OBESITY AND METABOLIC SYNDROME
Fabiola MS A - John MF Adam
Division of Endocrinology and Metabolism Dept. of Internal Medicine, Faculty of Medicine Hasanuddin University Makassar 2012
OBESITY
OBESITY THE DEFINITION
Obesity is defined as a condition in which there is an excess of fat accumulation in adipose tissue, to the extend that health may be impaired (WHO, 2000) The operational definition of obesity and overweight are based on Body Mass Index (BMI), which is closely related with body fatness
PROPOSED CLASSIFICATION of WEIGHT by BMI for ASIAN ADULTS
Classification
Underweight
BMI (kg/m2)
< 18.5
Risk of co-morbidities Low ( but Increased risk of other clinical problems) Average Increase Moderate Severe
Normal Range Overweight At Risk Obese I Obese II
18.5 22.9 > 23 23 - 24.9 25 - 29.9 > 30
Regional Office for the Western Pacific of the World Organization, The International Association for the Study of Obesity, The International Obesity Task Force. The Asia-Pacific perspective: Redefining obesity and its treatment. WHO Collaborating Centre for the epidemiology of Diabetes and Health Promotion for Noncommunicable Disease, Melbourne 2000 JMFA 7
OBESITY BODY FAT DISTRIBUTION
It is not the amount of fat but also its distribution that determines the risk associated with obesity (WHO, 2000)
Android obesity (abdominal or visceral
or central obesity) Gynoid obesity (gluteal obesity)
OBESITY and BODY FAT DISTRIBUTION
In men, fat distribution tends to accumulate in the upper part of the body or Android obesity in the abdominal region Gynoid obesity (android obesity), while in women, it tends to accumulate in the peripheral part of the body or gluteofemoral region (gynoid obesity)
JMFA 9
It is not just the amount of fat,
determines the risk of co-morbidities in obese subjects
Large Insulin-Resistant Adipocytes
but the distribution of fat
Small Insulin-Sensitive Adipocytes
Android Obesity
Gynoid
Obesity
JMFA 10
OBESITY- MEASUREMENT
1. Body Mass Index
BMI
=
Weight in kg
(Height in meters)2
2. Body Fat Distribution Android type (central obesity = visceral obesity) Gineoid type
MEASUREMENT OF CENTRAL OBESITY
Imaging
Computed tomography scanning (CT-scan) Magnetic resonance imaging (MRI) Dual energy x-ray absorptiometry (DEXA) Anthropometric Waist-hip ratio (WHR) Waist circumference
MEASUREMENT OF CENTRAL OBESITY
CT-scanning MRI DEXA Waist circumference Waist-to-hip ratio
Waist
20 years
Hip BMI = 24 Waist = 80 cm Hip = 100 cm WH Ratio = 0.80
Desprs JP, dkk. BMJ 2001;322:716-720
BMI = 35 Waist = 100 cm Hip = 125 cm WH Ratio = 0.80
Individual/biological susceptibility Dietary and physical activity patterns
Intake
Fat CH
Protein
Energy regulation Expenditure
Activity
TEF BMR
Body fat stores
WHY IS OBESITY INCREASE IN THE DEVELOPING COUNTRIES ? In the last two decades, obesity is linked to the adopting of Western lifestyle, - increased ability of overconsumption of cheap energy-dense food - and a shift to decreased physical activity and more sedentary life
Fast food
Makassar
OBESITY A DISEASE ?
OBESITY IS OBESITY A DISEASE ?
There has been a debate if obesity is disease or just a risk factors for some diseases such as diabetes, hypertension, dyslipidemia, and cardiovascular disease In 1985 The National Institute of Health in US decided that obesity is a disease Even though, clinicians are more interest in the management of the comorbidities related to obesity such as hypertension, diabetes mellitus and dyslipidemia than treating obesity
PROPORTION of DISEASE PREVALENCE ATTRIBUTABLE to OBESITY
Type 2 diabetes Gallbladder disease Hypertension Coronary heart disease Osteoarthritis Breast cancer Ulterine cancer Colon cancer 57% 30% 17% 17% 14% 11% 11% 11%
6 5 Odds ratio 4 3 2 1 0
Men
Diabetes Hypertension Dyslipidemia Albuminuria
22
23
24
25
26
27
28
29
30
6 5 Odds ratio 4 3 2 1 0
Women
Diabetes Hypertension Dyslipidemia Albuminuria
BMI (kg/m2)
22
23
24
25 26 27 BMI (kg/m2)
28
29
BMI and diabetes, hypertension, dyslipidemia and microalbuminuria in China Hongkong. Ko GTC, Chan JCN, Woo J, Lau E, Yeung VTF, Chow C-C, Wai HPS, LI YKS, So W-Y, Cockram CS. Chinese. Int J Obes 1997; 21: 995-1001 2.
OBESITY THE TREATMENT Should we treat obesity ??
2.5 2 1.5 1 0.5 0
RelativerRisk of ill health
Low Risk
Moderate Risk
High Risk
20
25
30
35
Body Mass Index
4 3 2 1 0 5 4 3 2 1
150
170
200 210 220 230 240 250
290
Cholesterol (mg/dl)
75
80
85
90
95 100
105
110
115
120
Diastolic Blood Pressure Relationship of BMI, cholesterol, and blood pressure to risk of ill health. The vertical lines accepted subdivisions for low, moderate, and high risk. All three curves show a curvilinear increase with increasing level of risk factor Bray GA, et al. Handbook of obesity, 1998
TREATMENT OF OBESITY
Change of lifestyles
- Diet - Physical activity
Pharmacotherapy
- Orlistat (Xenical)
Surgery
EXERCISE
Nice try!! But not effective
OBESITY : TREATMENT GUIDELINES FOR BMI BMI
18.5 - 24.9 25.0 - 29.9 - without disease 25.0 - 29.9 - with disease 30.0 - 39.9 > 40
Treatment
No treatment, diet and exercise to maintain body weight
Hypocaloric diet and exercise to reduce body weight Hypocaloric diet and exercise, anti-obesity drug
Hypocaloric diet and exercise, antiobesity drug
Surgery
Physicians guide to the management of obesity with Xenical (4)
Sudden death is more common in those who are naturally fat than in the slender
Hippocrates 410 B.C.
Messerli et al Arch Intern Med 1987; 147: 1725 - 1728
JMFA 4
METABOLIC SYNDROME
Fabiola MS A - John MF Adam
Division of Endocrinology and Metabolism Dept. of Internal Medicine, Faculty of Medicine Hasanuddin University Makassar 2011
DEFINITION
Metabolic syndrome
is a constellation of lipid and nonlipid risk factors of metabolic origin. This syndrome is closely linked to a generalized metabolic disorder called insulin resistance in which the normal actions of insulin are impaired
CRITERIA of METABOLIC SYNDROME
WHO 1999 National Cholesterol Education Program, Adult Treatment Panel III, 2001
Modified NCEP-ATP III for Asian, 2001
International Diabetes Federation, 2005
World Health Organization, 1999
COMPONENTS OF THE METABOLIC SYNDROME
Glucose intolerance, impaired glucose tolerance (IGT) or diabetes mellitus and/or insulin resistance together with two or more of the following : Raised arterial pressure
Raised plasma triglycerides
Central obesity Microalbuminuria
World Health Organization. Definition, diagnosis and classification of diabetes mellitus and its complication. Part 1: Diagnosis and classification of diabetes mellitus. Department of Noncommunicable Disease Surveillance, World Health Organization, Geneva 1999
JMFA 22
CLINICAL IDENTIFICATION OF THE METABOLIC SYNDROME Modified NCEP ATP III 2001
for Asian Adults
Risk factor
Abdominal obesity* (waist circumference) Men Women Triglycerides High-density lipoprotein cholesterol Men Women Blood pressure Fasting glucose
Defining level
> 90 cm > 80 cm > 150 mg/dl < 40 mg/dl < 50 mg/dl > 130 / > 85 mmHg > 110 mg/dl
Metabolic syndrome > 3 risk factors
IDF Criteria of Metabolic Syndrome
Abdominal obesity*
(waist circumference)
Men Women > 90 cm > 80 cm > 150 mg/dl Men < 40 mg/dl
Plus two of the following :
Triglycerides HDL chol
Women
Blood pressure Fasting plasma glucose
< 50 mg/dl > 130 / > 85 mmHg
> 115 mg/dl
CENTRAL OBESITY AND METABOLIC SYNDROME
Diabetes mellitus / Impaired glucose tolerance
Central Obesity
Dyslipidaemia (HyperTG, low HDL-C)
Hypertension
JMFA 27
PREVALENCE OF METABOLIC SYNDROME
USA 22% of adult population, 47 million
In Asian countries as well as other developing countries metabolic syndrome suggest to be higher
In Makassar,
Adriansjah and Adam (2003) 30,8% among males Adam and Adriansjah (2003) difference between two criteria 24,2% NCEP-ATP III, 35,7% modified NCEP-ATP III
Age-Specific Prevalence of the Metabolic Syndrome Among 8,814 US Adults (Age > 20 Years)
(NHANES III, 1988-1994) Women
Men
50 Mean SE 40
Prevalence (%)
30
20 10 0
20-29
30-39
40-49
50-59
60-69
>70
Ford ES et al. JAMA 2002; 287: 356-359
WHY IS METABOLIC SYNDROME IMPORTANT?
Subjects with metabolic syndrome are high risk for: - diabetes mellitus - cardiovascular disease For these reasons, patients with MetS should be treated
Treatment modalities: - lifestyle modification, diet and exercise - treating the risk factors, lipid abnormalities, hypertension, hyperglycemia
TREATMENT OF METABOLIC SYNDROME
TREATMENT OF METABOLIC SYNDROME
Treatment of Diabetes Mellitus Treatment of Dyslipidemia
LDL-cholesterol, Triglycerides, HDLcholesterol
Treatment of Hypertension
Treatment of Obesity
Calorie restriction, Exercise, Pharmacotherapy
TREATMENT OF METABOLIC SYNDROME
Diabetes Mellitus
Dyslipidemia
Metformin, Thiozolidinedione
Statins, Fibrates
Hypertension
ACE inhibitor, ARB, Ca Channel blocker, HCT
