Institute
OBESITY, DYSLIPIDEMIA AND THE METABOLIC SYNDROME
Vincent Bufalino, MD
Senior Vice President Advocate Heart Institute
Senior Medical Director of Cardiology - AMG
Evolution
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.
1990
2008
No Data
<10%
10%14%
15%19%
20%24%
25%29%
30%
4
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
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.
Definition
Metabolic syndrome:
The NCEP ATP III definition*
Defining Level
Abdominal obesity
Men
Women
Waist circumference
>102 cm (>40 in)
>88 cm (>35 in)
Triglycerides
HDL cholesterol
Men
Women
Blood pressure
130/ 85 mmHg
Fasting glucose
11
IDF Worldwide Definition of the Metabolic Syndrome. www.idf.org/metabolic_syndrome
12
13
Bays HE. JACC 2011;57:2461-73.
14
Hypertension
14% 0% 17%
5% 1%
8% 2%
22%
12%
14%
Dyslipidemia
26%
10%
10%
22%
13%
23%
23%
15%
22%
22%
21%
18.5-24.9
25-26.9
Normal
27-29.9
30-34.9
35-39.9
Overweight
Obese
15
40
20
15
10
5
0
20-29
30-39
40-49
50-59
60-69
70
Age, y
16
Prevalence, %
40%
30%
28%
25%
26%
21%
20%
36%
23%
20%
16%
10%
0%
Men
Women
17
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
Cardiometabolic Risk:
Metabolic Syndrome Associated With Increased
CV Morbidity and Mortality
19
20
Courtesy of Prof. Yuji Matsuzawa, Osaka, Japan
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.
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
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
86
6
28
8
852
279
834
234
29
2
10
0
Metabolic Syndrome:
866
288
834
234
852
279
Yes
No
852
279
834
234
292
100
25
Treatment
26
27
2006 American
Heart Association,
Inc. rese
2010, American
Heart Association.
All rights
28
Ideal CV Health
Ideal Health Behaviors Metric (ALL)
Nonsmoking
Healthy Weight
Appropriate Levels of Physical Activity
Healthy Eating Pattern
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
Intermediate
Ideal
2 Major RFs
1 Major RF
1 Elevated RF
1 Not Optimal RF
Optimal RFs
69%
0.6
50%
46%
0.5
0.4
36%
0.3
0.2
0.1
5%
0.7
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
34
35
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
Physical Activity
Adiposopathy
(Sick Fat Disease)
Non-adipose
Health Parameters
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
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
Pharmacotherapy
Approved < 1999
Phentermine
Diethylpropion
Phendimetrazine
Benzphetamine
Orlistat
Lorcaserin
Phentermine
HCI/Topiramate
extended-release
43
Weight Loss
44
Glucose Management
45
46
Lipid Management
47
Comprehensive Management
48
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