Advocate Heart

Institute
OBESITY, DYSLIPIDEMIA AND THE METABOLIC SYNDROME

Vincent Bufalino, MD
Senior Vice President Advocate Heart Institute
Senior Medical Director of Cardiology - AMG

Evolution

The Obesity Epidemic

Age-adjusted prevalence of obesity in adults 2074 years of age,
by sex and survey year (NAHES: 19601962; NHANES: 19711975,
19761980, 19881994, 1999-2002 and 2003-2006)
40

35

34.0

33.1

30

35.2

28.1
26.0

25
20.6
Percent of Population

20

16.8 17.1
15.7

15
10.7

12.212.8

10
5
0
Men

1960-62

1971-75

1976-80

Women

1988-94

1999-2002

2003-06

Obesity is defined as a BMI of 30.0. Source: Health, United States, 2009 (NCHS).
Roger VL et al. Circulation 2011. Circulation. 2011;123(4):e18-e209.

Obesity Trends* Among U.S. Adults

BRFSS, 1990, 1999, 2008

(*BMI 30, or about 30 lbs. overweight for 54 person)

1999

1990

2008

No Data

<10%

10%14%

15%19%

20%24%

25%29%

30%
4

www.cdc.gov/obesity/data/trends.htm . Accessed Feb 3, 2010.

BMI and Prevalence of Metabolic Disease

NHANES 1999-2002
70

68

Diabetes Mellitus
Hypertension
Dyslipidemia

60

62.5

62.2
53.1

% of Patients

44
39.3

38.2

40

30.8

30
22.3

27.3

25.3

24
17.6

20

52.9

51.3

50

10

67.5

16.4
10.1

1.7

<18.5

Lean

4.2

12.2

5.7

18.5-24.9 25-26.9

Normal

28.9

27-29.9

Overweight

30-34.9

Obese

Body Mass Index (BMI)

Bays HE, et al. Int J Clin Pract. 2007;61:737-747.
Bays HE. Am J Med. 2009;122(1 suppl):S26-37.

40

35-39.9

OVERALL

Obesity-related Hypertension:
Pathogenesis, Cardiovascular Risk,
and Treatment -- A Position Paper
of The Obesity Society and The
American Society of Hypertension

Landsberg L, Aronne LJ, Beilin LJ, Burke V, Igel LI, et al. Obesity (Silver Spring, Md). 2013;21:8-24.

Clinical Practice Guidelines for Healthy Eating for the

Prevention and Treatment of Metabolic and Endocrine
Diseases in Adults: Cosponsored by American
Association of Clinical Endocrinologists and The
Obesity Society

Primary disturbances in adipose tissue anatomy and function,

adiposopathy, are etiologic in the development of . . . metabolic
derangements

Thus, . . . a major focus of nutrition counseling for overweight or

obesity is to correct adiposopathy

Nutrition counseling for overweight and obesity should be aimed to

decrease fat mass and also to correct adipose tissue dysfunction
(adiposopathy)

Gonzalez-Campoy JM, et a. Endocr Pract. 2013. Vol 19 (Suppl 3).

Definition

Metabolic syndrome:
The NCEP ATP III definition*

Three or more of the following five risk factors:

Risk Factor

Defining Level

Abdominal obesity
Men
Women

Waist circumference
>102 cm (>40 in)
>88 cm (>35 in)

Triglycerides

150 mg/dL (1.7 mmol/L)

HDL cholesterol
Men
Women

<40 mg/dL (1.04 mmol/L)

<50 mg/dL (1.30 mmol/L)

Blood pressure

130/ 85 mmHg

Fasting glucose

100 mg/dL (5.6 mmol/L)

*2001, updated 2005

Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, 10
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final
Report. Circulation. 2002;106;3143.

11
IDF Worldwide Definition of the Metabolic Syndrome. www.idf.org/metabolic_syndrome

Obesity and Metabolic Syndrome: A

Cluster of Coronary Heart Disease Risk
Factors

Adapter from Grundy SM. J Clin Endocrinol Metab. Jun 2004;89(6):2595-2600.

Slide Source: Obesityonline.org

12

Contribution of Adipose Tissue to Metabolic Syndrome and CVD Risk

13
Bays HE. JACC 2011;57:2461-73.

Metabolic Syndrome: Mechanisms

Bays H, Ballantyne C. Future Lipidology. 2006;1:389-420.

Kalant D, et al. Can J Diabetes. 2003;27:154-171.
Pausova Z. Curr Opin Nephrol Hypertens. 2006;15:173-178.
Landsberg L. Cell Mol Neurobiol. 2006;26:497-508.
Yu YH, Ginsberg HN; Circ Res. 2005;96:1042-1052.

14

BMI Among Patients With Metabolic Disease

NHANES 1999-2002
Diabetes Mellitus

Hypertension

14% 0% 17%

5% 1%

8% 2%
22%

12%
14%

Dyslipidemia

26%

10%

10%

22%
13%

23%
23%

15%

22%

22%

21%

Body Mass Index (BMI)

18.5
Lean

18.5-24.9

25-26.9

Normal

Bays HE, et al. Int J Clin Pract. 2007;61:737-747.

Bays HE. Am J Med. 2009;122(1 suppl):S26-37.

27-29.9

30-34.9

35-39.9

Overweight

Obese
15

40

Age-Specific Prevalence of the

Metabolic Syndrome
8814 US adults from NHANES III Survey, 1988-94
45
40
35
Percentage,
%
30
25
Men
Women

20
15
10
5
0

20-29

30-39

40-49

50-59

60-69

70

Age, y

Data are presented as percentage (SE)

Ford E et al. JAMA 2002;287:356-359 .

16

Prevalence of the NCEP Metabolic Syndrome:

NHANES III by Sex and Race/Ethnicity
White
African American
Mexican American
Other

Prevalence, %

40%

30%

28%

25%

26%
21%

20%

36%

23%
20%

16%

10%

0%

Men

Women
17

Ford ES et al. JAMA 2002;287:356-359.

Ford ES et al. JAMA 2002;287:356-359.

Prevalence of CHD by the Metabolic

Syndrome & Diabetes in the NHANES
Population Age 50+
Chart Title

25%

19.2%

20%
CHD Prevalence

13.9%
15%
8.7%
10%

7.5%

5%
0%

No MS/No DM
% of
54.2%
Population =

MS/No DM
28.7%

DM/No MS
2.3%

DM/MS
14.8%
18

Alexander CM et al. Diabetes 2003;52:1210-1214.

Cardiometabolic Risk:
Metabolic Syndrome Associated With Increased
CV Morbidity and Mortality

* Cardiovascular mortality was defined using ICD-9 (codes

390-459) before 1997 and ICD-10 (codes 100-199)
thereafter,

19

Isomaa B, Almgren P, Tuomi T, et al. Diabetes Care. Apr 2001;24(4):683-689.

20
Courtesy of Prof. Yuji Matsuzawa, Osaka, Japan

All Fat Cells Are Not Created Equal

Large insulinresistant
adipocyte

Adrenergic
receptors

Small insulin-sensitive
adipocytes

Insulinmediated
antilypolysis

Adrenergic receptors

Catecholaminemediated
lipolysis

Fatty Acids
21

Diet

M
E
T
A
B
O
L
I
C
S
Y
N
D
R
O
M
E

Physical activity/
Fitness

Elevated fasting or
2-h post-load glycemia

Socioeconomic
status

Birth size,
childhood growth

Genes

Inflammation

Overweight
Hyperuricemia

Dyslipidemia
Low HDL, high TG
High ApoB, low Apo A
Small dense LDL

Hypertension

Abdominal obesity/
Ectopic fat deposition

Adipose hormones

Endothelial dysfunction

Insulin resistance/
Hyperinsulinemia

Hypercoagulability,
impaired fibrinolysis

Hypoandrogenism (men),
Hyperandrogenism (women)

Diabetes

CVD

22

Cardiometabolic Risk:
Abdominal Adiposity Is Associated With Increased
Risk of CV Events

23
Dagenais GR, Yi Q, Mann JF, et al. Am Heart J. Jan 2005;149(1):54-60.

Proportion without major CHD event

Risk of Major CHD Event Associated

with
High Insulin Levels in Non-diabetic
Kaplan-Meier
Survival Curve
Men
1.00
0.95
Q1

0.90
0.85

Q2
Log rank:
Overall P = 0.001
Q5 vs Q1 P <0.001

0.80
0.75

Q3
Q4
Q5

0
0

10

15

20

25

Years
Q1 to Q5=quintiles of area under the curve (AUC) insulin
(Q1=lowest quintile; Q5=highest quintile).
Pyrl M, et al. Circulation. 1998;98:398404.

24

Unadjusted Kaplan-Meier Curve

Coronary Heart
Disease Mortality

Cumulative Hazard (%)

20

All-cause
Mortality

Cardiovascular
Disease Mortality

15
RR (95% CI),
2.43 (1.64-3.61)

RR (95% CI),
3.55 (1.96-6.43)

RR (95% CI),
3.77 (1.74-8.17)

10

0
0

8 10 12
4 6
Follow-up, Y

8 10
6
4
Follow-up, Y

12

292
100

866
288

4 6 8 10 12
Follow-up, Y

No. at Risk Metabolic Syndrome

Yes
No

86
6
28
8

852
279

834
234

29
2
10
0

Metabolic Syndrome:

Lakka H-M, et al. JAMA. 2002;288:2709-2716.

866
288

834
234

852
279

Yes

No

852
279

834
234

292
100

25

Treatment

26

Aggressive comprehensive risk

factor management improves
survival, reduces recurrent events
and the need for interventional
procedures, and improves quality
of life for these patients.
Smith (2006). AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update.
Circulation

27

2006 American
Heart Association,
Inc. rese
2010, American
Heart Association.
All rights

What Is Ideal Cardiovascular Health?

Absence of disease
Favorable levels of health factors
Favorable health behaviors

28

2010, American Heart Association. All rights rese

Ideal CV Health
Ideal Health Behaviors Metric (ALL)
Nonsmoking
Healthy Weight
Appropriate Levels of Physical Activity
Healthy Eating Pattern

Ideal Health Factors Metric (ALL)

Total cholesterol
Blood pressure
Nondiabetic
29

2010, American Heart Association. All rights rese

Lifes Simple 7
1. Never smoked or quit more than one
year ago
2. Body mass index less than 25 kg/m2
3. Physical activity of at least 150 mins (moderate
intensity) or 75 mins (vigorous intensity) each
week
4. Four to five key components of a healthy diet
consistent with current AHA guidelines
5. Total cholesterol of less than 200 mg/dL
6. Blood pressure below 120/80 mm Hg
30
7. Fasting blood glucose less than 100 mg/dL

Healthy Diet

(4-5 Dietary Goals met)

1. Fruits and vegetables: 4.5 cups per day
2. Fish (preferably oily): 2 3.5-oz servings per week
3. Fiber-rich whole grains (1.1 grams fiber per 10 grams
carbohydrate): 3 1-oz-equivalent servings per day
4. Sodium: <1500 mg per day
5. Sugar-sweetened beverages: 450 kcal (36 oz) /week

Other Dietary Measures

1. Saturated fat: < 7% of total energy intake
2. Nuts, legumes, and seeds: 4 servings/week
3. Processed meats: 2 servings/week
31

CV Health Metric Definitions*

Poor

Intermediate

Ideal

Goal: 20% overall improvement

* The average net percentage of people who

32
move up one level of health

2 Major RFs
1 Major RF
1 Elevated RF
1 Not Optimal RF
Optimal RFs

Lifetime Risk: Age 50

Men

69%

0.6
50%
46%

0.5
0.4

36%

0.3
0.2
0.1

5%

0.7
Adjusted Cumulative Incidence

Adjusted Cumulative Incidence

0.7

Women
0.6
0.5

50%

0.4

39%
39%

0.3

27%

0.2
0.1

8%

0
50

60

70

80

Attained Age

90

50

60

70

80

90

Attained Age
33

Lloyd-Jones, Circulation 2006

My Life Check Assessment

34

2010, American Heart Association. All rights rese

My Life Check Assessment

35

2010, American Heart Association. All rights rese

Nutritional Therapy
Energy consumption intended to cause
negative caloric balance and fat weight
loss
Low calorie diet is often described as 800
1500 kcal/day
Very low calorie diet is often described as
<800 kcal/day
Restricted
dietary
carbohydrate

Restricted
dietary fat

Very low calorie

diets
36

Physical Activity
Adiposopathy
(Sick Fat Disease)

Assist with weight

maintenance
Assist with weight loss
Improve body
composition

Non-adipose
Health Parameters

Improve metabolic health

Improve musculoskeletal
health
Improve cardiovascular
health
Improve pulmonary
health
Improve mental health
Improve sexual health
37

Physical Activity
Priority is to increase energy
expenditure
Aerobic
Moderate exercise = 70
minutes per week
Vigorous exercise = 150
minutes per week

Anaerobic
Percent body fat better
assessment of body
composition than BMI
Emphasize core muscle
exercise

38

39

Exercise and the Heart

Insulin resistance
HDL Cholesterol
Skeletal muscle
glycogen transport
Rate & amount fat
oxidation at rest

LDL Cholesterol
Weight
Hypercoagulability
Atherosclerosis
Preferential loss of
abdominal fat
Reduces CRP

40

Behavior Therapy

Frequent
encounters with
medical
professional or
other resources

Education

41

Weight Management
Pharmacotherapy
Adjunct to nutritional, physical
activity, and behavioral therapies

Facilitate management of eating behavior

Slow progression of weight gain/regain
Improve the health, quality of life, and
body weight of the obese and/or
overweight patient
42

Pharmacotherapy
Approved < 1999

Phentermine
Diethylpropion
Phendimetrazine
Benzphetamine
Orlistat

2012 and Beyond

Lorcaserin
Phentermine
HCI/Topiramate
extended-release

43

Weight Loss

44

Glucose Management

45

Blood Pressure Management

46

Lipid Management

47

Comprehensive Management

48

Is Eugastrosis (a Normal Stomach) a

Disease?
Gastric Band

Roux en Y Gastric Bypass

Gastric Sleeve
49

Conclusions
Obesity is increasing worldwide at an
alarming rate
Adiposopathy leads to atherogenic
dyslipidemia as well as several other risk
factors for CAD
7%-10% weight loss significantly affects CHD
risk
Calorie restriction is the most important
criteria for the diet
Increased physical activity is also critical
Many drugs can contribute to weight gain
Surgical and pharmacologic therapies can50be
helpful in selected patients

THANK YOU

51