XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Obesity has become a major worldwide health problem. In every single country in the world, the incidence of obesity is rising continuously and therefore, the associated morbidity, mortality and both medical and economical costs are expected to increase as well. The majority of these complications are related to co-morbid conditions that include coronary artery disease, hypertension, type 2 diabetes mellitus, respiratory disorders and dyslipidemia. Obesity increases cardiovascular risk through risk factors such as increased fasting plasma triglycerides, high LDL cholesterol, low HDL cholesterol, elevated blood glucose and insulin levels and high blood pressure. Novel lipid dependent, metabolic risk factors associated to obesity are the presence of the small dense LDL phenotype, postprandial hyperlipidemia with accumulation of atherogenic remnants and hepatic overproduction of apoB containing lipoproteins. All these lipid abnormalities are typical features of the metabolic syndrome and may be associated to a pro-inflammatory gradient which in part may originate in the adipose tissue itself and directly affect the endothelium. An important link between obesity, the metabolic syndrome and dyslipidemia, seems to be the development of insulin resistance in peripheral tissues leading to an enhanced hepatic flux of fatty acids from dietary sources, intravascular lipolysis and from adipose tissue resistant to the antilipolytic effects of insulin. The current review will focus on these aspects of lipid metabolism in obesity and potential interventions to treat the obesity related dyslipidemia.

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Dyslipidemia in Obesity: Mechanisms and Potential Targets

The traditional role of food packaging is continuing to evolve in response to changing market needs. Current drivers such as consumer's demand for safer, "healthier," and higher-quality foods, ideally with a long shelf-life; the demand for convenient and transparent packaging, and the preference for more sustainable packaging materials, have led to the development of new packaging technologies, such as active packaging (AP). As defined in the European regulation (EC) No 450/2009, AP systems are designed to "deliberately incorporate components that would release or absorb substances into or from the packaged food or the environment surrounding the food." Active packaging materials are thereby "intended to extend the shelf-life or to maintain or improve the condition of packaged food." Although extensive research on AP technologies is being undertaken, many of these technologies have not yet been implemented successfully in commercial food packaging systems. Broad communication of their benefits in food product applications will facilitate the successful development and market introduction. In this review, an overview of AP technologies, such as antimicrobial, antioxidant or carbon dioxide-releasing systems, and systems absorbing oxygen, moisture or ethylene, is provided, and, in particular, scientific publications illustrating the benefits of such technologies for specific food products are reviewed. Furthermore, the challenges in applying such AP technologies to food systems and the anticipated direction of future developments are discussed. This review will provide food and packaging scientists with a thorough understanding of the benefits of AP technologies when applied to specific foods and hence can assist in accelerating commercial adoption.

Active Packaging Applications for Food.

In a time where the public is more aware and interested with what they eat, natural additives have been gaining interest both from the food industries and the consumers. Some studies show that consumers prefer food prepared with natural additives rather than chemical ones, due to health reasons. Although quite promising, natural additives still face some drawbacks and limitations as well as conflicting information. In this manuscript, the most important natural additives are overviewed, as well as their use, benefits and risks. The future of these molecules along with new types of additives is also summarized.

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Natural food additives: Quo vadis?

Foods contamination leading to spoilage and growth of pathogenic microorganisms can happen when exposed to environment during slaughtering, processing, packaging and shipping. Although traditional food preservation methods such as drying, heating, freezing, fermentation and salting can extend food shelf-life, it is not consummate especially to inhibit the growth of pathogenic microorganisms that may endanger consumers' health. Antimicrobial packaging is a novel development that incorporates antimicrobial agent into polymer film to suppress the activities of targeted microorganisms. However, antimicrobial packaging is still an extremely challenging technology and there are only a few commercialized products found in the market. This review focuses on analyzing the antimicrobial agent development for the past decades till recent technology. The information about performance of antimicrobial packaging such as microbiology performance and physico-mechanical properties of the packaging film were discussed. It is expected such information would provide an overview as well as promote the development of antimicrobial packaging in the food related field and industry.

Antimicrobial agents for food packaging applications

O estresse oxidativo decorre de um desequilibrio entre a geracao de compostos oxidantes e a atuacao dos sistemas de defesa antioxidante. A geracao de radicais livres e/ou especies reativas nao radicais e resultante do metabolismo de oxigenio. A mitocondria, por meio da cadeia transportadora de eletrons, e a principal fonte geradora. O sistema de defesa antioxidante tem a funcao de inibir e/ou reduzir os danos causados pela acao deleteria dos radicais livres e/ou especies reativas nao radicais. Esse sistema, usualmente, e dividido em enzimatico (superoxido dismutase, catalase e glutationa peroxidase) e nao-enzimatico. No ultimo caso, e constituido por grande variedade de substâncias antioxidantes, que podem ter origem endogena ou dietetica. Objetivou-se revisar os principais mecanismos de geracao de radicais livres, bem como a acao dos agentes mais relevantes do sistema de defesa antioxidante, ressaltando suas implicacoes sobre os marcadores do estresse oxidativo. Tambem serao abordados os principais fatores exogenos moduladores do estresse oxidativo.

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Estresse oxidativo: conceito, implicações e fatores modulatórios

Antimicrobial efficiency of film incorporated with pediocin (ALTA® 2351) on preservation of sliced ham.

Os fenomenos puberais apresentam variabilidade no que diz respeito as idades de inicio e termino, a velocidade e magnitude com que se expressam e as suas inter-relacoes. Tais fenomenos influenciam as modificacoes antropometricas e de composicao corporal que caracterizam o processo de crescimento e desenvolvimento da adolescencia. O artigo tem como objetivo analisar a influencia dos estagios de maturacao sexual, no estado nutricional, antropometria e composicao corporal de adolescentes de ambos os sexos. A revisao de literatura foi realizada utilizando-se os termos "Adolescent, Puberty and Body Composition", por meio de consulta na base de dados do HighWire Press®. Trabalhou-se com artigos publicados desde janeiro de 1995 ate julho de 2006, incluindo, outros relevantes ao tema, publicados anteriormente. Na adolescencia, para se avaliar o estado nutricional e as modificacoes antropometricas e de composicao corporal, e de extrema importância a consideracao nao somente da idade cronologica, mas tambem do estagio de maturacao sexual. Cabe ressaltar as consideraveis dificuldades metodologicas existentes nos estudos acerca do estadiamento pubertario. Destaca-se a importância da realizacao de mais estudos, no sentido de elucidar a influencia dos estagios de maturacao sexual na evolucao dos parâmetros antropometricos e de composicao corporal, possibilitando a construcao e utilizacao sistematica de referencias que considerem o desenvolvimento pubertario.

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Influência dos estágios de maturação sexual no estado nutricional, antropometria e composição corporal de adolescentes

Past research has shown the importance of zinc in several metabolic processes, such as the glucidic metabolism. The present systematic review aims to discuss zinc’s participation in the glycemic control of type 2 diabetes mellitus (DM2) patients. In order to accomplish that, a systematic search was performed in the Pubmed database using the following indexed and theme-related descriptors: “zinc” AND “type 2 diabetes mellitus”, AND MeSH terms related to glycemic control combined with the boolean operator OR. In total, 1078 articles were retrieved from the research, of which 15 articles of original studies conducted with DM2 patients were included, with three being about the effect of mineral supplementation and 12 reporting observational studies. The main findings of these studies consisted of low body contents of zinc and high excretion of zinc in urine. Hyperglycemia was one of the mechanisms that caused these alterations owing to its interference in zinc reabsorption via renal cells. Another evidence was the negative correlation between the glycated hemoglobin percentage (%HbA1c) and the plasma zinc levels. Additionally, it has been observed that zinc supplementation in DM2 patients has improved glycemic control, since the %HbA1c significantly reduced in these individuals. This present review shows the positive effect of adequate zinc levels on glycemic control, whether it is through dietetic ingestion or supplementation, since its role in insulin homeostasis is clear.

Zinc’s role in the glycemic control of patients with type 2 diabetes: a systematic review

Oxidative stress is related to an imbalance between the production of reactive species and the antioxidant defenses. In essence, oxidative stress has been defined as a disturbance in the pro-oxidant/antioxidant balance, leading to potential damage. It has been suggested that oxidative stress is involved in the etiology of several chronic diseases including cardiovascular disease, diabetes, cancer and neurodegenerative processes. The antioxidant defenses include nonenzymatic (especially dietary antioxidants) and antioxidant enzymes. Vitamins, minerals and phytochemicals (polyphenols and carotenoids) are among the major dietary antioxidants. The assessment of oxidative stress status though specific biomarkers has acquired great importance. The major biomarkers include the products of the attack of free radicals and reactive species to various substrates: lipids, proteins and nucleic acids. Measurement of antioxidant capacity may also involve the assessment of specific oxidative stress biomarkers. Most of the studies that have examined the association between diet and oxidative stress consider the effects of antioxidant supplements (vitamins and minerals), drinks and foods with bioactive compounds or dietary patterns on oxidative stress biomarkers. Some of these studies have demonstrated beneficial results on oxidative stress markers. However, the role of diet on oxidative stress biomarkers remains unclear and represents a potentially fruitful area for further research in the health area.

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Kiriaque Barra Ferreira Barbosa

Papers

Estresse oxidativo: conceito, implicações e fatores modulatórios

Antimicrobial efficiency of film incorporated with pediocin (ALTA® 2351) on preservation of sliced ham.

Influência dos estágios de maturação sexual no estado nutricional, antropometria e composição corporal de adolescentes

Zinc’s role in the glycemic control of patients with type 2 diabetes: a systematic review

Influence of dietary intake on plasma biomarkers of oxidative stress in humans