THE METABOLIC SYNDROME

THE NEW IDF DEFINTION

and

THE SOCIO-ECONOMIC BURDEN

Prof. Morsi Arab

University of Alexandria

IDF Chairman EMME Region

THE SIMPLE CONCEPT OF THE METABOLIC SYNDROME ( MTS )

The Metabolic Syndrome is a cluster of the mostdangerous risk factors for heart attack:

- diabetes / raised fasting plasma glucose,+

- abdominal obesity , - high blood pressure

- defective Cholesterol Metab.

GLOBAL SIZE OF THE ( MTS ) PROBLEM

20-25 % of the world adult population have the metabolic syndrome ( MTS) , and these are:

- twice likely to die

- 3 times likely to have a heart attack

or stroke

- 5 times at risk to develop diabetes type 2

THE CV RISK IN DIABETES AND IN THE METABOLIC SYNDROME ( MTS)

Diabetes is the leading cause of CVD

The existence of Metabolic Syndrome confers an additional risk for CVD

The more components of MTS the higher the CVD risk and mortality

The MTS , even before the diagnosis of diabetes , increases the risk and mortality of CVD

Causative Factors in the Metabolic Syndrome

The Two significant factors: )Insulin Resistance( and ( Central Obesity )

Other possible Factors: - Genetics

- physical inactivity - aging

- a pro inflammatory state - a hormonal state

) These may play variable roles in different ethnic groups(

“Obesity” is always involved , or associated with all elements of the Metabolic

Syndrome: Obesity is associated with Insulin Resistance

Obesity contributes to hypertension – high Cholesterol – low HDL Cholesterol -

hyperglycemia and type 2 diabetes

Obesity is associated with a high CVD risk

But Which type of Obesity?

“Abdominal Obesity “ as measured by waist

circumference is more indicative of the

Metabolic Syndrome profile than increased BMI

Historical Context: - 250 ys ago , Morgagni : associated visceral ob.

- HT - atheroscl - uric ac. - obstruct. sleep apena.

- 1947 Vague ( France ) : Android obesity. - 1960 : Plurimetabolic Syndrome ) ob+ diab + bld lipids + risk CHD( .

- 1980 : Syndrome X : glucose & insulin metab + + obesity + HT + dyslipidemia

Reavan : Insulin sensitivity - risk CHD - insulin resistance

Historical ( cont.) -1998 : WHO definition

: - EGIR Definition

) European Group Study of Insulin Resistance(

- 2001 : NCEP Definition

) National Cholesterol Education Program(

ATP III (Adult Treatment Panel )

- 2005/6 : The IDF Definition

The WHO Definition : 1998

I- Criteria : [ Type 2 diabetes or IGT ] * + 2 out of 4 :- 1 -Hypertension

2 -Blood fat 3 -Obesity ( BMI)**

4 -micro albuminuria

* In case of normal glucose tolerance , evidence of diminished insulin sensitivity

(by Euglycemic clamp or HOMA)

** Obesity is assessed by BMI or waist/ hip ratio

Draw backs in the WHO Definition

1 -BMI is not a reliable measure to obesity

2 -Microalbuminuria is very rarely found in

absence of diabetes.

3 -Euglyc. clamp is not practically applicable

) clinically or epidem(.

The ATP III ( Adult Treatment Panel ) Definition, 2001 …… by The US National

Cholesterol Education Program

Revised Criteria = at least 3 out of 5-: M F

1 -Visceral Obesity Waist circumference: 102 88 2 -TG ………………………. above 150 mg 3 -HDL Cholesterol …………. below 40 50

4 -Hypertension …………………….. ( 130 / 85 ) 5 -Fasting glucose : 100 mg/dl

) if diabetes or IGT is not already diagnosed (

The ATP III Definition 2001( cont. )

+Optional -C-reactive protein ( marker of inflammation )

- Fibrinogen ( marker of prothrombolic state )

Draw back - absence of ethnic consideration in the cut-off

points .

Confusion results from different definitions

Why?

differences in 1- the components of the MTS

2 -the cut- off points

This causes difficulties in:

1 -identifying the MTS i.e. diagnosing

2 -interpretation of its causation

3- comparing its burden in different populations

Therefore : A new IDF Definition is needed.… why?

1 -to define a set of criteria for use, both epidemiologically and in clinical practice ,

worldwide , so as to easily identify the MTS ( i.e. Diagnosis )

2 -can better define the nature of MTS ( Pathogenesis )

3 -to focus on …………… appropriate ( management )

4 -so as to contribute to long term reduction of risk to CVD and type 2 diabetes ( Prevention)

The new international Diabetes Federation (IDF) definitionAccording to the new IDF definition , for a person to be defined as having the

metabolic syndrome he/she must have: Central Obesity ( defined as waist circumference * with ethnicity specific values )

plus any two of the following four factors:

Raised triglycerides

150 mg/dL (1.7 mmol/L )

or specifc 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 pressure

Systolic BP 130 or diastolic BP 85 mmHg

Or treatment of previously diagnosed hypertension

Raised fasting plasma glucose

)FPG (100 mg/dL (5.6 mmol/L)

or previously diagnosed type 2 diabetes

Ethnic specific values for waist circumference

Country / Ethnic group Waist circumference

Europids*

In the USA, the ATP III values ( 102 cm male; 88 cm female) are likely to continue to be

used for clinical purposes

Male

Female

94 cm

80 cm

South Asians

Based on a Chinese , Malay and Asian-Indian population

Male

Female

90 cm

80 cm

ChineseMale

Female

90 cm

80 cm

Japanese**Male

Female

90 cm

80 cm

Ethnic South and Central AmericansUse South Asian recommendations until more specific data are available

Sub-Saharan Africans Use European data until more specific

data are available EMME ( Arab) populationsUse South Asian recommendations

until more specific data are available

Characteristic features of the IDF definition

-Single, universally accepted - Simple to use clinically

- Clear cut-off points, considering different ethnic groups

- Central obesity is the core, and waist circumference is the proxy.

- Open to additional criteria for research , and - Open to areas for further studies

The IDF Definition does not have the final word:

1 -more research will possibly reveal more accurate

predictive indices.

2 -other major risk factors for CVD

) e.g. smoking & LDL cholesterol(

must be taken in consideration

The MTS in Young PeopleResearch studies so far denote :1. Prevalence ? probably 30 % in overweight

adolescents (US sample)

2. A high BMI in childhood is predictive of MTS in

adult life .

3. CV risk factors in ( LDH & BMI ) are present in

childhood , and are predictive of CHD in

adulthood

MTS in the young ( cont.) There are no established criteria for diagnosis in the young

There is urgent need to decide:

1.The cut -off values in children.

2 .if the 100 mg/dl fasting glucose is correct.

3.The proper method to assess central obesity by accurate measuring waist circumference.

The IDF definition of the at risk group and metabolic syndrome in children and adolescents

Age group (years)

Obesity*

)WC(

TriglyceridesHDL-CBlood pressure

Glucose (mg/ dl) or known T2DM

6< - 1090Metabolic syndrome cannot be diagnosed , but further measurements should be made if there is a family history of metabolic syndrome, T2 DM , dyslipidemia, cardiovascular disease , hypertension and/or obesity

10 - < 16 90 or adult cut-off if lower

) 150 mg/dL( < )40mg/dL(Syst. 130 diast85mmHg

)100 mg/dL(

]or known T2DM[

16+ Use existing IDF criteria for adults

The Socio economic Burden

World wide = 3.2 millions die from complications

associated with diabetes

In the ME : ( with high prev. of diab.)

one in 4 deaths in adults 35-64 years

is related to diabetes

�ِAt The EMME Region

Prevalence of Diabetes is 9.2 % (age 20 -79)Prevalence of IGT …….is 8.1%

24.5 millions with Diabetes & 22.4 with IGT

out of the top 10 highest diabetes prevalence rate countries 6 are EMME countries

Estimated death due to DM as % of all deaths is 11.5% ) 11.1% in Europe and 11.8 % in NA (

Can we meet the Challenge?

Mean Health Expenditure per person with diabetes ( 2007 ) in ID ( international Dollar) in different regions Africa 180SEA 233EMME (514)SACA 625WP 684NA 1188EUR 1561----------------------------------Global av. 712

Mean Health Expenditure /person with diabetes in different regions

180 233514 625 684

11881561

0

500

1000

1500

2000ID

<200200-600600 -1000 <1000

Afghanistan 56

Iraq 72

Pakistan 99

Sudan 103

Yemen 110

Syria 185

Alger 273

Morocco 285

Egypt 286

Libya 384

Oman 614

Tunisia 637

Jordan 711

Iran 744

Kuwait 806

Saudi Arabia 891

Emirates 929

Bahrain 1047

Lebanon 1050

Qatar 1198

EMME Countries according to The Mean Health Expenditure per person with diabetes in ID (international Dollar) : Diabetes Atlas, 3rd Ed.

Cost of DM in relation to funds available(Egyptian Study)

DIRECT COST

OF TREATMENT

OF DM

L.E.235.2m

AVAILABLE GOVERNMENT

EXPENDITURE ON HEALTH

L.E. 351.8m

2/3!!

100%120.80%

354% 346%

0%

50%

100%

150%

200%

250%

300%

350%

400%

DM +CVD +R.F. +Diab. Foot

Hospital Treatment 2001 Cost /Day

(Egyptian Study )

55% Medicine & Supp.

45% Basic( Food : 5%

H.C.Team 11%

Others: 29%)

Distribution of Hospital Cost

8.85%

EGYPT

1.9%

QATAR

3.1%

SAUDI ARABIA

Year Cost / percapit. Burden for Human Insulin (40 u /d)

EGYPT

29.9%

Cost Burden of Oral Treatment related to Per capitum

QATAR

4.2%

8.4%

SAUDI ARABIA

Alexandria – Montazah Palace

Thank You