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