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Contemporary Management of Cardiometabolic Risk. A continuing epidemic: 2 of 3 US adults are overweight or obese. National Health and Nutrition Examination Surveys 1999-2004 US adults ≥20 years of age. Year of survey. Overweight = BMI 25-29.9 kg/m 2 Obesity = BMI ≥30 kg/m 2.

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a continuing epidemic 2 of 3 us adults are overweight or obese
A continuing epidemic: 2 of 3 US adults are overweight or obese

National Health and Nutrition Examination Surveys 1999-2004US adults ≥20 years of age

Year of survey

Overweight = BMI 25-29.9 kg/m2Obesity = BMI ≥30 kg/m2

Ogden CL et al. JAMA. 2006;295:1549-55.

parallel epidemics of diabetes and obesity
Parallel epidemics of diabetes and obesity

1994

2004

Diabetes

<4%

4%-4.9%

5%-5.9%

≥6%

Obesity

(BMI ≥30 kg/m2)

10%-14%

15%-19%

20%-24%

≥25%

CDC. www.cdc.gov.

defining cardiometabolic risk
Defining cardiometabolic risk

Risk factors linked to cardiovascular disease (CVD)and diabetes

Adiposity

Dyslipidemia

Dysglycemia

Hypertension

Cardiometabolic risk factors

Eckel RH et al. Circulation. 2006;113:2943-6.

associations of adiposity with cvd
Associations of adiposity with CVD

Insulin resistance

Dysglycemia

Dyslipidemia

Left ventricular dysfunction

Hypertension

CAD

Sleep apnea syndrome

White = visceral fat area (VFA) Black = subcutaneous (sc) fat

Matsuzawa Y. Nat Clin Pract Cardiovasc Med. 2006;3:35-42.

adiposity predicts mortality
Adiposity predicts mortality

3.0

2.5

2.0

Relative

risk of

1.5

death

1.0

0

0

20

25

30

35

40

45

Current BMI (kg/m2)

All men (n = 313,047; 42,173 deaths)All women (n = 214,218; 19,144 deaths)

Adams KF et al. New Engl J Med. 2006;355:763-78.

adiposity associated with premature mi
Adiposity associated with premature MI

N = 906 consecutive patients with AMI

75

72.9

10.6 years earlier occurrence of MI

70

66.9

Age at presentation with AMI (years)

65

62.3

60

55

<25(n = 306)

25-30(n = 362)

>30(n = 238)

BMI (kg/m2)

Suwaidi JA et al. Clin Cardiol. 2001;24:542-7.

majority of patients undergoing pci are overweight or obese
Majority of patients undergoing PCI are overweight or obese

N = 9633

BMI <25 kg/m2(n = 1923)

BMI ≥25 kg/m2(n = 7710)

Gruberg L et al. J Am Coll Cardiol. 2002;39:578-84.

adverse consequences of chronic adiposity and ectopic fat
Adverse consequences of chronic adiposity and ectopic fat

Lipid overflow ectopic fat

Muscle fat(Intracellular lipid)

Cardiac functionInsulin sensitivityDyslipidemiaβ-cell functionAtherosclerosisNASH

Altered FFA metabolism

Altered release of adipokines

Epicardial fat

Liver fat andaltered function

FFA = free fatty acidsNASH = nonalcoholic steatohepatitis

Adapted from Després J-P, Lemieux I. Nature. 2006;444:881-7.Molavi B et al. Curr Opin Cardiol. 2006;21:479-85.

epicardial adipose tissue may be increased in visceral obesity
Epicardial adipose tissue may be increased in visceral obesity

Patient withvisceral obesity

Patient withperipheral obesity

  • Hypertension
  • Diabetes
  • Dyslipidemia

No metabolic complications

Iacobellis G et al. Clin Cardiol. 2003;26:237.

adiposity in the development of nash
Adiposity in the development of NASH

Adipose

Insulin

Leptin

Adiponectin

Fatty acids

Liver

Normal

Steatosis(fatty liver)

Steatohepatitis(steatosis and inflammation)

Fibrosis(collagen deposition)

Adapted from Ahima RS. Gastroenterology. 2007;132:444-6.

Angulo P. N Engl J Med. 2002;346:1221-31.

visceral vs subcutaneous adiposity
Visceral vs subcutaneous adiposity

CT scans matched for BMI and total body fat

Visceral obesity

Fat mass: 19.8 kg

VFA: 155 cm2

Subcutaneous (sc) obesity

Fat mass: 19.8 kg

VFA: 96 cm2

White = VFA Black = sc fat

Després J-P. Eur Heart J Suppl. 2006;8(suppl B):B4-12.

neutral effect of liposuction on cardiometabolic risk factors
No significant change at 10-12 weeks

BP

Plasma glucose

Plasma insulin

Total-C, LDL-C, HDL-C, TG

Adiponectin

TNF-α

IL-6

CRP

Neutral effect of liposuction on cardiometabolic risk factors

Magnetic resonance images

Pre-liposuction

sc fat

Post-liposuction

Klein S et al. N Engl J Med. 2004;350:2549-57.

central adiposity better marker of cvd than bmi
Central adiposity: Better marker of CVD than BMI

N = 8802 HOPE Study participants

1.5

P = 0.14

P = 0.003

P = 0.0127

BMI, WHR, WC tertiles

1

Adjusted RR of CVD death

First

Second

Third

0.5

0

BMI(kg/m2)

WHR

WC(cm)

WC = waist circumferenceWHR = waist/hip ratio

Dagenais GR et al. Am Heart J. 2005;149:54-60.

a new vital sign waist circumference
A new vital sign: Waist circumference

Abdominal adiposity

Coronaryheart disease

Hypertension

Dyslipidemia

RISK

Dysglycemia

Adapted from Després J-P et al. BMJ. 2001;322:716-20.

continued burden of disease
Continued burden of disease

Central adiposity, hypertension, dyslipidemia, and dysglycemia drive “cardiometabolic risk”

Cardiometabolic risk is associated with substantial cardiovascular morbidity and mortality

The ongoing epidemic of adiposity mandates evaluation of new approaches for managing cardiometabolic risk