determinants and dynamics of the cvd epidemic in the developing countries data from south asian...
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Determinants and dynamics of the CVD Epidemic in the developing
Countries Data from South Asian Immigrant studies
• Excess, early, and extensive CHD in persons of South Asian origin
• The excess mortality has not been fully explained by the major conventional risk factors.
• Diabetes mellitus and impaired glucose tolerance highly prevalent. (Reddy KS, circ 1998).
• Central obesity, ↑triglycerides, ↓HDL with or without glucose intolerance, characterize a phenotype.
• genetic factors predispose to ↑lipoprotein(a) levels, the central obesity/glucose intolerance/dyslipidemia complex collectively labeled as the “metabolic syndrome”
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Determinants and dynamics of the CVD epidemic in the developing
countries
Other Possible factors
• Relationship between early life characteristics and susceptibility to NCD in adult hood ( Barker’s hypothesis) (Baker DJP,BMJ,1993)
– Low birth weight associated with increased CVD
– Poor infant growth and CVD relation
•Genetic–environment interactions(Enas EA, Clin. Cardiol. 1995; 18: 131–5)
- Amplification of expression of risk to some environmental changes esp. South Asian population)
- Thrifty gene (e.g. in South Asians)
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CVD epidemic in developing &developed countries. Are they
same?• Urban populations have higher levels of CVD risk
factors related to diet and physical activity (overweight, hypertension, dyslipidaemia and diabetes)
• Tobacco consumption is more widely prevalent in rural population
• The social gradient will reverse as the epidemics mature.
• The poor will become progressively vulnerable to the ravages of these diseases and will have little access to the expensive and technology-curative care.
• The scarce societal resources to the treatment of these disorders dangerously depletes the resources available for the ‘unfinished agenda’ of infectious and nutritional disorders that almost exclusively afflict the poor
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Burden of CVD in Pakistan
Coronary heart disease
Mortality statistics • Specific mortality data ideal for making
comparisons with other countries are not available
• Inadequate and inappropriate death certification, and multiple concurrent causes of death
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Central obesity: a driving force for cardiovascular disease & diabetes
“Balzac” by RodinFront
Back
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Developing A New Definition of the Metabolic Syndrome: IDF Objectives
Needs:
• To identify individuals at high risk of developing
cardiovascular disease (and diabetes)
• To be useful for clinicians
• To be useful for international comparisons
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The new IDF definition focusses on abdominal obesity
rather than insulin resistance
International Diabetes Federation (IDF) Consensus Definition 2005
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Why people physically inactive?
• Lack of awareness regarding the of physical activity for health fitness and prevention of diseases
• Social values and traditions regarding physical
exercise (women, restriction).
• Non-availability public places suitable for physical activity (walking and cycling path, gymnasium).
• Modernization of life that reduce physical activity (sedentary life, TV, Computers, tel, cars).
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Insulin Resistance: Associated Conditions
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Prevalence of the Metabolic Syndrome Among US Adults NHANES 1988-1994Prevalence of the Metabolic Syndrome Among US Adults NHANES 1988-1994
Pre
vale
nc
e (
%)
P
reva
len
ce
(%
)
05
10
15
2025
3035
40
45
20-29 30-39 40-49 50-59 60-69 > 70
MenMenWomenWomen
Age (years)Age (years)Ford E et al. JAMA. 2002(287):356.Ford E et al. JAMA. 2002(287):356.
1999-2002 Prevalence by IDF vs. NCEP Definitions (Ford ES, Diabetes Care 2005; 28: 2745-9) (unadjusted, age 20+)NCEP : 33.7% in men and 35.4% in women IDF: 39.9% in men and 38.1% in women
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Prevention of CVD
• There is an urgent need to establish appropriate research studies, increase awareness of the CVD burden, and develop preventive strategies.
• Prevention and treatment strategies that have been proven to be effective in developed countries should be adapted for developing countries.
• Prevention is the best option as an approach to reduce CVD burden.
• Do we know enough to prevent this CVD Epidemic in the first place.
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The new IDF definition focusses on
abdominal obesity rather than insulin
resistance
International Diabetes Federation (IDF) Consensus Definition 2005
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International Diabetes Federation (IDF) Consensus Definition 2005
Central Obesity
Waist circumference – ethnicity specific*
– for Europids: Male > 94 cm
Female > 80 cm
plus any two of the following:
Raised triglycerides> 150 mg/dL (1.7 mmol/L)
or specific treatment for this lipid abnormality
Reduced HDL cholesterol< 40 mg/dL (1.03 mmol/L) in males
< 50 mg/dL (1.29 mmol/L) in females
or specific treatment for this lipid abnormality
Raised blood pressureSystolic : > 130 mmHg or
Diastolic: > 85 mmHg or
Treatment of previously diagnosed hypertension
Raised fasting plasma glucose
Fasting plasma glucose > 100 mg/dL (5.6 mmol/L) or
Previously diagnosed type 2 diabetes
If above 5.6 mmol/L or 100 mg/dL, OGTT is strongly recommended but is not necessary to define presence of the syndrome.
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Treatment of Metabolic Syndrome: 2005
AspirinDiet,
Exercise, Lifestyle
change
Stop smoking
CB1 Receptor Blocker
Oral hypoglycaemics
Antihypertensives
Statins & Fibrates
Insulin
ACEI &/or A2 receptor blockers
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Primary management for the Metabolic Syndrome is healthy lifestyle promotion. This includes:
• moderate calorie restriction (to achieve a 5-10% loss of body weight in the first year)
• moderate increases in physical activity
• change dietary composition to reduce saturated fat and total intake, increase fibre and, if appropriate, reduce salt intake.
Recommendations for treatment
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• Appropriate & aggressive therapy is essentialfor reducing patient risk of cardiovascular disease
• Lifestyle measures should be the first action
• Pharmacotherapy should have beneficial effects on– Glucose intolerance/diabetes– Obesity– Hypertension– Dyslipidaemia
• Ideally, treatment should address all of the components of the syndrome and not the individual components
Management of the Metabolic Syndrome
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Summary: new IDF definition for the Metabolic Syndrome
The new IDF definition addresses both clinical and research needs :
•provides a simple entry point for primary care physicians to diagnose the Metabolic Syndrome
•providing an accessible, diagnostic tool suitable for worldwide use, taking into account
ethnic differences
•establishing a comprehensive ‘platinum standard’ list of additional criteria that should
be included in epidemiological studies and other research into the Metabolic Syndrome
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Lifestyle modification
• Diet• Exercise• Weight loss• Smoking
cessation
If a 1% reduction in HbA1c is achieved, you could
expect a reduction in risk of:
• 21% for any diabetes-related endpoint
• 37% for microvascular complications
• 14% for myocardial infarction
However, compliance is poor and most patients will require oral pharmacotherapy within a few years of diagnosis
Stratton IM et al. BMJ 2000; 321: 405–412.