Iranian Journal of

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Diabetes during pregnancy is either concurrent diabetes, diagnosed before pregnancy, or ‘gestational diabetes mellitus’ (GDM), first diagnosed in pregnancy. GDM is the commonest metabolic disorder of pregnancy, with a prevalence of one to 14 percent, depending on the reporting team. The prevalence of GDM in Tehran is 4.7%. Diabetes concurrent with pregnancy is diagnosed according to the recently revised criteria of the National Diabetes Data Group (NDDG). GDM is diagnosed with a 100-gram 3-hour glucose tolerance test (3hGTT100), with at least two abnormally high readings being required for a definite diagnosis. Screening for GDM is still a matter of dispute. Universal or selective screening? Each has its supporters. The American Diabetes Association (ADA) recommended universal screening until 1997, and this is still recommended for areas with a high prevalence of GDM. Diabetes during pregnancy has multiple potential consequences for mother and fetus fetal macrosomia being the commonest. The children of diabetic mothers are also more likely to become overweight and develop impaired glucose tolerance. ADA recommendations for glycemic control in diabetic mothers-to-be include maintaining their fasting blood glucose between 60 and 95mg/dl, and their postprandial blood glucose between 80 and 120mg/dl. Measurement of urinary ketones is recommended when the patient is on a calorie-restricted diet. Lifestyle changes are an integral part of management. Insulin requirements and calorie intake must be adjusted in line with weight gain as pregnancy progresses.

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Background: Diabetes mellitus is a common chronic disorder with multiple disabling long- and shorter-term complications, the majority of which can be controlled if not prevented. The management of diabetic patients is a major drain on both health budgets and time.
Methods: We reviewed the records of 101 patients with diabetic foot ulcer, who had received treatment at either Doctor Shariati or Imam Khomeini hospital.
Results: Out of 101 patients (56.4% male and 43.6% female) with diabetic foot ulcer, 34.7% had eventually undergone amputation.
Conclusion: Our findings highlight the need for control and prevention programmes aimed at reducing the risk factors for and complications of diabetic foot ulcer.

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Background: Cardiac X Syndrome is the occurrence of angina pectoris in spite of a normal coronary angiogram, probably due to a disorder of the cardiac sensory nervous system (pain perception). The insulin resistance (metabolic X) syndrome is an important determinant of coronary artery disease. There is a dearth of research on the association between insulin resistance and cardiac X syndrome. We compared the hormonal status of three groups of postmenopausal women: those with cardiac X syndrome, those with coronary artery disease, and healthy controls.
Methods: 149 postmenopausal women (age range 48-58 years), matched for duration of menopause, were recruited for this study. Gonadotrophin and fasting insulin levels as well as blood pressure and body mass index were measured in all three groups.
Results: LH, FSH, oestradiol and progesterone levels were similar in all three groups. Women in the first two groups (that is, those with angina pectoris regardless of the result of coronary angiography) had a significantly higher BMI than controls. Fasting insulin levels were significantly higher in the first two groups compared with controls (p<0.01). There was no difference in fasting insulin level between the normal and abnormal angiography groups. There was no significant correlation between fasting insulin and any of the other variables, even though the association between fasting insulin and BMI in the abnormal angiography-confirmed CAD group very nearly approached statistical significance (p=0.059).
Conclusion: Women with angina pectoris, regardless of the outcome of coronary angiography, have hyperinsulinism and a higher BMI than controls. It seems that hyperinsulinism is the fundamental mechanism by which both the cardiac X and metabolic X syndromes occur. Further research is needed to elucidate this matter.

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Diabetes mellitus is characterized by several adverse consequences among which diabetic foot is a major complication. With a life long incidence of 15%, diabetic foot is accountable for more than 50% of non-traumatic lower limb amputations. Regular care, proper footwear and early treatment, but, have proved effective measures in preventing such outcome. The problem and features as infection, ulceration, or gangrene. Neuropathy, poor circulation, and decreased resistance to infection are the three major contributors to the development of diabetic foot which when present, foot deformities or minor trauma can readily lead to ulceration and infection. Not all diabetic foots are preventable, but appropriate preventive measures can dramatically reduce their occurrence.

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The current challenge in health services research is disability to present comprehensive and effective intervention plans for community health promotion. There are numerous reasons in this regard, some of which can be overcome through performance-based participatory research methods. The Population Research Center (PRC) in Tehran University of Medical Sciences (TUMS) provides the necessary ground: 1) to innovate original methods in participatory research that are compatible with our native culture, and 2) to make the results of the population research applicable to the whole society through target-based executive steps. The steps to implement health promotion (known as Planned Approach To Community Health) include: acquirement of people’s participation, health needs assessment, priority setting for health problems, designing health interventions, and evaluation of the activities. Those parts of this approach, which are mainly concerned with needs assessment in the area of endocrinology and the causal factors of related diseases, have been accomplished. The next step in this field is to plan appropriate intervention projects and to put them into practice through the principles of community participation and community empowerment.

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Background: This study was performed to evaluate the prevalence and risk factors of asymptomatic bacteriuria (ASB) in women with type 2 diabetes mellitus in Iranian population.
Methods: Between March 2003 and December 2003, 202 nonpregnant women with diabetes type 2 who were between 31 to 78 years old and had no abnormalities of the urinary tract system were included. We defined ASB as the presence of at least 105 colony-forming units/ml of 1 or 2 bacterial species, in two separated cultures of clean-voided midstream urine. All the participants were free from any symptoms of urinary tract infection (UTI). Risk factors for developing bacteriuria was assessed and compared in participants with and without bacteriuria.
Results: In this study, the prevalence of ASB was 10.9% among diabetic women. E.coli was the most prevalent microorganism responsible for positive urine culture. Most of the isolated microorganisms were resistant to Co-trimoxazole, Nalidixic acid and Ciprofloxacin. Pyuria (P<0.001) and glucosuria (P<0.05) had meaningful relation with bacteriuria but no association was evident between age (P<0.45), duration of diabetes (P<0.09), macroalbuminuria (P<0.10) and HbA1c level (P<0.75), and the presence of ASB.
Conclusion: The prevalence of ASB is more prevalent in women with type 2 diabetes, which pyuria and glucosuria can be considered as risk factors in this regard. Routine urine culture can be recommended for diabetic women even when there is not any urinary symptom.

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Leptin is a 16-kD protein which is secreted from white adipocytes and, its discovery has generated enormous interest in the regulation of energy balance. Leptin has been implicated in the regulation of food intake, energy expenditure, and whole-body energy balance in animals and human. Plasma leptin levels correlate with fat storages and respond to changes in energy balance. It was initially proposed that leptin serves a primary role as an anti-obesity hormone, but this role is commonly thwarted by leptin resistance. The profound effects of leptin on regulating body energy balance, make it as a prime candidate for drug therapies of obesity in humans and animals. Despite the recent achievements in unearthing the role of leptin in the pathophysiology of obesity, many important questions still remained that must be responded. More studies with follow-up designs and genetic evaluations are warranted to understand the comprehensive role of leptin in human. In this letter we have a review of known effects of leptin on human obesity up to now.

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Background: Foot complications are among the important problems of diabetic patients. Vascular and neurological involvements are two major causes for such complications.
Methods: We studied 142 diabetic outpatients referred to diabetes clinic of Dr.Shariati Hospital from Dec. 2003 to Sep. 2004. We performed different neurological and vascular tests to assess the diabetic foot and data were analyzed by SPSS software.
Results: 54.9% of the cases reached the symptom score of 5 and upper so they had neuropathy regarding the Michigan Neuropathy Disability Score (MNDS). By analyzing the overall symptom and sign scores, 61% had neuropathy. Regarding MNDS, 42.7% of the subjects were neuropathic. Finally 23.9% were unable to sense at least one point from 12 points of monofilament examination. 16.9% of the patients had the complaint of intermittent claudication, in 8.8% at least one of the peripheral pulses was not palpable, whereas 10.6% had some degree of PAD regarding to ABI and toe pressure.
Conclusion: Using a monofilament is the most reliable method for screening of the neuropathy in diabetic patients. On the other hand, relying on symptoms like intermittent claudication and physical examination in order to find peripheral arterial disease in diabetic patients may lead to miss many cases, thus, performing some more precise diagnostic tests, such as ABI and toe pressure are highly recommended and reliable.

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One of the most important summary measures of population health, is Disability Adjusted Life Years (DALY), introduced for the first time in the project of Global Burden of Disease (GBD), that is the newest as well as the most accepted and familial summary measure of health and the burden of diseases has been measured by this measure at national and regional levels in many countries of the world. One of the most important results of the project of the global burden of disease was revealing the great burden of mental diseases. For measuring the burden of disease, there is frequently need to do value judgments or ethical judgments. Also, this methodology has been criticized ethically. In Iran, these ethical concerns have not been assessed separately yet. In thid article we briefly assessed the ethical issues regarding this methodology and its implications in measuring the burden of the mental diseases.

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Background: It is well recognized that an increased body weight is often associated with increased blood pressure. Moreover, leptin an adipocyte-derived hormone is strongly suggested to have an important role in pathogenesis of the obesity. We aimed to evaluate the levels of serum leptin in association with obesity and hypertension in a sample of Iranian obese children.
Methods: Children from all the primary schools of a distinct of Tehran were screened for obesity. Children with a waist circumference equal to or above 90th percentile for their age and height were invited for the study. Anthropometric measurements were done and blood samples for fasting serum leptin levels were collected from 563 enrolled obese children. Multivariate linear regression analysis was used to evaluate relationship of various factors with obesity.
Results: Mean Serum leptin levels were 8.65 ±2.18 (ng/ml). Serum Leptin levels were higher in girls than boys (P=0.009). There were significant correlations between body mass index (BMI) and serum Leptin levels, child age, systolic and diastolic blood pressure. Systolic blood pressure and diastolic blood pressure lost their association with serum Leptin level in multivariate linear regression analysis.
Conclusion: BMI is independently associated with Leptin levels among obese children. This may affirm a role for this hormone in the pathogenesis of childhood obesity. It seems unlikely that plasma Leptin be a major mediator of association between obesity and hypertension. However, severe hyperleptinemia may act as a risk factor for increased blood pressure.

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Background: The aim of this study was to determine the level of agreement between the impaired fasting glucose (IFG) and abnormal glucose tolerance before and after application of the new IFG definition and to evaluate the impact of adding common clinical data on this agreement.
Methods: A cross sectional population based study was carried out in an Iranian urban population which enrolled 8766 men and women over 20 years. Fasting and 2-hour plasma glucose were measured in all subjects excluding those with previously diagnosed diabetes and fasting plasma glucose ≥126 mg/dl. The diagnostic parameters and kappa coefficient between the previous and revised definitions of IFG for detecting impaired glucose tolerance (IGT) and dysglycemia (IGT and diabetes) were calculated. Logistic regression and ROC curve analysis were used to determine the independent clinical risk factors and their optimal cut-points associated with IGT and dysglycemia. Results: After using the new criteria, sensitivity of IFG for detecting IGT or dysglycemia increased but specificity and positive likelihood ratio (LR+) decreased and the κ slightly improved (0.16 to 0.29 for IGT and 0.24 to 0.35 for dysglycemia). Adding the clinical data to the revised criteria considerably improved the agreement between IFG with IGT and dysglycemia (κ increased from 0.286 to 0.470 for IGT and from 0.354 to 0.574 for dysglycemia). This also increased the LR+ from 3.86 to 14.5 and from 4.46 to 17.4 respectively for detecting IGT or dysglycemia.
Conclusion: The new IFG definition in combination with common clinical risk factors most likely predicts IGT and dysglycemia.

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 Background: Microalbominuria (MA) is early presentation of renal damage which acts as an independent factor of cardiovascular events in these patients. There are various methods for sampling and also different laboratory tests to measuring albominuria. The aim of this study was to compare of different urine collection methods for measuring albominuria using immunoturbidometry assay which has acceptable accuracy and sensitivity after HPLC (High Performance Lipid Chromathography).

Methods: Forty seven diabetic patients were selected for a cross-sectional study in 2006. For all patients 24-h urine sample were collected, also an overnight urine sample (8 hour long) and spot urine sample (morning time) was provided in the next day. The level of albumin in all samples were measured via immunoturbidometry assay. Then the results of agreement coefficient were accounted and comprised with each others.

Results: In this study 47 patients were selected which 46 of them were type 2 and one of them type 1 diabetic. Our results revealed significant correlation between all methods. In addition agreement coefficient (kappa) was accounted for all methods, time 24-h urine in comparison with 8 hours overnight urine, timed 24-h urine in comparison with spot urine and overnight urine samples in comparison with spot urine which were 0.876, 0.936 and 0.807 respectively.

Conclusion: Regarding significant agreement for screening of microalbominuria between different collecting methods, we suggest 8-h overnight or spot urine sampling carry out instead of 24-h urine collection.

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Background: Limited data are available relating intake of fruits and vegetables to inflammatory markers and risk of metabolic syndrome. The aim of this study was to evaluate the relationship between fruits and vegetables intake and C-reactive protein (CRP) and the prevalence of the metabolic syndrome.

Methods: Fruits and vegetables intake were assessed using a validated semi-quantitative food frequency questionnaire in a cross-sectional study of 486 Tehranian female teachers aged 40-60 y. Anthropometric measurements were done and blood pressure was assessed according to standard methods. Fasting blood samples were taken for biochemical measurements. The metabolic syndrome was defined according to Adult Treatment Panel III guidelines.

Results: The reported mean daily intake of fruits and vegetables were 228±79 and 186±88 g/d respectively. Both fruits and vegetables intake were inversely associated with plasma CRP concentrations. After statistically controlling for age, BMI and waist circumference, mean plasma concentrations of CRP across increasing quintile categories of fruits were 1.94, 1.79, 1.65, 1.61 and 1.56 mg/L respectively (P for trend <0.01) and of vegetables were 2.03, 1.82, 1.58, 1.52 and 1.47 mg/L respectively (P for trend<0.01). These inverse associations remained significant after additional control for other potential confounding variables and dietary factors. After controlling for potential confounders individuals in the highest quintile of fruits intake had 34% (95% CI: 20%-46%) lower and those in the highest quintile of vegetables intake had 30% (95% CI: 16%-39%) lower chance of having the metabolic syndrome compared to those in the lowest quintiles.

Conclusion: In this study higher intake of fruits and vegetables were associated with lower risk of metabolic syndrome part of this association may be mediated through CRP. These findings support current dietary recommendations to increase the intake of fruits and vegetables as a primary preventive measure against cardiovascular disease.

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Background: Recently on the metabolic syndrome is considered as an inflammatory disease. So factors affecting inflammation are important in this condition.

Methods: This randomized cross-over clinical trial was undertaken on 42 postmenopausal women with metabolic syndrome. Participants were randomly assigned to consume a control diet (Dietary Approaches to Stop Hypertension= DASH), soy protein diet, or soy nut diet, each for eight weeks. Inflammatory markers were measured by ELISA.

 Results: The difference from the control diet for E-selectin (an inflammatory markers which shows the endothelial function) was -11.4% (P<0.01) on the soy nut consumption and -4.7% (p=0.19) on the soy protein diets. Soy nut consumption reduced interleukin-18 compared to the control diet (difference from the control diet: -9.2%, p<0.01). For C-reactive protein the difference from the control diet was -8.9% (P<0.01) on the soy nut diet and -1.6% (P<0.01) on the soy protein diet.

Conclusion: Short-term soy nut consumption reduced some markers of inflammation and increased plasma nitric oxide levels in postmenopausal women with the metabolic syndrome.

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Background: Little evidence exists regarding the effects of soy consumption on the metabolic syndrome in humans. We aimed to determine the effects of soy consumption on components of the metabolic syndrome, plasma lipids, lipoproteins, insulin resistance and glycemic control in postmenopausal women with the metabolic syndrome.

Methods: This randomized cross-over clinical trial was undertaken on 42 postmenopausal women with the metabolic syndrome. Participants were randomly assigned to consume a control diet (Dietary Approaches to Stop Hypertension= DASH), soy protein diet, or soy nut diet, each for eight weeks. Red meat in the DASH diet was replaced by soy protein in the soy protein period and by soy nut in the soy nut period.

Results: Total cholesterol was significantly reduced compared to the control (P<0.01) and soy protein groups (P<0.01). The results were the same regarding the fasting insulin serum (P<0.01 compared with the control and soy protein group), HOMA-IR (P<0.01 compared with the control and soy protein group), Fasting blood sugar (P<0.01 compared with the control and soy protein group), and LDL cholesterol (P<0.01 compared with the control and P<0.05 compared with the soy protein group). Both soy nut and soy protein reduced Apo B100 compared to the control group (P<0.01).  

Conclusion: Short-term soy nut consumption improved glycemic control and lipid profiles in postmenopausal women with the metabolic syndrome

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Background: 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.

Methods: 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.

Results: 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.

Conclusion: This study provides evidence showing a positive association between HW phenotype and markers of systemic inflammation and endothelial dysfunction.

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Introduction: Studying of physical and mental health of older adults is important for health care services to elderly. With increasing ageing population and chronic diseases among older people, the expenditure of ageing services will increase. Thus, it is necessary to clear a cut point chronological age for starting ageing career. The aim of this paper is to understand health differences between two cohorts (60-64 and 65-69) of older adults. Methods: This study is cross-sectional and descriptive-analytical study. Data collected by structured questionnaire. The study population was 60 -64 and 65-69 cohort groups of older adults who living in rural and urban areas of Tehran in 2011. The sample size was estimated 400 people those were chosen using cluster sampling. Findings: The findings of study showed significantly differences between two groups of older adults, 60-64 and 65-69, in terms of physical health that measured using activity of daily living(ADL) and limitation of physical function. In contrast, there were no significant differences between two age groups in psychological wellbeing and mental illness. Based on results, complementary health services can start from 65 years old and providing counseling services according to women and men differences.

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Introduction: Mental disorders are common in the elderly.The purpose of this study was to assess the general health status and its related factors among people ≥ 65 years in different districts of Tehran. Methods: This study has used data of the participants ≥ 65 years old in urban health equity and response tool (Urban-HEART) study. Finally the data of 1313 elderly were considered for this study. Variables included demographic characteristics (gender, age, education level, family size, marital status and employment status) and mental health using the Persian GHQ -28 questionnaire (domains: somatic, depression, insomnia and anxiety) and quality of life using the SF12. Results: The mean age of participants was 73.68 (5.91) (women=627 and men=686). GHQ-28 median of scores the participants were 24.00 (22.00)[20.00 (27.00) in women and 19.00 (19.00) in men (P<0.01)].Based on GHQ-28 cut-point 23, 50.2%of the participants had mental health problems, [61.2% women and 40.1% men (P<0.01)].The residents of third municipality districts had the best mental health (26.3% of men and 38.5% of women had mental health problems) and the aged of 20th municipality district had the worst health status (65.7% of males and 84.2% of women had mental health problems).In multivariable logistic regression model, for each year of increment age, 2.9% chance of mental health problems increased (P<0.01). With increasing level of education, mental health status was improved (P trend < 0.01). The relationship between family size and mental health was not significant (P =0.06). Conclusion: Mental health status of the elderly in Tehran was worse than the many other countries. The elderly lived in 20th municipal district, had the worst and the dwellers in the 3th district had the best mental health status.

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Background: Food insecurity refers to the inability to afford enough food for an active, healthy life. The metabolic syndrome, otherwise known as syndrome X or the insulin resistance syndrome, is a collection of cardiovascular risk factors including hypertriglyceridemia, lowered HDL-cholesterol, glucose intolerance, abdominal obesity and hypertension. Recent studies indicate widespread prevalence of food insecurity and metabolic syndrome in various regions of Iran. No studies have been conducted so far to investigate the relationship between food insecurity and the metabolic syndrome in Iran. This study was conducted to investigate the relationship between food insecurity and metabolic syndrome in women. Methods: In this study, 130 women 30 to 60 years old with metabolic syndrome as cases and 130 women without metabolic syndrome as controls referred to clinics affiliated to Shiraz University of Medical Sciences were selected. The USDA household food security questionnaire was used to assess food insecurity status. The metabolic syndrome was defined according to the criteria of the Adult Treatment Pane l II (ATP III). Results: The prevalence of food insecurity was 69.2% in cases and 45.4% in controls (P< 0.001). After multiple logistic regression and removal of potential confounders, food insecurity was significantly associated with metabolic syndrome (OR3.2&CI 95%: 1.9-5.6)(P<0.05). Conclusion: Given that food insecurity is an important risk factors for metabolic syndrome, Planners should reduce food insecurity in society, especially women through measures to improve the economic situation and dietary patterns of households.

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Background: Discordance (the presence of different categories of T scores in two skeletal sites of a single patient) can affect the physician’s decision to start medication or not. The present study was therefore conducted to assess the prevalence of T-score discordance between spine and femoral neck as well as its risk factors in a group of postmenopausal Iranian women. Methods: The present analytical cross sectional research was conducted based on the results of IROSTEOPs study on 8146 postmenopausal women referred to the bone mineral density (BMD) center of Shariati Hospital affiliated to Tehran University of Medical Sciences between 2000 and 2011. Based on their BMD results, the patients were categorized into three groups: Concordance and Minor and Major discordance. The factors affecting the risk of developing discordance was then studied through uni/and multivariate logistic regression. Results: Discordance between spine and femoral neck was reported in 3741 (45.9%) of the participants. Multivariate logistic regression revealed that older age, higher number of pregnancies and higher body mass index (BMI) are the main risk factors for T-score discordance at the studied sites. The use of hormonal replacement therapy (HRT) on the other hand played a protective role. Conclusion: It could be concluded that performing BMD at two different sites is necessary for the Iranian population, particularly postmenopausal women.