Open Journal Systems

RESEARCH

How to cite this article:

Sosa-García BC, García-Reza C, Gómez-Martínez V, Basurto-Acevedo ML, Oros-Pantoja R, Díaz-Martínez AG. Metabolic and non-metabolic risk factors in adults from a health center in the Estado de México. Rev Enferm Inst Mex Seguro Soc. 2017 Jan-Mar;25 (1):29-35.

Metabolic and non-metabolic risk factors in adults from a health center in the Estado de México

Betsy Corina Sosa-García,¹ Cleotilde García-Reza,² Vicenta Gómez-Martínez,² María de Lourdes Basurto-Acevedo,³ Rigoberto Oros-Pantoja,⁴ Alma Grisel Díaz-Martínez³

^1,2,4Universidad Autónoma del Estado de México. Toluca, Estado de México, México. ³Instituto Mexicano del Seguro Social, Unidad de Investigación Médica en Enfermedades Endocrinas, Ciudad de México, México

¹Laboratorio de Neuroquímica, ²Facultad de Enfermería, ⁴Departamento de Neurociencias

Correspondence: Cleotilde García-Reza

Email: cgarc0506@yahoo.com.mx

Received: April 13^th 2016

Judged: July 8^th 2016

Accepted: October 14^th 2016

Abstract

Introduction: In the last decades, type 2 diabetes mellitus (T2DM) has increased considerably in Mexico. In 2000 the National Health Survey reported 2.1 millions of people affected; in 2006, 3.7 millions; and in 2012, 6.4 millions. Acting together, T2DM and cardiovascular disease are the leading cause of mortality with a trend that is increasing progressively in recent years.

Objective: To identify and describe metabolic and non-metabolic risk factors in adults enrolled in a health center in the Estado de México.

Methods: A non-random sampling of 586 male and female patients was divided into three groups: normal glucose (NG), impaired fasting glucose (IFG) and T2DM. Metabolic (triglycerides, HDL-cholesterol, LDL-cholesterol, as well as systolic and diastolic blood pressure) and non-metabolic (weight, height and waist circumference) variables were measured.

Results: Mean levels of total cholesterol in the three groups were higher in the GN group with 203.6 ± 36.7 mg/dL vs. 199.4 ± 39.7mg/dL vs. 200.6 ± 44.7mg/dL, respectively. Serum levels of LDL-cholesterol in the GN and GAA groups were similar with 120.7 ± 32.3 vs. 120.5 ± 33.7, respectively; in the T2DM group, the serum level of LDL-C decreased (114.6 ± 36.5 mg/dL).

Conclusions: Our findings show that patients with T2DM along with patients without diabetes show high frequency of alterations in lipid profiles and diastolic blood pressure, as well as abdominal obesity.

Keywords: Diabetes mellitus; Risk factors; Nutritional physiological phenomena; Chronic disease

---

Introduction

The American Diabetes Association (ADA) notes that type 2 diabetes mellitus (DM2) is a metabolic disease characterized by the presence of hyperglycemia. One-third of patients with DM2 increase their risk of developing cardiovascular disease two to four times.^1-5 More women than men suffer from this epidemic, especially in developed countries. China, India, and the United States are the countries with the largest number of people with diabetes.⁶

The World Health Organization (2014) reports that worldwide the number of people with DM2 increased from 30 million in 1995 to 366 million in 2011; and estimates that by 2030; there will be 592 million people who will have altered glucose when fasting.^5-10

On the other hand, a study carried out in nine Latin American countries demonstrated that glycemic control is poor,^3-5 the reason why diabetes is a public health problem. The magnitude of the problem means that every six seconds a person dies from diabetes mellitus and there are 5.1 million deaths per year. The impact on economic, social, and quality of life terms makes this problem a global priority.^11-15

It has recently been determined that the risk of cardiovascular disease is 11 times higher in the diabetic population than in the population without diabetes.^13-18 To this regard, almost 500 million people in the world are obese, a figure that corresponds to 12% of the world population. At the same time, the 26% of the adult population with the highest degree of obesity has been identified as  from the American continent, and the lowest degree in Southeast Asia, with 3%. This suggests an existing risk of cardiovascular disease.^19,20

The term impaired fasting glucose (IFG), dysglycemia, or prediabetes is applied to those clinical cases with glucose levels above normal values but below the levels considered for DM2. Given its high frequency, it is convenient to consider prediabetes as a high risk for developing diabetes and vascular complications.^4-7 The modification or alteration of these variables can occur in people with normal glucose, IFG and DM2. As such, DM2 and cardiovascular disease are two diseases of high morbidity and mortality, results of the metabolic syndrome.^7,21-23

In the last decades, DM2 has had a notable increase in Mexico. In 2000, the Encuesta Nacional de Salud (ENSA) reported 2.1 million people affected (4.6%); in 2006, 3.7 million (7.3%); and 6.4 million (9.2%) in 2012.^16-18 Regarding incidence of DM2 in Mexico, in 1995, it ranked ninth; and seventh in 2011; and it is possible that it will occupy the sixth place by the year 2030. Currently, along with cardiovascular disease, it is the leading cause of mortality with a progressive upward trend in recent years.^17-18

The importance of an early and timely diagnosis helps people to reach a life expectancy greater than estimated, have a decent quality of life, as well as to reduce higher expenditures in the health sector.²¹

The purpose of the present study was to identify and describe the metabolic and non-metabolic risk factors in adults enrolled in a health center in the Estado de México.

The groups conformed to the following criteria:

• Normal glucose level.
• Impaired glucose in fasting.
• Type 2 diabetes mellitus.

Methodology

Descriptive and transversal study, derived from a research project of the Instituto Nacional de Ciencias Médicas y Nutrición. In March and August 2014, 586 people, of both sexes, between 30 and 70 years of age enrolled in a health center in the Estado de México. From a non-probabilistic sampling, three groups were formed based on the following criteria: Group 1 included people with normal glucose (NG) levels, between 70 and 99 mg/dL; Group 2, people with altered fasting glucose (IFG), between 100 and 125 mg/dL; and Group 3, people with type 2 diabetes mellitus (DM2); a BMI≥23 kg/m²; and treatment with oral hypoglycemic agents, insulin, or both.

Other criteria were also considered to include participants, such as the presence of fever (>38°C); having been in bed for more than 48 hours in the two weeks prior to enrollment; suffering from coronary artery disease (CAD); or risk equivalent of congenital heart disease (CHD); active liver disease or presented during the previous six months; significant renal dysfunction, including serum creatinine>1.7 mg, above the ULN or nephrotic syndrome; history of neoplasia; current abuse or dependence on alcoholic beverages or drugs; as well as suffering from depression or uncontrolled psychosis.

People under 30 years of age with DM1 or gestational diabetes, a body mass index (BMI)<23 kg/m², incomplete data on anthropometry, lipid profile, or glucose levels were excluded.

For the clinical evaluation of the people participating in the study, a questionnaire was applied and weight, height, blood pressure, waist circumference, and fasting blood sample were measured. The day before the sampling date, researchers contacted the head of the health center to confirm the attendance of the participants and remind them to fast.

Body weight (kg) and height (m) were measured based on the recommendations of Norma Oficial Mexicana NOM-043-SSA2-2005, Servicios básicos de salud. Promoción y educación para la salud en materia alimentaria. Criterios para brindar orientación.²⁴ With these measurements, each participant's BMI was calculated. Waist circumference was measured at the level of the greater trochanters and hip circumference at the level of the gluteal zone at maximum extension of the buttocks posteriorly.²⁵ A mercury sphygmomanometer was used to measure blood pressure with the person at rest in a seated position. This measurement was performed at three moments to obtain the average systolic and diastolic pressures.

The basal glucose test was performed after 12 hours of fasting. The criteria for diagnosis of glucose were, according to the ADA,¹ considered controled when the person had a fasting glucose level between 70 and 129 mg/dL, and poor control when there was a glucose level>130 mg/dL.

Biochemical tests included glycemic assessment, lipid profile including triglycerides, total cholesterol, and HDL-cholesterol. LDL cholesterol was calculated using the Friedewald formula.²⁶ The alteration of metabolic and non-metabolic variables was studied based on the criteria of the Third Report of the Expert Panel on Detection, Evaluation and Treatment of Adult Hypercholesterolemia of the Program National Cholesterol Education Institute, also known as NCEP-III: impaired fasting glucose (≥100 mg/dL); dyslipidemia (triglycerides≥150 mg/dL, HDL<50 mg/dL in women and<40 mg/dL in men); arterial hypertension (≥130/85 mm Hg); obesity (waist circumference≥80 cm in women and≥90 cm in men).^27,28

For statistical analysis, a database was constructed with the statistical package SPSS, version 21. The results were analyzed by means of descriptive statistics of arithmetic mean and standard deviation (SD), in order to determine the significant differences. Bonferroni test was used to determine statistical significance, with a confidence level of 95% (p<0.05), and a multivariate regression analysis of variances (ANOVA) to determine the description of non-metabolic variables (weight, height, waist circumference) and metabolic variables (triglycerides, HDL-C, LDL-C, systolic and diastolic blood pressure) in the three study groups.

Results

Of the 586 participants, 172 (29%) were diagnosed with normal glucose, 59 (10%) with altered glucose, and 355 (61%) with DM2.

The group of participants with normal glucose consisted of 49 men (29%) and 123 women (71%). Those with impaired glucose consisted of 38 men (64%), and 21 women (36%). The group of patients with DM2 were 123 men (35%) and 232 women (65%). The mean age for the NG group was 50.9 years (30-70); the IFG group was 52.0 years (33-69); and for the DM2 group, 56.0 years (35-70). Among the participants, the average socioeconomic stratum prevailed: 30% belonged to the NG group; 38% to the IFG group; and 32% to the DM2 group. The education level was secondary education or a technical career in 27.9% of the NG group; 33.9% of the IFG group; and 27.0% of the DM2 group.

Mean weight was similar in the normal glucose and altered glucose groups with 73.3±13.0 kg. This value was higher when comparing the data with the DM2 group (70.4±14.7 kg), but there was no significant difference between the groups.

According to the mean BMI values, it is evident that the three study groups present values above the established limit, however, there was no significant difference when associated with the groups (NG 28.4±5.0; IFG 28.2±4.4; and DM2 27.9±4.7).

The waist circumference figure was similar for in all three groups. Most participants had one or more components of the metabolic syndrome. Central obesity was present in both women and men with a value of p=0.554 (Table I).

When comparing the metabolic variables among the three groups (NG, IFG, DM2), it is unquestionable that mean total cholesterol levels were higher in the normal glucose group (203.6±36.7 mg/dL; 199.4±39.7 mg/dL; and 200.6±44.7 mg/dL, respectively).

Both the NG and IFG groups had similar serum LDL-C levels (120.7±32.3 vs 120.5±33.7); However, the group of participants with DM2 had a decrease in serum LDL-C levels (114.6±36.5 mg/dL). These data place the study population at risk for developing metabolic complications related to diabetes.

The triglyceride concentration and systolic blood pressure (149.5±23.9 mm Hg), were slightly higher in the DM2 group,. Also, the association between high cholesterol and blood pressure was statistically significant, with a Pearson correlation of p<0.0001 (Table II).

Discussion

Of the total number of participants studied, the DM2 group presented a higher frequency of cardiometabolic risk factors. However, an increase in metabolic risk factors, such as abdominal obesity, elevated LDL-C, and hypertriglyceridemia, was identified in the NG and IFG groups; that is to say, this is population with a high cardiovascular risk.^9-19

Alterations present in the NG and IFG groups, such as abdominal obesity, arterial hypertension, and dyslipidemia, suggest presence of insulin resistance in this non-diabetic population, a probable endothelial dysfunction and fibrinolysis involvement. All these elements are part of the transition period from prediabetes to diabetes.²⁹

The proportion of men and women with DM2 in this study exceeds the general figure reported by ENSANUT in 2016 (9.6%).²¹ On the other hand, it coincides with that described by Franzini and Soriguer.^30,31 Although the sample in the present study is not representative of the national population, there are possible explanations regarding type of diet, sedentarism, and biological sustenance.32 With the present data (taking into account the context in which they were obtained), efforts should be directed towards generating effective prevention strategies as a cornerstone to delay the presentation of diabetes or chronic complications.^33-36

Achieving glucose control is a major challenge for health services and for people with diabetes mellitus.¹⁸ The challenge is and will be increasing as the global prevalence of diabetes increases, given that it was 6.4% of people aged 20 to 79 years in 2010, and will increase to 7.7% by 2030. These estimates correspond to a 69% increase in adults with diabetes developing countries and in developed countries, this increase is 20% for the same population.⁶

On the other hand, it is accepted that adequate glycemic control has a close relationship with the probability of suffering complications.^33,34 The timely diagnosis of glucose intolerance can delay the onset of microvascular complications and decrease the progression of diabetes. It is known that molecular effects associated with insulin resistance in the endothelial cell lead to a proinflammatory and prothrombotic state, which would explain the increase in cardiovascular risk.³¹

Cholesterol levels did not show significant variations among the groups in this study. However, they indicate that they are not a fundamental element of the lipid profile with a higher atherogenic risk, which coincides with that reported in several published studies.^3-13

Similarly, hypertriglyceridemia and decreased HDL-C are similar in the different groups of both normal and altered glycemia. Lipid alterations, such as those observed in LDL-C, suggest alteration of fat fraction by small, dense particles of high atherogenic power, called phenotype B.³² The HDL-C and LDL-C fractions are associated with an increased risk of stroke of up to two times, and triple the risk of coronary heart disease  and cardiovascular mortality.³⁶

In diabetes mellitus, there is a situation of accelerated atherogenesis, which is associated not only with hyperglycemia, but also with other risk factors, such as dyslipidemia, hypertension, hyperinsulinemia/insulin resistance, and coagulation alterations, among others.³³

With the results of this study, it is opportune to notice elevation in BMI and waist circumference as a potential component of metabolic syndrome, even in non-diabetic patients. According to WHO, obesity is estimated to occur in 12% of the world's population, with large contrasts ranging from the highest level in America to the lowest in Southeast Asia. This is determinant for the population to be at risk of developing diabetes, cancer, and cardiovascular problems. In addition, the presence of intra-abdominal fat, increased lipolytic activity, and increased fatty acids have a further impact on liver function.³⁶ Després states that the simultaneous presence of abdominal perimeter and triglyceride levels≥180 mg/dL in men is associated with a 3.5-fold increased risk for cardiovascular events.³⁷

Limitations of the study

The number of participants recruited in this study, mostly carriers of type 2 diabetes mellitus, are not a strict representation of the Mexican population. However, with the results obtained an estimate of what is happening in our country can be made.

Another limitation is that glucose tolerance curve was not performed in non-diabetic individuals, which would have allowed the identification of people with postprandial alteration of glucose, an entity that is currently considered within the prediabetes category and therefore these people are considered an at-risk population.

It is suggested to continue with future research, using indices to determine insulin resistance and other markers, in the field of prevention.

Conclusions

In this study, a high frequency of other metabolic risk factors was identified in the DM2 group. However, in the groups with normal glucose and with fasting glucose alteration, components of metabolic syndrome, such as abdominal obesity and hypertriglyceridemia, presented.

Timely identification of metabolic alterations is the main tool to predict cardiovascular disease. The latter is a cause of high morbidity and mortality in the Mexican population.

Another condition that should be emphasized regarding the study population is glycemic control, effective in reducing the potential risk of complications from diabetes mellitus.

Prospective analysis

The questioning process on this public health issue is impressive, as hyperglycemia is considered a global epidemic due to its high occurrence and its presentation at earlier ages. This health problem is becoming more frequent and is accentuated by the prevalence of obesity. The problem represents a great challenge, but there is also a range of possibilities to offer prevention programs under the perspective of continuous and ongoing monitoring. The results of this work underscore the importance of the glucose level, which is a powerful predictor of cardiovascular risk.

Acknowledgements

Thanks to the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zúbiran, for the support received to carry out this study.

References

1. American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care. 2014 Mar;37(3):887. http://dx.doi.org/10.2337/dc14-er03 [Cited: 2014 Jun 7]. Available from: http://care.diabetesjournals.org/content/37/Supplement_1/S14.extract
2. OMS alerta sobre aumento de Hipertensão e Diabetes no Mundo. WSCOM (sitio web). [Cited: 2015 Jan 25]. Available from: http://www.wscom.com.br/mobile/blog/joaomodesto/oms+alerta+sobre+aumento+de+hipertensao+e+diabetes+no+mundo-7981
3. Organización Mundial de la Salud (OMS). Dia Mundial do Diabetes 2014: Vida saudável e diabetes. Available from: http://www.paho.org/bireme/index.php?option=com_content&view=article&id=262%3Adia-mundial-do-diabetes-2014-vida-saudavel-e-diabetes&catid=
4. World Health Organization. Investing in a healthy breakfast will reduce the global burden of diabetes, and save billions in lost productivity and healthcare costs. [Cited: 2012 Mar 18]. Available from: http://www.idf.org/sites/default/files/wdd-guidebook-2014-en.pdf
5. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33(1):S62-9.
6. Grimaldi A. Polidipsia-poliuria. EMC - Tratado de Medicina. 2012; 16(2):1-2.
7. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010 Jan;87(1):4-14. doi: 10.1016/j.diabres.2009.10.007. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19896746
8. Lorenzo C, Haffner SM. Performance Characteristics of the New Definition of Diabetes. The Insulin Resistance Atherosclerosis Study. Diabetes Care. 2010;33(2):335-7.
9. Morris-Danielle H, Khunti K, Achana F, Srinivasan B, Gray LJ, Davies MJ et al. Progression rates from HbA1c 6.0-6.4% and other prediabetes definitions to type 2 diabetes: a meta-analysis. Diabetologia. 2013;56(7):1489-93.
10. Buysschaert M, Bergma M. Definition of prediabetes. Medical Clinics of North America. 2011;95(2):289-97.
11. Mata-Cases M. Diabetes mellitus tipo 2: Protocolo de actuación. Grupo de Estudio de la Diabetes en Atención Primaria de Salud (GEDAPS) de la Societat Catalana de Medicina Familiar Comunitària, Barcelona, España.
12. Díaz-Díaz O, Cabrera-Rode E, Orlandi-González N, Araña-Rosaínz M. Aspectos epidemiológicos de la prediabetes, diagnóstico y clasificación. Rev Cubana Endocrinol. 2011;22(1):3-10. Available from:: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1561-29532011000100003&lng=es
13. Asociación Mexicana de Diabetes (AMD). Diagnóstico de diabetes. México: AMD; 2011.
14. Mazón-Ramos P, Cordero A, González-Juanatey JR, Bertomeu-Martínez V, Delgado E, Vitale G et al. Control de factores de riesgo cardiovascular en pacientes diabéticos revascularizados: un subanálisis del estudio” ICP - Bypass Rev Esp Cardiol. 2015;68(2):115-20. DOI: 10.1016/j.recesp.2014.03.021
15. Pérez L, Saltijeral A, Vitale G, González B, Torres A, Álvarez LA. Prevalencia de colesterol LDL inadecuado en pacientes con enfermedad coronaria y/o diabetes mellitus tipo 2. Revista Clínica Española. 2012;212(10):475-81.
16. Herrero A, Garzón G, Gil A, García I, Vargas E, Torres N. Grado de control de factores de riesgo cardiovascular en pacientes con diabetes con y sin enfermedad cardiovascular. Medicina de Familia-SEMERGEN 2015;41(7): 354-61.
17. Rodríguez-Bernardino Á, García-Polavieja P, Reviriego-Fernández JJ, Serrano-Ríos M. Prevalencia del síndrome metabólico y grado de concordancia en su diagnóstico en pacientes con diabetes mellitus tipo 2 en España. Endocrinología y nutrición. 2010;57(2):60-70. doi: 10.1016/j.endonu.2009.12.002
18. International Diabetes Federation (IDF). Diabetes Atlas. 5th edition. Bruselas: IDF; 2012.
19. Vinagre I, Mata-Cases M, Hermosilla E, Morros R, Fina F, Rosell M, et al. Control of Glycemia and Cardiovascular Risk Factors in Patients With Type 2 Diabetes in Primary Care in Catalonia (Spain). Diabetes Care. 2012;4(35):774-9.
20. World Health Organization (WHO). Global Health Observatory (GHO) data. Monitoring health for the SDGs. [Cited: 2015 Feb 11]. Available from:: http://www.who.int/gho/en/
21. Gutiérrez JP, Rivera-Dommarco J, Shamah-Levy T, Villalpando-Hernandez S, Franco A, Cuevas-Nasu L et al. Encuesta Nacional de Salud y Nutricion 2012. Resultados Nacionales. Cuernavaca, Mexico: Instituto Nacional de Salud Pública (MX); 2012.
22. Orlandi-González N, Álvarez-Seijas E, Elías-Calles LC, Hernández-Rodríguez J, Rodríguez-Anzardo BR, González-Calero TM, et al. Guías cubanas de práctica clínica basadas en la evidencia sobre el pesquisaje, diagnóstico y tratamiento de la diabetes mellitus tipo 2. Available from: http://files.sld.cu/pdvedado/files/2010/05/gpc-dm2-final.pdf
23. Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, et al. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care. 2011 Jun;34(6):e61-99. doi: 10.2337/dc11-9998.
24. Secretaría de Salud (SS). Norma Oficial Mexicana NOM-043-SSA2-2005, Servicios básicos de salud. Promoción y educación para la salud en materia alimentaria. Criterios para brindar orientación. México: SS; 2006. Available from: http://www.salud.gob.mx/unidades/cdi/nom/compi/043ssa205.pdf
25. Siegel D. Concerns About the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 8 Blood Pressure Panel Member Recommendations and Their Relevance to Metabolic Syndrome. Jun 2014;12(5):251-4.
26. Querales M, Dominguez MI, Rojas S. Estimación del colesterol LDL a través de la ecuación brasilera: comparación con otras metodologías. Rev Latinoam Patol Clín Med Lab. 2015;62(2):91-6. Available from: http://www.medigraphic.com/pdfs/patol/pt-2015/pt152d.pdf
27. Consejo Mexicano de Aterosclerosis. Revisión del 3° Informe del Programa de Tratamiento de la Aterosclerosis (ATP III), 2009. Available from: http://lancet.mx/FASCICULOS/Monografias/ATPIII.pdf
28. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002 Dec 17; 106(25):3143-421.
29. Arnlöv J, Ingelsson E, Sundström J, Lind L. Impact of body mass index and the metabolic syndrome on the risk of cardiovascular disease and death in middle-aged men. Circulation. 2010;121(2):230-6. doi: 10.1161/CIRCULATIONAHA.109.887521.
30. Franzini L, Ardigò D, Cavalot F, Miccoli R, Rivellese AA, Trovati M, et al. Women show worse control of type 2 diabetes and cardiovascular disease risk factors than men: results from the MIND.IT Study Group of the Italian Society of Diabetology. Nutr Metab Cardiovasc Dis. 2013 Mar;23(3):235-41. doi: 10.1016/j.numecd.2011.12.003.
31. Soriguer F, Goday A, Bosch-Comas A, Bordiú E, Calle-Pascual A, Carmena R, et al. Prevalence of diabetes mellitus and impaired glucose regulation in Spain: the Di@bet.es Study. Diabetologia. 2012 Jan;55(1):88-93. doi: 10.1007/s00125-011-2336-9.
32. Ayala Y, Acosta M, Zapata L. Control metabólico de pacientes con diabetes mellitus tipo 2. Rev Soc Peru. Med Interna. 2013; 26(2): 68-70.
33. Almaguer-Herrera A, Miguel-Soca PE, Reynaldo-Será C, Mariño-Soler AL, Oliveros-Guerra RC. Actualización sobre diabetes mellitus. CCM. 2012;16(2). Available from: http://www.revcocmed.sld.cu/index.php/cocmed/article/view/507/71
34. Hummasti S, Hotamisligil GS. Endoplasmic reticulum stress and inflammation in obesity and diabetes. Circ Res. 2010;107(5):579-91.
35. Nathan MD, for the DCCT/EDIC Research Group. The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study at 30 Years: Overview. Diabetes Care. Jan 2014;37(1):9-16.
36. Yoon U, Kwok LL, Magkidis A. Efficacy of lifestyle interventions in reducing diabetes incidence in patients with impaired glucose tolerance: a systematic review of randomized controlled trials. Metabolism. 2013 Feb;62(2):303-14. doi: 10.1016/j.metabol.2012.07.009.
37. Després JP. Assessing the Cardiometabolic Risk of Obesity: Importance of Visceral/Ectopic Fat and of the Use of Hypertriglyceridemic Waist. Controversies in Obesity. 2014:127-35.

Enlaces refback

• No hay ningún enlace refback.