kuliah - obesity - metabolic syndrome 2012
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OBESITY
ANDMETABOLIC SYNDROME
Fabiola MS A - John MF Adam
Division of Endocrinology and MetabolismDept. of Internal Medicine, Faculty of MedicineHasanuddin University
Makassar 2012
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OBESITY
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Obesity is defined as a condition in whichthere is an excess of fat accumulation inadipose tissue, to the extend that healthmay be impaired (WHO, 2000)
The operational definition of obesity and over-weight are based on Body Mass Index
(BMI), which is closely related with bodyfatness
OBESITY THE DEFINITION
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Regional Office for the Western Pacific of the World Organization, The InternationalAssociation for the Study of Obesity, The International Obesity Task Force. The Asia-Pacificperspective: Redefining obesity and its treatment. WHO Collaborating Centre for theepidemiology of Diabetes and Health Promotion for Noncommunicable Disease, Melbourne2000
PROPOSED CLASSIFICATION of WEIGHT byBMI for ASIAN ADULTS
BMI (kg/m2) Risk of co-morbiditiesClassification
Underweight < 18.5 Low ( but Increased risk
of other clinical problems)
Normal Range 18.5
22.9 AverageOverweight > 23
At Risk 23 - 24.9 Increase
Obese I 25 - 29.9 Moderate
Obese II > 30 Severe
JMFA 7
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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)
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In men, fat distributiontends to accumulate in theupper part of the body or
in the abdominal region(android obesity), while inwomen, it tends toaccumulate in theperipheral part of the body
or gluteofemoral region(gynoid obesity)
Android obesity
Gynoid obesity
OBESITY and BODY FATDISTRIBUTION
JMFA 9
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It is not just the amount of fat,
but the distribution offat
determines the risk of co-morbidities in obese subjects
Large Insulin-ResistantAdipocytes Small Insulin-Sensitive
Adipocytes
AndroidObesity GynoidObesity
JMFA 10
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1. Body Mass Index
BMI =Weight in kg
(Height in meters)2
2. Body Fat Distribution
Android type (central obesity = visceralobesity)
Gineoid type
OBESITY-MEASUREMENT
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MEASUREMENT OF CENTRALOBESITY
Anthropometric
Waist-hip ratio (WHR)Waist circumference
Imaging
Computed tomography scanning (CT-scan)
Magnetic resonance imaging (MRI)Dual energy x-ray absorptiometry (DEXA)
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CT-scanningMRIDEXA
Waist circumferenceWaist-to-hip ratio
MEASUREMENT OF CENTRAL OBESITY
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http://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeg -
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Desprs JP, dkk. BMJ 2001;322:716-720
Waist
Hip
20 years
BMI = 35Waist = 100 cmHip = 125 cm
WH Ratio = 0.80
BMI = 24Waist = 80 cmHip =100 cm
WH Ratio = 0.80
http://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeghttp://bmj.com/content/vol322/issue7288/images/large/desj3114.f2.jpeg -
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Individual/biological
susceptibility
Dietary and physical
activity patterns
Energy regulation
Intake
Fat
CH
Protein
Activity
TEF
BMR
Expenditure
Body fat stores
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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 ofcheap energy-dense food
- and a shift to decreased physical activity
and more sedentary life
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Fast foodMakassar
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OBESITY -
A DISEASE ?
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There has been a debate if obesity is disease orjust a risk factors for some diseases such asdiabetes, hypertension, dyslipidemia, andcardiovascular disease
In 1985The National Institute of Health in USdecided that obesity is a disease
Even though, clinicians are more interest inthe management of the comorbiditiesrelated
to obesity such as hypertension, diabetesmellitus and dyslipidemia than treatingobesity
OBESITY IS OBESITY A DISEASE ?
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PROPORTION of DISEASE PREVALENCEATTRIBUTABLE to OBESITY
Type 2 diabetes 57%Gallbladder disease 30%
Hypertension 17%Coronary heart disease 17%Osteoarthritis 14%Breast cancer 11%
Ulterine cancer 11%Colon cancer 11%
Men
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Men
Oddsratio
BMI (kg/m2)
6
5
4
3
2
1
022 23 24 25 26 27 28 29 30
Diabetes
Hypertension
Dyslipidemia
Albuminuria
Oddsratio
BMI (kg/m2)
Women6
5
4
3
21
022 23 24 25 26 27 28 29
Diabetes
Hypertension
Dyslipidemia
Albuminuria
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 JObes 1997; 21: 995-1001 2.
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OBESITY
THE TREATMENTShould we treat obesity ??
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2.52
1.51
0.50
Low
Risk
Moderate
RiskHigh
Risk
20 25 30 35Body Mass Index
4
3
2
10
150 170 200 210 220 230 240 250 290
Cholesterol (mg/dl)RelativerRiskofillhealth
54
3
21
Diastolic Blood Pressure
75 80 85 90 95 100 105 110 115 120
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
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TREATMENT OF OBESITY
Change of lifestyles
- Diet
- Physical activity
Pharmacotherapy
- Orlistat (Xenical)
Surgery
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EXERCISE
Nice try!! But not effective
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OBESITY : TREATMENT GUIDELINES FOR BMI
BMI Treatment
18.5 - 24.9
25.0 - 29.9
- without disease
25.0 - 29.9
- with disease
30.0 - 39.9
> 40
No treatment, diet and exercise to maintain
body weight
Hypocaloric diet and exercise to reducebody weight
Hypocaloric diet and exercise, anti-obesitydrug
Hypocaloric diet and exercise, anti-
obesity drugSurgery
Physicians guide to the management of obesity with Xenical (4)
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Sudden death is more common in thosewho are naturally fat than in the slender
Hippocrates 410 B.C.
Messerli et al Arch Intern Med 1987; 147: 1725 - 1728 JMFA 4
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DEFINITION
Metabolic syndrome is a
constellation of lipid and nonlipidrisk factors of metabolic origin.
This syndrome is closely linked
to a generalized metabolic
disorder called insulin resistancein which the normal actions of
insulin are impaired
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WHO 1999
National Cholesterol Education Program,Adult Treatment Panel III, 2001Modified NCEP-ATP III for Asian, 2001
International Diabetes Federation, 2005
CRITERIAof METABOLIC SYNDROME
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CLINICAL IDENTIFICATION OF THE METABOLIC
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CLINICAL IDENTIFICATION OF THE METABOLICSYNDROME Modified NCEP ATP III 2001for Asian Adults
Metabolic syndrome > 3 risk factors
Risk factor Defining level
Abdominal obesity*(waist circumference)
Men > 90 cmWomen > 80 cm
Triglycerides > 150 mg/dlHigh-density lipoprotein
cholesterol
Men < 40 mg/dlWomen < 50 mg/dlBlood pressure > 130 / > 85 mmHgFasting glucose > 110 mg/dl
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IDF Criteriaof Metabolic Syndrome
> 150 mg/dl
< 40 mg/dl
< 50 mg/dl> 130 / > 85 mmHg
> 115 mg/dl
Abdominal obesity*
(waist circumference)
Men
Women
Plus two of the following :
Triglycerides
HDL chol Men
WomenBlood pressure
Fasting plasma glucose
> 90 cm
> 80 cm
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CENTRAL OBESITY ANDMETABOLIC SYNDROME
Hypertension
Diabetes mellitus /Impaired glucose tolerance
Dyslipidaemia(HyperTG, low HDL-C)
CentralObesity
JMFA 27
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PREVALENCE OF METABOLIC SYNDROME
USA 22% of adult population, 47 million
In Asian countries as well as other developingcountries metabolic syndrome suggest to be higher
In Makassar,
Adriansjah and Adam (2003) 30,8% among males
Adam and Adriansjah (2003) difference betweentwo criteria 24,2% NCEP-ATP III, 35,7%modified NCEP-ATP III
A S ifi P l f th M t b li S d
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Prevalence(%
)
20
20-29 30-39 40-49 50-59 60-69 >70
10
40
30
50
0
Ford ES et al. JAMA 2002; 287: 356-359
Age-Specific Prevalence of the Metabolic SyndromeAmong 8,814 US Adults (Age > 20 Years)
(NHANES III, 1988-1994)
WomenMen
Mean SE
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Subjects with metabolic syndrome are high risk for:
- diabetes mellitus
- cardiovascular diseaseFor these reasons, patients with MetS should be treated
Treatment modalities:
- lifestyle modification, diet and exercise- treating the risk factors, lipid abnormalities,
hypertension, hyperglycemia
WHY IS METABOLIC SYNDROMEIMPORTANT?
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TREATMENT OFMETABOLIC SYNDROME
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Diabetes MellitusMetformin, Thiozolidinedione
TREATMENT OF METABOLIC SYNDROME
DyslipidemiaStatins, Fibrates
Hypertension
ACE
inhibitor, ARB, Ca
Channel blocker, HCT
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