THE METABOLIC SYNDROME

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• THE METABOLIC SYNDROME
• THE NEW IDF DEFINTION
• and
• THE SOCIO-ECONOMIC BURDEN
• Prof. Morsi Arab
• University of Alexandria
• IDF Chairman EMME Region

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• THE SIMPLE CONCEPT OF THE
• METABOLIC SYNDROME ( MTS )
• The Metabolic Syndrome is a cluster of the most
• dangerous risk factors for heart attack
• - diabetes / raised fasting plasma glucose,
• - abdominal obesity ,
• - high blood pressure
• - defective Cholesterol Metab.

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• 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

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• 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

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• 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)

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• 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 ?

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• Abdominal Obesity as measured by waist
• circumference is more indicative of the
• Metabolic Syndrome profile than increased
  BMI

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• 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

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• 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

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• 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
  

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• 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.)

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• 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)

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• 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.

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• 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

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• 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)

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• The new international Diabetes Federation (IDF)
  definition
• According 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

?150 mg/dL (1.7 mmol/L ) or specifc treatment for this lipid abnormality . Raised triglycerides
? 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 Reduced HDL Cholesterol
Systolic BP 130 or diastolic BP 85 mmHg Or treatment of previously diagnosed hypertension Raised blood pressure
( FPG) 100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes Raised fasting plasma glucose
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• Ethnic specific values for waist circumference

Waist circumference Country / Ethnic group Country / Ethnic group
94 cm 80 cm Male Female Europids In the USA, the ATP III values ( 102 cm male 88 cm female) are likely to continue to be used for clinical purposes
90 cm 80 cm Male Female South Asians Based on a Chinese , Malay and Asian-Indian population
90 cm 80 cm Male Female Chinese
90 cm 80 cm Male Female Japanese
Use South Asian recommendations until more specific data are available Use South Asian recommendations until more specific data are available Ethnic South and Central Americans
Use European data until more specific data are available Use European data until more specific data are available Sub-Saharan Africans
Use South Asian recommendations until more specific data are available Use South Asian recommendations until more specific data are available EMME ( Arab) populations
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• 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

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• 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

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• The MTS in Young People
• Research 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

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• 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.

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

Glucose (mg/ dl) or known T2DM Glucose (mg/ dl) or known T2DM Blood pressure Blood pressure HDL-C HDL-C Triglycerides Obesity ( WC ) Age group (years)
Metabolic 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 Metabolic 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 Metabolic 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 Metabolic 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 Metabolic 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 Metabolic 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 Metabolic 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 ?90 6 - lt10
(100 mg/dL) or known T2DM Syst. ?130 diast?85mmHg Syst. ?130 diast?85mmHg ( lt 40mg/dL) ( lt 40mg/dL) (? 150 mg/dL) (? 150 mg/dL) ?90 or adult cut-off if lower 10 - lt 16
Use existing IDF criteria for adults Use existing IDF criteria for adults Use existing IDF criteria for adults Use existing IDF criteria for adults Use existing IDF criteria for adults Use existing IDF criteria for adults Use existing IDF criteria for adults Use existing IDF criteria for adults 16
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• The Socio economic Burden

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• 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

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?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 )

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

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EMME Countries according to The Mean Health
Expenditure per person with diabetes in ID
(international Dollar) Diabetes Atlas, 3rd Ed.
gt 1000 600- 1000 200-600 gt 200
Bahrain 1047 Lebanon 1050 Qatar 1198 Oman 614 Tunisia 637 Jordan 711 Iran 744 Kuwait 806 Saudi Arabia 891 Emirates 929 Alger 273 Morocco 285 Egypt 286 Libya 384 Afghanistan 56 Iraq 72 Pakistan 99 Sudan 103 Yemen 110 Syria 185
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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!!
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Hospital Treatment 2001 Cost /Day
(Egyptian Study )
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Distribution of Hospital Cost
45 Basic ( Food 5 H.C.Team 11 Others 29)
55 Medicine Supp.
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Year Cost / percapit. Burden for Human Insulin
(40 u /d)
8.85
EGYPT
1.9
3.1
SAUDI ARABIA
QATAR
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Cost Burden of Oral Treatment related to Per
capitum
4.2
29.9
EGYPT
QATAR
8.4
SAUDI ARABIA
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Alexandria Montazah Palace
Thank You