have not found significant
differences, objectives that the subjects with dislipidemia had greater time of
evolution of his DM, greater levels of glycemia basal and creatinine and
greater values of IMC. To his time, the feminine sex, the black race, the
familiar economic level “annual incomes < 18.000 D”, the low level of
education (without studies and primary studies), the labor situation “retired”
and the urban habitat were more prevalent in the subjects dyslipidemias.
Likewise, the habit tobacco (smoker and exfumador), the HTA, the
oligoalbuminuria, the proteinuria and the retinopathy diabetic were more
prevalent in dislipidemic patients that in no dislipidemic. He also objectified
that the prevalence of the dislipidemia was elder to measure that increased the
oligoalbuminuria and the degree of retinopathy diabetic, as well as, when the
TFGe diminished.
The model contains the following variables: sex (woman vs. man), personal antecedents of ECV (ictus, cardiopathy ischemic and peripheral arteriopathy), HbA1c>7% and age (continuous, by every year of more).
B: Coefficient of regression; ECV: cardiovascular illness; EE: standard error
of B; H: men; HbA1c: glycosylated hemoglobin; IC: interval of confidence; M:
women; OR: odds ratio.
In the analysis multivariable,
identify that the variables that associate of independent form with the
dislipidemia are the feminine sex and the personal antecedent of ECV (Table 2).
Discussion
The results indicate that the
prevalence of dislipidemia in patients with DM2 of Castile-La Mancha is
elevated and that less than 15% of the patients show the lipidic values normal
or recommended by the main guides of clinical practice. Said findings of
prevalence are consistent with the found in other works so much in Spain as in
the international field. When we compare these results with different
publications, observe that it exists a big variability. In the majority of the
studies the prevalence of dislipidemia finds above 50%, with a rank that
oscillates between 56.2% in the one of Dominguez and 92.6% in the study OBEDIA.
On the other hand, the variability found in the prevalence of dislipidemia can
be due to the heterogeneity in the form to diagnose it and to that is in
relation with the different criteria diagnostics. In this context, the greater
prevalence observed in the study OBEDIA could be in relation with the point of
court of the cLDL considered in the definition of dislipidemia, that is lower
that the used in the present study. These discrepancies are something usual in
the medical bibliography, since the methodologies used to the hour to carry out
the studies (is possible that other studies use distinct criteria diagnostics,
methods of laboratory or different points of cut to determine the diverse
factors lipidemic and his cardiovascular risk), as well as the populational
diversity, affect to the results ends of the studies. Also it is important
emphasize that the studies from populational samples can have the inconvenient
that, in spite of his randomness in the selection of the subjects, the sample
do not represent the population of reference or that this find very delimited
in the space and the time and, therefore, was not comparable with other
studies. This prevalence so high could be related with the profile of the
patients studied (high taxes of obesity, sick age, bad metabolic control of the
diabetes, etc.), since in the sample studied 69% were greater of 65 years.
These analytical values do not depend of the register made by the professionals
and are a faithful reflection of the reality. Although in multiple studies
epidemiological longitudinal has analyzed the prevalency of dislipidemia in
populations diabetics with distinct levels of cardiovascular risk, east is the
first study in Spain that analyses the characteristics, prevalence and factors
associated to the dislipidemia of a representative sample of patients with DM2
of Castile-La Mancha. Besides, the previous studies to the moment to value the
prevalence of dislipidemia center usually in the isolated alteration of the CT
or cLDL according to the recommendations of the NCEP ATP III, without a
complete analysis of the lipid profile and without taking into account to
patients in treatment lipid lowering.
In the subjects with diagnostic of dislipidemia and without treatment lipid
lowering we objectify that the low values of cHDL is the alteration lipidic
more frequent (79%). Of the same way, observe a considerable increase of the
levels of TG (51.3%) beside a discreet increase of the values of cLDL (14.3%).
These results are concordant with the quantitative alterations described in the
dislipidemia in the patient with DM “dislipidemia atherogenic”. The
dislipidemia atherogenic is a characteristic element of the vascular residual
risk of origin lipidic no associated to changes in the neither of them of cLDL
and is a dislipidemia very prevalent in the people with DM2, in the patients
with high risk or very high risk, with visceral obesity or metabolic syndrome.
In the sample studied observes that
a high proportion of patients do not reach the aims of cLDL. Also, objectives
that an important proportion of cases has TG high and cHDL low, which saves
concordance with the described in the bibliography, where finds elevation of
the TG and decrease of the cHDL in approximate mind the half of the patients
with DM2. These data signal an important residual risk (levels of cLDL, cHDL
and TG suboptimal) that probably have to be controlled with more intensity of
what does in the daily clinical practice and that perhaps was in relation with
the inertia and therapeutic fulfillment; in patients with DM2, the percentage
of breach therapeutic is very high, and is of the 32, 36 and 38% for the lipid
lowering, antidiabetics and antihypertensives. If we examine the fulfillment of
objectives according to the recommendations of the guides of clinical practice,
objectives that the 2/3 parts of the subjects have suitable levels of TG
(67.2%) and less than the half do not reach the optimum levels of cLDL (45.1%)
and cHDL (46%).
If we compare these results with the
obtained in a transversal study made in the 17 autonomous communities of Spain,
observe that the subjects studied attain more frequently the aims lipidics
recommended. In patients with DM2 and dislipidemia the approach global
therapeutic has to consider, in addition to cLDL, the control of the levels of
cHDL and of TG like secondary therapeutic aims, what can involve a change in
our therapeutic attitude to achieve such aims. The main contribution of this
work is the knowledge of the high prevalence of dislipidemia (85.3%) in
patients with DM2 of the Community of Castile-La Mancha and that the factors
associated of independent form to the dislipidemia were the feminine sex and
the antecedent of ECV. This knowledge is the first stair to implant the
necessary means that make possible to improve the group of the profile lipidic,
and, therefore, would have to be useful to establish strategies of continuous
improvement that involve to all the agents involves (medical personnel,
personnel of infirmary and sanitary authorities) in the implementation of the
clinical guides and in improving the adherence of the patients. Our results
indicate that frequently it exists more than an alteration of the values of
plasmatic lipids. Like this, 23.7% showed conjoint alterations of cLDL and
cHDL; 14.7%, of cLDL, cHDL and TG and, 6.6%, of the 4 parameters. On the other
hand, the CT, cHDL and cLDL were significantly greater in women and the TG were
significantly Minimal in men; these findings are similar to the described in a
study made in Catalonia. In the Or.K. Prospective Diabetes Study 27, observed
that the CT, cHDL and the cLDL were significantly greater in women, what saves
relation with encountered in our study.
By means of the analysis
multivariable, identify that the feminine sex and the personal antecedent of
ECV associate of independent way with the dislipidemia, above the age and of
the HbA1c. The prevalence of dislipidemia sand associated with the feminine
sex, what was consistent with other studies [4]. Regarding the association
between sex and dislipidemia, in the current investigation the feminine sex was
the most affected by dislipidemia, although 52.1% of the participants were of
masculine sex. The association of both categorical variables by means of the
analysis multivariant allowed to estimate that belong to the feminine sex in
this group of patients increased in almost 3 times the relative risk to present
dislipidemia. The lipid profile altered is a characteristic of the DM and
confers greater risk to present ECV, especially EAC. The relative risk of
coronary cardiac illness fatal associated with the DM is 50% higher in the
women that in the men. The caused the greater risk of coronary cardiopathy in
women with DM still does not know completely. However, the changes induced by
the DM2 in some factors of cardiovascular risk, like the cLDL, cHDL, TG and the
PA, have found more pronounced in the women that in the men, and this can
explain the greater increase in the risk of arteriosclerosis in women
diabetics. Besides, the differences between the sexes in the lipid profile
could exert a paper in the most negative impact that has gave diabetes on the
cardiovascular risk in the women in comparison with the men. Likewise, it has
posited that the increase of the prevalence of the dislipidemia in the women of
age advanced can be related with the hormonal changes in the pre- and
post-menopausal. The prevalence of dislipidemia associated with the personal
antecedent of ECV [6]. In the current investigation, the antecedent of ECV was
significantly more prevalent in the masculine sex (39.5%) and almost 4 of each
10 of patients with dislipidemia had the antecedent of ECV (35.8%). The
association of both categorical variables by means of the analysis multivariant
allowed to estimate that have the personal antecedent of ECV in this group of
patients increased in 3.5 times the risk to present says lipidemia [7]. In this
sense, is important to emphasize that the hypercholesterolemia is a factor of
risk very prevalent in patients with ECV and confers special risk to suffer it,
especially ischemic cardiopathy. Likewise, the high levels of CT and cLDL are
between the most important factors of risk of ECV, the cHDL low and the TG high
are independent factors of risk of ECV and the treatment with statins has a
beneficial effect in the incidence of the ECV atherosclerotic [8]. Our studies
presents diverse limitations and fortresses. Between the main limitations find
the inherent to the type of study (longitudinal) and of analysis of the
information; in this sense has to recognize the presence of the bias of
survival, the impossibility to generalize the results to populations with
different characteristics to the described; to his time, is necessary to make
studies perspectives that can confirm these results and analyze with greater
precision the variables associated tool to prevalence of dislipidemia.
Of the present study fits to stand
out the sampling in which it is based, that is a representative sample of
Castile-La Mancha, as well as the fact that it have been objective by several
observers, what does it more damtativo in the recollection of data. In
comparison of our results with the studies published to national and
international level allows us to see the consistency of the data. Besides,
other variables could be predictors valid of dislipidemia. Our study did not
take into account the possible modifications of the therapy lipid lowering and
the therapeutic fulfillment of the patients. Finally, the longitudinal design
is very used, since his cost is relative inferior body to the of other
epidemiological designs, like the transversal studies, and provide notable
information and of fast form for the management of the services of health.
Because of the importance of the object of analysis that occupies us, believe
necessary emphasize the importance to follow investigating in this line.
Conclusion
This investigation shows that in the
patients with DM2 of Castile- La Mancha there is a high prevalence of
dislipidemia. The factors of risk associated of form independent were the
feminine sex and the personal antecedent of ECV. In sight of these results,
exists the need of a handle integral and intensive of the dislipidemia, for
which has to try improve the metabolic control of the diabetes, decrease the
obesity and promote changes in the lifestyles (cessation of the habit tobacco,
physical exercise and decrease of the consumption of saturated fats and of
alcohol), with the end to diminish the ECV and to improve the quality of
individual and collective life of the population.
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