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OBESITY

(Criteria, etiology, and management)


AND
METABOLIC SYNDROME
(Criteria and management)

John MF Adam
Division of Endocrinology and Metabolism
Dept. of Internal Medicine, Faculty of Medicine
Hasanuddin University

Makassar
OBESITY
Criteria, etiology, and management

John MF Adam
Division of Endocrinology and Metabolism
Dept. of Internal Medicine, Faculty of Medicine
Hasanuddin University

Makassar 2006
DEFINITION

Obesity is defined as a condition in


which there is an excess of body
fat. The operational definitions of
obesity and overweight however
are based on BMI which is closely
correlated with body fatness
CAUSE OF OBESITY
Primary
Genetic / overeating

Secondary
Hypotyroidism
Cushing syndrome
Insulinoma
Hypothalamus disorders
Etc
EPIDEMIOLOGY

In many countries in the world, the prevalence of


obesity are rapidly rising, reflecting an overall
increase in general fatness

There is a global epidemic of obesity.


WHO report launched in 1998 signifying the
seriousness of this problem

Sorensen TIA. Diabetes Care 2000;23 (Suppl. 2):B1-B4


Pathologic Consequences of Obesity
Obesity is associated with an increase in
mortality, with a 50100% increased risk
of death from all causes compared to
normal-weight individuals ; mostly due to
cardiovascular causes

Second leading cause of preventable


death in the United States, accounting for
300,000 deaths per year
Pathologic Consequences of Obesity

Mortality rates rise as obesity increases,


particularly when obesity is associated with
increased intra-abdominal fat

Hyperinsulinemia and insulin resistance


are pervasive features of obesity,
increasing with weight gain and
diminishing with weight loss
Obesity as a Risk Factor for CAD
The Importance of Abdominal Fat

Android Obesity
Gynecoid
Obesity
Sharma 2002
MEASUREMENT of OBESITY

1. Body Mass Index


Weight in kg
BMI =
(Height in meters)2

2. Body Fat Distribution


Android type (central obesity = visceral obesity)
Ginecoid type (perifer obesity)
PROPOSED CLASSIFICATION of WEIGHT
by BMI in ADULT ASIANS (WHO 2000)
Classification BMI (kg/m2) Risk of co-morbidities
Underweight < 18.5 Low ( but Increased risk
of other clinical problems)
Normal Range 18.5 22.9 Average
Overweight > 23
At Risk 23 - 24.9 Increase
Obese I 25 - 29.9 Moderate
Obese II > 30 Severe

Regional Office for the Western Pacific of the World Organization, The International
Association for the Study of Obesity, The International Obesity Task Force. The Asia-
Pacific perspective: Redefining obesity and its treatment. WHO Collaborating Centre for
the epidemiology of Diabetes and Health Promotion for Noncommunicable Disease,
Melbourne 2000
The Asia-Pacific Perspective: Redefining Obesity and its Treatment.
Assessment Diagnosis. 2000
PREVALENCE of OVERWEIGHT / OBESITY
in SOME ASIAN COUNTRIES
Country Obese Overweight
(BMI >30 kg/m2) (BMI 25-29,9 kg/m2)

Korea (1995) 1,5% 20,5%

Thailand 4,0% 16,0%

Malaysia 4,7% (men)


7,7% (women)

Japan <3,0% 24,3% (men)


20,2% (women)
Indonesia ???
MEASUREMENT OF CENTRAL OBESITY
Imaging
CT-scanning
MRI
DEXA

Anthropometric
Waist circumference
(N: Men < 90 cm, Women <80 cm)
Waist-to-hip ratio
(N: Men 1.0, Women 0.85)
Waist

Waist?
OBESITY
Body Mass Index

? Waist-to-Hip Ratio
Waist circumference
Waist
20 years

Hip

BMI = 24 BMI = 35
Waist = 80 cm Waist = 100 cm
Hip = 100 cm Hip = 125 cm
WH Ratio = 0.80 WH Ratio = 0.80
Desprs JP, dkk. BMJ 2001;322:716-720
128
140
Incidence/100,000 Person-years

Waist Circumference
106 110
120 83

Tertiles (cm)
97
Age-Adjusted CHD

89
100
80 77
46 55
60

40

20 High (>81.8)
Medium (73.7-81.7)
0 Low (<73.6)
High Medium Low
(>25.2) (22.2-25.1) (>22.1)
BMI Tertiles (kg / m2)

Waist circumference identifies risk of


CHD independent of BMI
MEN
6
Diabetes
Hypertension
5 Dyslipidemia
Albuminuria

4
ODDS RATIO

0
22 23 24 25 26 27 28 29 30
BMI (kg/m2)

Risk of diabetes, hypertension, dyslipidemia or albuminuria according


to selected BMI cut-off in Hong Kong Chinese
Moderate
Risk
High
2.5 Low
Risk
2 Risk
1.5
1
0.5
0
20 25 30 35
Body Mass Index
4
Relative Risk

3
2
1
0
150 170 200 210 220 230 240 250 290
Cholesterol (mg/dl)
5
4
3
2
1
75 80 85 90 95 100 105 110 115 120
Diastolic Blood Pressure

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
IS OBESITY A DISEASE
PROPORTION of DISEASE PREVALENCE
ATTRIBUTABLE to OBESITY

Type 2 diabetes 57%


Gallbladder disease 30%
Hypertension 17%
Coronary heart disease 17%
Osteoarthritis 14%
Breast cancer 11%
Uterine cancer 11%
Colon cancer 11%
TREATMENT OF OBESITY
Change of lifestyles
- Diet
- Physical activity
Pharmacotherapy
- Orlistat (Xenical)
- Sibutramine (Reductil)
Surgery
TREATMENT OF OBESITY

Criteria Treatment success

Reduction of excess weight 5-6 kg or 10% of initial body weight


Maintenance of BMI < 23 kg/m2
Blood pressure any reduction
Blood glucose any reduction
Glycaemic control (HbA1c) any improvement
Other risk factors any reduction

For Asian populations. BMI cut-of will be higher in Pacific Islanders


Haemoglobin A1c

WHO, Februari 2000


OBESITY : TREATMENT GUIDELINE FOR BMI

BMI TREATMENT
No treatment, diet and exercise to
18.5 - 24.9 maintain body weight

25 - 29.9 Hypocaloric diet and exercise to


reduce body weight
- without disease

25 - 29.9 Hypocaloric diet and exercise, anti-


- with disease obesity drug
30 - 39.9 Hypocaloric diet and exercise, anti-
obesity drug
> 40 Surgery
Physicians guide to the management of obesity with Xenical (4)
TREATMENT OF OBESITY
RESULTS OF ORLISTAT

JMFA 52
80
Placebo (n=340)
68.5% Orlistat 120 mg tid (n=343
P > 0.05
60
49.2%
Patient (%)

40 38.8%

20
17.6%

0
> 5% weight loss > 10% weight loss
Percentage of obese patients achieving weight loss of > 5% or > 10% after 1
year of treatment with Xenical 120 mg or placebo tid plus a mildly hypocaloric
diet. Sjostrom L, Rissanen A, Andersen T. Lancet 1998;352:167-72
TREATMENT OF OBESITY
RESULTS OF SIBUTRAMINE TRIALS

JMFA 52
STORM: Waist Circumference
Reduction and Maintenance Over 2 Years

Sibutramine Placebo

109
Waist circumference (cm)

107

105

103

101

99

97
Month
95
0 2 4 6 8 10 12 14 16 18 20 22 24

James WPT, Lancet 2000;356:2119-25

JMFA 53
Sudden death is more common in those
who are naturally fat than in the slender
Hippocrates 410 B.C.

Messerli et al Arch Intern Med 1987; 147: 1725 - 1728 JMFA 4


METABOLIC SYNDROME

John MF Adam
Division of Endocrinology and Metabolism
Dept. of Internal Medicine, Faculty of Medicine
Hasanuddin University

Makassar
DEFINITION

Metabolic syndrome is a
constellation of lipid and nonlipid risk
factors of metabolic origin. This
syndrome is closely linked to a
generalized metabolic disorder
called insulin resistance in which the
normal actions of insulin are
impaired
CRITERIA
of METABOLIC SYNDROME

World Health Organization, 1999

National Cholesterol Education Program,


Adult Treatment Panel III, 2001

International Diabetes Federation, 2005

JMFA 21
World Health Organization, 1999

COMPONENTS OF THE METABOLIC SYNDROME


Glucose intolerance, impaired glucose tolerance (IGT) or
diabetes mellitus and/or insulin resistance together with
two or more of the following :
Raised arterial pressure
Raised plasma triglycerides
Central obesity
Microalbuminuria

World Health Organization. Definition, diagnosis and classification of diabetes mellitus and
its complication. Part 1: Diagnosis and classification of diabetes mellitus. Department of
Noncommunicable Disease Surveillance, World Health Organization, Geneva 1999
JMFA 22
CLINICAL IDENTIFICATION OF THE METABOLIC
SYNDROME NCEP ATP III 2001

Risk factor Defining level


Abdominal obesity*
(waist circumference)
Men > 102 cm (> 40 in)
Women > 88 cm (> 35 in)
Triglycerides > 150 mg/dl
High-density lipoprotein
cholesterol
Men < 40 mg/dl
Women < 50 mg/dl
Blood pressure > 130 / > 85 mmHg
Fasting glucose > 110 mg/dl

Metabolic syndrome > 3 risk factors


Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel Ill).
JAMA 2001;285:2486-2497 JMFA 23
Co-morbidities risk associated with different levels
of BMI and suggested waist circumference in adult
Asians

Classification BMI (kg/m2) Risk of co-morbidilities


waist circulumference
< 90 cm (men) > 90 cm (men)
< 80 cm (women) > 80 cm (women)

Underweight < 18,5 Low (but increased risk Average


of other clinical problems)

Normal range 18.5-22.9 Average normal

Overweight: > 23
At risk 23-24.9 Increased Moderate
Obese I 25-29.9 Moderate Severe
Obese II > 30 Severe Very severe
CLINICAL IDENTIFICATION OF THE METABOLIC
SYNDROME Modified NCEP ATP III 2001
for Asian Adults

Risk factor Defining level


Abdominal obesity*
(waist circumference)
Men > 90 cm
Women > 80 cm
Triglycerides > 150 mg/dl
High-density lipoprotein
cholesterol
Men < 40 mg/dl
Women < 50 mg/dl
Blood pressure > 130 / > 85 mmHg
Fasting glucose > 110 mg/dl

Metabolic syndrome > 3 risk factors


JMFA 24
IDF Criteria of Metabolic Syndrome

Abdominal obesity*
(waist circumference)
Men > 90 cm
Women > 80 cm
Plus two of the following :
Triglycerides > 150 mg/dl
HDL chol Men < 40 mg/dl
Women < 50 mg/dl
Blood pressure > 130 / > 85 mmHg
Fasting plasma glucose > 115 mg/dl
PREVALENCE OF METABOLIC SYNDROME

USA 22% of adult population, 47 million


In Asian countries as well as other developing
countries metabolic syndrome suggest to be higher
In Makassar :
Adriansjah and Adam (2003) 30,8% among males
Adam and Adriansjah (2003) difference between
two criteria 24,2% NCEP-ATP III, 35,7%
modified NCEP-ATP III
Age-Specific Prevalence of the Metabolic Syndrome
Among 8,814 US Adults (Age > 20 Years)
(NHANES III., 1988-1994)

Men Women

50
Mean SE
40
Prevalence (%)

30

20

10

0
20-29 30-39 40-49 50-59 60-69 >70

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


JMFA 26
RELATION BETWEEN
OBESITY AND METABOLIC
SYNDROME
CENTRAL OBESITY AND
METABOLIC SYNDROME
Diabetes mellitus /
Impaired glucose tolerance

Central
Obesity

Dyslipidaemia
Hypertension
(HyperTG, low HDL-C)

JMFA 27
Effect of Metabolic Syndrome

METABOLIC
SYNDROME
CVD

DM
TREATMENT OF
METABOLIC SYNDROME

DIET - EXERCISE

JMFA 41
TREATMENT OF METABOLIC SYNDROME

Treatment of Hyperglicemia

Treatment of Dyslipidemia
LDL-cholesterol, Triglycerides, HDL-cholesterol

Treatment of Hypertension

Treatment of Obesity
Calorie restriction, Exercise,
Pharmacotherapy

JMFA 43
TREATMENT OF METABOLIC SYNDROME

Diabetes Mellitus
Metformin, Thiazolidinedione

Dyslipidemia
Statins, Fibrate, Nicotinic acid

Hypertension
ACE inhibitor, Ca Channel blocker, HCT

JMFA 44