Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC J4CvqMLTf3xxkpD6Q3rgfdk S0066-782X2023000400205 00205 10.36660/abc.20230182 Minieditorial O Jejum Intermitente Associado a Dieta Low-Carb pode Prevenir Doenças Cardiovasculares em Pré-Diabéticos? 0000-0001-7235-9467 Aranha Luciana Nicolau 1 Programa de Pós–Graduação em Medicina Universidade Federal do Rio de Janeiro Rio de Janeiro RJ Brasil Programa de Pós–Graduação em Medicina (Cardiologia) da Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ – Brasil Mailing Address: Luciana Nicolau Aranha •Universidade Federal do Rio de Janeiro - Programa de Pós-Graduação de Medicina - Hospital Universitário Clementino Fraga Filho – UFRJ - Rua Prof. Rodolpho P. Rocco, 255 - 8º andar - sala 6. Postal Code 21941-913, Cidade Universitária, Rio de Janeiro, RJ – Brazil E-mail: luciana_nicolau@hotmail.com 01 05 2023 2023 120 4 e20230182 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Estado Pré-Diabético Jejum Dieta Pobre em Carboidratos Estilo de Vida Atividade Física Exercício Restrição Calórica

Pré-diabetes é o termo utilizado para descrever indivíduos que apresentam o metabolismo da glicose alterado, no entanto não atendem aos critérios diagnósticos de diabetes.1Pessoas com pré-diabetes têm um risco aumentando de diabetes mellitus tipo 2 (DMT2), doença cardiovascular (DCV) e mortalidade por todas as causas.1,2

A modificação no estilo de vida, incluindo dieta e prática regular de atividade física tem se mostrado efetiva na prevenção de diabetes e DCV.3Para promover perda de peso e controle glicêmico, algumas abordagens nutricionais têm sido utilizadas. O jejum intermitente é uma prática alimentar que envolve a restrição do consumo de calorias durante um período controlado, seguido do consumo calórico ad libitum.4 A dieta restrita em carboidratos, conhecida como low-carb é caracterizada pela ingestão de carboidratos abaixo do limite inferior da faixa aceitável de distribuição de macronutrientes para adultos saudáveis (ou seja, < 45% da ingestão de energia).5

Nesta edição dos Arquivos Brasileiros de Cardiologia foi publicado um estudo para analisar os benefícios do jejum intermitente associado a dieta low-carb em resultados micro e macrovasculares em pré-diabéticos.6 O estudo acompanhou por 2 anos pacientes pré-diabéticos que foram randomizados em 2 grupos: grupo I que realizou jejum intermitente (16 h - 3-4 dias por semana) acompanhado da ingestão de baixo teor de carboidratos (<26% da ingestão total de energia) e grupo II com ingestão calórica ad libitum. No final do acompanhamento os autores observaram menor peso corporal, índice de massa corporal, circunferência da cintura, percentual de gordura corporal, hemoglobina glicada e menor incidência de progressão para diabetes no grupo I. O grupo II apresentou aumento na incidência de complicações micro e macrovasculares na forma de retinopatia, neuropatia e angina instável.6

De acordo com esses resultados, a combinação de jejum intermitente com dieta low-carb pode ser capaz de prevenir DMT2 e DCV em pré-diabéticos.6 Outros estudos que combinaram estas estratégias alimentares também observaram resultados semelhantes.7,8 Apesar dos achados promissores, faltam evidências que comprovem a eficácia e segurança da utilização do jejum intermitente associado a dieta low-carb em pré-diabéticos, o que limita a generalização dos resultados. É importante enfatizar que estas práticas alimentares podem não ser adequadas para todos os indivíduos, sendo fundamental o acompanhamento por um profissional de saúde, que deverá adequar a dieta ao perfil de cada paciente, considerando os hábitos alimentares, o estado nutricional e as condições de saúde.

As diretrizes têm enfatizado para prevenção de diabetes e DCV em pré-diabéticos a importância de um padrão alimentar saudável, contendo vegetais, frutas, legumes e grãos integrais, bem como a escolha por fontes saudáveis de proteína e por alimentos in natura e minimamente processados, logo, vários padrões alimentares podem ser considerados Além disso, recomenda-se individualizar os planos alimentares com a distribuição de macronutrientes mais consistente com a preferência pessoal e a ingestão habitual para aumentar a probabilidade de manutenção a longo prazo.9

Referências 1. Sayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, et al. 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023. Diabetes Care. 2023 Jan 1;46(Suppl 1):S19-S40. doi: 10.2337/dc23-S002 Sayed NA Aleppo G Aroda VR Bannuru RR Brown FM Bruemmer D et al 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023 Diabetes Care 2023 01 1 46 Suppl 1 S19 S40 10.2337/dc23-S002 2. Cai X, Zhang Y, Li M, Wu JH, Mai L, Li J, et al. Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis. BMJ. 2020 Jul 15;370:m2297. doi: https://doi.org/10.1136/bmj.m2297 Cai X Zhang Y Li M Wu JH Mai L Li J et al Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis BMJ 2020 07 15 370 m2297 https://doi.org/10.1136/bmj.m2297 3. Gong Q, Zhang P, Wang J, Ma J, An Y, Chen Y, et al. Morbidity and mortality after lifestyle intervention for people with impaired glucose tolerance: 30-year results of the Da Qing Diabetes Prevention Outcome Study. Lancet Diabetes Endocrinol. 2019 Jun;7(6):452-61. doi: 10.1016/S2213-8587(19)30093-2 Gong Q Zhang P Wang J Ma J An Y Chen Y et al Morbidity and mortality after lifestyle intervention for people with impaired glucose tolerance: 30-year results of the Da Qing Diabetes Prevention Outcome Study Lancet Diabetes Endocrinol 2019 06 7 6 452 461 10.1016/S2213-8587(19)30093-2 4. Chair SY, Cai H, Cao X, Qin Y, Cheng HY, Ng MT. Intermittent Fasting in Weight Loss and Cardiometabolic Risk Reduction: A Randomized Controlled Trial. J Nurs Res. 2022 Feb 1;30(1):e185. DOI: 10.1097/jnr.0000000000000469 Chair SY Cai H Cao X Qin Y Cheng HY Ng MT Intermittent Fasting in Weight Loss and Cardiometabolic Risk Reduction: A Randomized Controlled Trial J Nurs Res 2022 02 1 30 1 e185 10.1097/jnr.0000000000000469 5. Kirkpatrick CF, Bolick JP, Kris-Etherton PM, Sikand G, Aspry KE, Soffer DE, et al. Review of current evidence and clinical recommendations on the effects of low-carbohydrate and very-low-carbohydrate (including ketogenic) diets for the management of body weight and other cardiometabolic risk factors: A scientific statement from the National Lipid Association Nutrition and Lifestyle Task Force. J Clin Lipidol. 2019 Sep-Oct;13(5):689-711.e1. doi: 10.1016/j.jacl.2019.08.003. Kirkpatrick CF Bolick JP Kris-Etherton PM Sikand G Aspry KE Soffer DE et al Review of current evidence and clinical recommendations on the effects of low-carbohydrate and very-low-carbohydrate (including ketogenic) diets for the management of body weight and other cardiometabolic risk factors: A scientific statement from the National Lipid Association Nutrition and Lifestyle Task Force J Clin Lipidol 2019 Sep-Oct 13 5 689 711.e1 10.1016/j.jacl.2019.08.003 6. Mohamed Khalfallah, Basma Elnagar, Shaimaa S. Soliman, Ahmad Eissa, Amany Allaithy. The Value of Intermittent Fasting and Low Carbohydrate Diet in Prediabetic Patients for the Prevention of Cardiovascular Diseases. Arq Bras Cardiol. 2023; 120(4):e20220606 Khalfallah Mohamed Elnagar Basma Soliman Shaimaa S. Eissa Ahmad Allaithy Amany The Value of Intermittent Fasting and Low Carbohydrate Diet in Prediabetic Patients for the Prevention of Cardiovascular Diseases Arq Bras Cardiol 2023 120 4 e20220606 7. Kalam F, Gabel K, Cienfuegos S, Wiseman E, Ezpeleta M, Steward M, et al. Alternate day fasting combined with a low-carbohydrate diet for weight loss, weight maintenance, and metabolic disease risk reduction. Obes Sci Pract. 2019 Sep 13;5(6):531-9. doi: 10.1002/osp4.367. Kalam F Gabel K Cienfuegos S Wiseman E Ezpeleta M Steward M et al Alternate day fasting combined with a low-carbohydrate diet for weight loss, weight maintenance, and metabolic disease risk reduction Obes Sci Pract 2019 09 13 5 6 531 539 10.1002/osp4.367 8. O’Driscoll T, Minty R, Poirier D, Poirier J, Hopman W, et al. New obesity treatment: Fasting, exercise and low carb diet - The NOT-FED study. Can J Rural Med. 2021 Apr-Jun;26(2):55-60 DOI: 10.4103/CJRM.CJRM_1_20 O’Driscoll T Minty R Poirier D Poirier J Hopman W et al New obesity treatment: Fasting, exercise and low carb diet - The NOT-FED study Can J Rural Med 2021 Apr-Jun 26 2 55 60 DOI 10.4103/CJRM.CJRM_1_20 9. ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, et al. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023. Diabetes Care. 2023 Jan 1;46(Suppl 1):S68-S96. doi:https://doi.org/10.2337/dc23-Sint ElSayed NA Aleppo G Aroda VR Bannuru RR Brown FM Bruemmer D et al Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023 Diabetes Care 2023 01 1 46 Suppl 1 S68 S96 https://doi.org/10.2337/dc23-Sint Short Editorial Can Intermittent Fasting Associated with a Low-Carb Diet Prevent Cardiovascular Disease in Pre-Diabetics? 0000-0001-7235-9467 Aranha Luciana Nicolau 1 Brasil Programa de Pós–Graduação em Medicina (Cardiologia) da Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ – Brasil Mailing Address: Luciana Nicolau Aranha • Universidade Federal do Rio de Janeiro - Programa de Pós-Graduação de Medicina – Hospital Universitário Clementino Fraga Filho – UFRJ - Rua Prof. Rodolpho P. Rocco, 255 - 8º andar - sala 6. Postal Code 21941-913, Cidade Universitária, Rio de Janeiro, RJ – Brazil E-mail: luciana_nicolau@hotmail.com Prediabetic State Fasting Diet Low-Carbohydrate Life Style Physical Activity Exercise Caloric Restriction

Pre-diabetes is the term used to describe individuals who have altered glucose metabolism but do not meet the diagnostic criteria for diabetes.1 People with pre-diabetes have an increased risk of type 2 diabetes mellitus (DM2), cardiovascular disease (CVD), and all-cause mortality.1,2

Lifestyle changes, including diet and regular physical activity, are effective in preventing diabetes and CVD.3 Some nutritional approaches have been used to promote weight loss and glycemic control. Intermittent fasting is a dietary practice restricting calorie consumption during a controlled period, followed by ad libitum caloric consumption.4 A carbohydrate-restricted diet, known as low-carb, is characterized by carbohydrate intake below the lower limit of an acceptable macronutrient distribution range for healthy adults (i.e., < 45% of energy intake).5

A study was published in the Arquivos Brasileiros de Cardiologia to analyze the benefits of intermittent fasting associated with a low-carb diet in micro and macrovascular results in pre-diabetics.6The study followed for 2 years pre-diabetic patients who were randomized into 2 groups: group I, who performed intermittent fasting (16 h - 3-4 days a week) followed by low carbohydrate intake (<26% of total energy), and group II with ad libitum caloric intake. At the end of the follow-up, the authors observed lower body weight, body mass index, waist circumference, percentage of body fat, glycated hemoglobin, and a lower incidence of progression to diabetes in group I. Group II showed increased micro and macrovascular complications such as retinopathy, neuropathy, and unstable angina.6

According to these results, combining intermittent fasting with a low-carb diet may prevent T2DM and CVD in pre-diabetics.6 Other studies that combined these dietary strategies also observed similar results.7,8 Despite the promising findings, there is a lack of evidence proving the effectiveness and safety of using intermittent fasting associated with a low-carb diet to reduce cardiovascular risk in pre-diabetics, which limits the generalization of the results. It is important to emphasize that these dietary practices may not be appropriate for all individuals, and it is essential to be monitored by a health professional, who will adjust the diet to the profile of each patient, considering the eating habits, nutritional status, and health conditions.

Guidelines have been emphasized for preventing diabetes and CVD in pre-diabetics, and the importance of a healthy dietary pattern containing vegetables, fruits, legumes and whole grains, as well as choosing healthy sources of protein and fresh and minimally processed foods, In addition, it is recommended to individualize eating plans with the distribution of macronutrients more consistent with personal preference and usual intake to increase the likelihood of long-term maintenance.9