Health Risks and Comorbid Conditions

1
Health Risks and Comorbid Conditions
2
Outline

• Overview of the Metabolic Syndrome
• Risks of Obesity and the Metabolic Syndrome
• Specific Health Risks
• Answers to Questions Summary

3
Question 1

• Which of the following is not part of the
  Metabolic Syndrome?
• High HDL-cholesterol ( 50 mg/dL)
• High blood pressure ( 130/85)
• High Triglyceride ( 150 mg/dL)
• Impaired fasting glucose (100-126 mg/dL)
• Increased waist circumference 88cm (F) 102cm
  (M)

4
Development of the Concept

• 1904 - Life insurance data
• 1947 - Vague introduces adipomuscular ratio
• 1967 - Crepaldi insulin resistance and disease
• 1970 - Feldman Epidemiological relation
• 1982 - Ratio of waist to hip circumference
  related to morbidity and mortality in 2
  separate laboratories
• 1988 - Reaven describes Syndrome X

5
Abdominal Adiposity
Abdominal Obesity
Visceral
Subcutaneous
Courtesy of Steven Smith, M.D.
6
Body Fat Distribution and Glucose Tolerance
Kissebah JCEM 198254254-260.
7
Visceral Obesity and Risk of Dyslipidemia
Despres JP, et al. Arteriosclerosis.
199010497-511.
8
Metabolic Syndrome NCEP ATP III
JAMA 20012852486-2497.
9
Age-Adjusted Prevalence of the Metabolic Syndrome
Among 8814 Adults Age 20
Ford. JAMA 2002287356-9.
10
Characteristics of the Metabolic Syndrome
Full members
Wannabes

• Abdominal obesity
• Glucose intolerance
• High triglycerides
• Low HDL-cholesterol
• High blood pressure
• Insulin resistance

• Microalbuminuria
• Small dense LDL
• Inflammatory markers
• Thrombotic factors
• Endothelial dysfunction
• Hyperuricemia

11
Central Fat and Lifestyle Health Risk
1.0
Probability of remaining free of myocardial
infarction
Waist to hip ratio
0.95
1.0
Probability of survival
0.95
Years of follow-up
Lapidus. BMJ 19842891257-61.
12
Outline

• Overview of the Metabolic Syndrome
• Risks of Obesity and the Metabolic Syndrome
• Specific Health Risks
• Answers to questions Summary

13
Pathogenesis of Health Problems Associated with
Obesity
Genes
Environment
Activity
Food Intake
Excess fat stores
Diseases due to increased fat cell size
visceral fat
Diseases due to increased fat mass
Diabetes
CVD
Stigma
Osteoarthritis
NAFLD
Sleep apnea
GB Disease
Cancer
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The Fat Cell is an Endocrine Cell
Fat Cell
15
Medical Complications of Obesity
Idiopathic intracranial hypertension
Pulmonary disease abnormal function obstructive
sleep apnea hypoventilation syndrome
Stroke
Cataracts
Nonalcoholic fatty liver disease steatosis steatoh
epatitis cirrhosis
Coronary heart disease Diabetes
Dyslipidemia Hypertension
Severe pancreatitis
Gall bladder disease
Cancer breast, uterus, cervix colon, esophagus,
pancreas kidney, prostate
Gynecologic abnormalities abnormal
menses infertility polycystic ovarian syndrome
Osteoarthritis
Phlebitis venous stasis
Skin
Gout
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Outline

• Overview of the Metabolic Syndrome
• Risks of Obesity and the Metabolic Syndrome
• Mortality
• Morbidity
• Specific Health Risks
• Answers to questions Summary

17
Question 2

• Which of the following is NOT an estimate of
  excess deaths from obesity?
• 450,000
• 365,000
• 325,000
• 275,000
• 112,000

18
BMI and Mortality by Ethnic Group The American
Cancer Society Study
Calle NEJM 19993411097.
19
Relative Risk of Death by BMI Levels from the
NHANES I, II, III Surveys
Flegal et al JAMA. 20051861.
20
Range of Estimates of Mortality Associated with
Overweight
21
Obesity Decreases Life ExpectancyThe Framingham
Study
Compared to a BMI 18.5-24.9 kg/m2
Peeters Ann Int Med 200313824-32.
22
Question 3

• Which disease has the highest risk in association
  with obesity?
• Breast cancer
• Diabetes
• Cardiovascular disease
• Osteoarthritis
• Kidney stones

23
Outline

• Overview of the Metabolic Syndrome
• Risks from Obesity and Metabolic Syndrome
• Increased mortality
• Increased morbidity
• Specific Health Risks
• Answers to Questions Summary

24
Relationship Between BMI and Comorbidities Is
Positive, Even in the Normal Range
Women
Men
Relative Risk
Relative Risk
Body Mass Index(kg/m2)
Body Mass Index(kg/m2)
Willett WC, et al. N Engl J Med. 1999341427-434.
25
BMI and Chronic Disease Prevalence in the Nurses
Health Study
Coakley et al IJO 199822958.
26
Proportion of Disease Prevalence Attributable to
Obesity
27
Age- and Sex-Adjusted Prevalence of Risk Factors
for BMI 30 kg/m2
Gregg et al JAMA 20052931868.
28
Outline

• Overview of the Metabolic Syndrome
• Specific Health Risks
• Increased risk of diabetes
• Increased risk of heart disease
• Increased risk of hypertension
• Increased risk of cancer
• Other increased risks
• Answers to Questions Summary

29
Relationship Between BMI and Risk of Type 2
Diabetes Mellitus
100
75
Age-Adjusted Relative Risk
50
25
0
23 - 23.9
24 - 24.9
25 - 26.9
27 - 28.9
33 - 34.9
29 - 30.9
31 - 32.9
35
Body Mass Index (kg/m2)
Chan J et al. Diabetes Care 199417961. Colditz
G et al. Ann Intern Med 1995122481.
30
Nurses Health Study Waist Circumference
Directly Related to Risk for Type 2 Diabetes
Controlled for age, family history of diabetes,
exercise, smoking, saturated fat intake,
calcium, potassium, magnesium, and glycemic
index.
Carey et al. Am J Epidemiol. 1997145614.
31
Prevalence of Type 2 Diabetes Among Diabetic
Children in 4 Studies
Fagot-Campagna et al. J Pediatr 2000136664.
32
Nurses Health Study Diabetes MI/Stroke
Hu Diab Care 2002251129.
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Outline

• Overview of the Metabolic Syndrome
• Specific Health Risks
• Increased risk of diabetes
• Increased risk of heart disease
• Increased risk of hypertension
• Increased risk of cancer
• Other increased risks
• Answers to Questions Summary

34
BMI and Risk of Coronary Heart Disease in the
Nurses Health Study
p Manson et al NEJM 1995333677-85.
35
Abdominal Fat Distribution Increases the Risk of
Coronary Heart DiseaseThe Iowa Womens Health
Study
Relative Risk
3
2
Waist-Hip Ratio Tertile
1
3
2
1
Body Mass Index Tertile
Folsom et al. Arch Intern Med 20001602117.
36
BMI Weight Gain and Cardiovascular Risk
Relative Risk
Weight Change, kg
Body Mass Index (kg/m2) at 18 Years of Age
Willett et al JAMA. 1995273461-5.
37
Body Weight and Weight Gain During Adult Life and
Risk of CHD
Rosengren et al Europ H J 199920269-277.
38
The Interheart Study Risk of MI
Adj for Age, Sex Geography Adj Age, Sex
Smoking
Yusuf et al Lancet 2004364-352.
39
Obesity and the Risk of New Onset Atrial
Fibrillation
Wang et al JAMA 20042922471-77.
40
10-Year Cumulative Incidence of Heart Failure in
the Framingham Study
Kenchaiah et al NEJM 2002347305-313.
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Outline

• Overview of the Metabolic Syndrome
• Specific Health Risks
• Increased risk of diabetes
• Increased risk of heart disease
• Increased risk of hypertension
• Increased risk of cancer
• Other increased risks
• Answers to Questions Summary

42
Prevalence of Elevated Blood Pressure by BMI
Category
NHLBI Evidence Report 1988.
43
Outline

• Overview of the Metabolic Syndrome
• Specific Health Risks
• Increased risk of diabetes
• Increased risk of heart disease
• Increased risk of hypertension
• Increased risk of cancer
• Other increased risks
• Answers to Questions Summary

44
Mortality from Cancer in American Men and Women
Calle NEJM 20033481625.
45
Outline

• Overview of the Metabolic Syndrome
• Overview of Risks
• Specific Health Risks
• Increased risk of diabetes
• Increased risk of heart disease
• Increased risk of hypertension
• Increased risk of cancer
• Other increased risks
• Answers to Questions and Summary

46
Other Increased Risks

• Kidney stones
• Complications of pregnancy
• Sleep disorders
• Osteoarthritis
• Stigmatization

47
Body Mass Index and the Relative Risk of
Symptomatic Kidney Stones
Taylor et al JAMA 2005293455-462.
48
Pregnancy Complications in Obese and Overweight
Nulliparous Women
Baeten et al Am J Pub Health 200191436-440.
49
Moderate Weight Change and Sleep Disordered
Breathing
Peppard et al JAMA 20002843015-3021.
50
Adjusted Odds Ratio for Osteoarthritis by
Tertiles of BMI
Oliveria et al Epidemiology 199910161.
51
BMI and Physical Functioning (SF-36)The Nurses
Health Study
Coakley et al IJO 199822958-963.
52
Outline

• Overview of the Metabolic Syndrome
• Risks of Obesity and the Metabolic Syndrome
• Specific Health Risks
• Answers to Questions Summary

53
Question 1

• Which of the following is not part of the
  Metabolic Syndrome?
• High HDL-cholesterol ( 50 mg/dL)
• High blood pressure ( 130/85)
• High Triglyceride ( 150 mg/dL)
• Impaired fasting glucose (100-126 mg/dL)
• Increased waist circumference 88cm (F) 102cm
  (M)

54
Question 1

• Which of the following is not part of the
  Metabolic Syndrome?
• High HDL-cholesterol ( 50 mg/dL)
• High blood pressure ( 130/85)
• High Triglyceride ( 150 mg/dL)
• Impaired fasting glucose (100-126 mg/dL)
• Increased waist circumference 88cm (F) 102cm
  (M)

55
Question 2

• Which of the following is NOT an estimate of
  excess deaths from obesity?
• 450,000
• 365,000
• 325,000
• 275,000
• 112,000

56
Question 2

• Which of the following is NOT an estimate of
  excess deaths from obesity?
• 450,000
• 365,000
• 325,000
• 275,000
• 112,000

57
Question 3

• Which disease has the highest risk in association
  with obesity?
• Breast cancer
• Diabetes
• Cardiovascular disease
• Osteoarthritis
• Kidney stones

58
Question 3

• Which disease has the highest risk in association
  with obesity?
• Breast cancer
• Diabetes
• Cardiovascular disease
• Osteoarthritis
• Kidney stones

59
Summary

• The metabolic syndrome defined as central
  adiposity, hypertension, impaired fasting glucose
  and dyslipidemia is a major risk factor for heart
  disease and diabetes
• Obesity shortens life and increases the number of
  excess deaths
• Diabetes, heart disease, osteoarthritis, cancer,
  kidney stones, complications of pregnancy, sleep
  apnea and impaired physical functioning are all
  associated with obesity