04/21/23 قلب و عروق 1

Central obesity

By :Dr. H – Aghajani

Interventional cardiologistNCDC Director

Ministry of Health and Education

2

Approximately 2/3 billion adult : overweightMore than 700 million adult : obese

3

An estimated 300 million people around the world are obese as defined by a body mass index (BMI) of 30 or more

At least 155 million school-age children

worldwide are overweight or obese

In the world:

By 2015, an estimated 20 million people will die from cardiovascular disease every year, mainly from heart attacks and strokes (WHO)

Despite the decline in the number of deaths in the developed world, CVD is still pre-eminent as a public health issue.

IHD is responsible for all deaths in 2004 and is estimated to be 14.2% in 2030

In the developing world the prevalence of the risk factors for CVD is increasing

17.5 million people died from cardiovascular disease in 2005, representing around 30 % of all global deaths

7.6 million deaths were due to heart attacks and 5.7 million were due to stroke

80% of these deaths occurred in low and middle income countries

In EMRO: CVD is 31% of all Death causes

Lancet 2007 ; 370:1929 -38

In Iran: Chronic NCDs are 79% of death causes and

85%of diseases burden

CVD is the first cause of death(46%) and IHD is the main causes

Risk factorsRisk factorsRegional Regional

adjusted mean-adjusted mean-

20022002

Iran,2006Iran,2006Iran,2007Iran,2007

SmokingSmokingMalesMales

FemalesFemales4040

131322.9922.99

1.251.2527.0827.08

3.123.12

Hypertension>=140/Hypertension>=140/

909026269.89.817.3817.38

DiabetesDiabetes14.514.5----------10.710.7

Overweight/obesityOverweight/obesity434344.4644.4646.0146.01

Food Environment – Influencing Factors(Causal Web of influence on the prevalence of obesity – Harris, University of North Carolina)

Macro physical, cultural, economic and social environment

Dietary intakes

Energyexpenditures

Obesity

Household/individual/social/demographic/economic

Psychological/behavioural

Clinical

Biological (genetic,neurochemical, etc)

ChildhoodEmergingadulthood

Youngadulthood

OlderadulthoodAdolescence

Sedentary lifestyle

Diabetes Hypertension Obesity Stress Hostile

personality

Cigarette smoking Anabolic steroids Amphetamines Oral contraceptives Diet high in

saturated fats Heredity

12

CountryYear of field

work

Hypercholestrolemia (%)

Smoking (%)

Low physical activity

(%)

Low intake of fresh fruit and vegetables (%)

cholesterol level ≥ 5.2mmoL/dl

current daily smokers

daily activity ≤ 10 min

≤5 serving / day

Iraq200537.521.656.791.4

Jordan200746255184

Saudi Arabia200719.151167.793.45

Syrian Arab Republic20033424.731.1595.7

Kuwait200538.620.664.781

Egypt2005-200619.41850.679

Oman200627.69.369.933.2

Sudan200519.81286.8

Iran20073311.435.287(<5)

13

Chronic heart failure

ArrhythmiaArterial & venousthrombosis/

cardiac & cerebral events

AtherosclerosisAtherosclerosis

HypertensionDiabetes

Dyslipidaemia

Obesity

StressSmoking

Physicalinactivity

Excessivefood intakeLife style

intervention

Risk factor modification

Life style is a Driver of CVD

Unmet clinical needs to address in the next decade

CARDIOVASCULAR DISEASE

Classical Risk Factors Novel Risk Factors

Major Unmet Clinical Need

Metabolic syndromeMetabolic syndrome

AbdominalObesity

HDL-C

TG

TNF IL-6

PAI-1

Glu

Insulin

T2DM Smoking LDL-C BP

Adiponectin in IAA

Anti-atherogenic/antidiabetic:

foam cells vascular remodelling insulin sensitivity hepatic glucose output

IL-6 in IAA

Pro-atherogenic/pro-diabetic:

vascular inflammation insulin signalling

TNF in IAA

Pro-atherogenic/pro-diabetic:

insulin sensitivity in adipocytes (paracrine)

PAI-1 in IAA

Pro-atherogenic:

atherothrombotic risk

Properties of key adipokines

IAA: intra-abdominal adiposity

Marette 2002

Health threat from abdominal obesity is largely due to intra-abdominal adiposity

AbdominalObesityDyslipidemia

HypertensionGlucose IntoleranceInsulin Resistance

Increased Cardiometabolic Risk

Intra-AbdominalAdiposity

Adapted from Eckel et al 2005

Why is abdominal obesity harmful?

Abdominal obesity is often associated with other CV risk

factors

is an independent CV risk factor

Adipocytes are metabolically active endocrine organs, not simply inert fat storage

Wajchenberg 2000

Multiple cardiovascular risk factors drive adverse clinical outcomes

Abdominalobesity

DyslipidaemiaHypertension

Glucose intoleranceInsulin resistance

Increased Cardiometabolic Risk

Metabolic Syndrome

Direct observations show that abdominal

(visceral) obesity is more closely associated

to NIDDM than CVD, while an increased

WHR without obesity may be more closely

linked to CVD than NIDDM .

20

For a 1 cm increase in WC, the relative risk (RR) of a CVD event increased by 2% (95% CI: 1-3%) overall after adjusting for age, cohort year, or treatment.

For a 0.01 U increase in WHR, the RR increased by 5% (95% CI: 4-7%). These results were consistent in men and women.

21

Abdominal obesity andincreased risk of CHD

Waist circumference was independently associated with increased age-adjusted risk of CHD, even after adjusting for

BMI and other CV risk factors

0.0

0.5

1.0

1.5

2.0

2.5

3.0

<69.8 69.8-<74.2 74.2-<79.2 79.2-<86.3 86.3-<139.7

1.27

2.06 2.31

2.44p for trend = 0.007

Rel

ativ

e ri

sk

Rexrode et al 1998

Quintiles of waist circumference (cm)

Abdominal obesity and increased risk of cardiovascular events

Dagenais et al 2005

Ad

just

ed r

elat

ive

risk

1 1 1

1.17 1.16 1.14

1.29 1.27

1.35

0.8

1

1.2

1.4

CVD death MI All-cause deaths

Tertile 1Tertile 2Tertile 3

Men Women<95

95–103>103

<8787–98>98

Waistcirc. (cm):

Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-C, total-C

The HOPE Study

Unmet clinical need associated with abdominal obesity

Patients with

abdominal obesity

(high waist

circumference) often

present with one or

more additional

CV risk factors

CV risk factors in a typical patient with abdominal obesity

Abdominal obesity increases the risk of developing type 2 diabetes

<71 71–75.9 76–81 81.1–86 86.1–91 91.1–96.3 >96.3

24

20

16

12

8

4

0

Rel

ativ

e ri

sk

Waist circumference (cm)

Carey et al 1997

30

20

10

0Low

HDL-Ca

HighTGb

HighFPGc

HighBPd

<2 riskfactorse

Pre

vale

nce

of h

igh

wai

stci

rcum

fere

nce

asso

ciat

ed w

ith%

) (

a<40 mg/dL (men) or <50 mg/dL (women); b>150 mg/dL; c>110 mg/dL; d>130/85 mmHg; eNCEP/ATP III metabolic syndrome

US population age >20 years

NHANES 1999–2000 cohort; data on file

Female

Male

27

FemaleMale

28

29

30

%

31

32

33

34

35

36

37

38

39

40

41

RR

42

Obesity and CancerObesity and Cancer

Obesity is associated with the following Obesity is associated with the following types of cancer: types of cancer:

coloncolon breast (postmenopausal)breast (postmenopausal) endometrium (the lining of the uterus)endometrium (the lining of the uterus) kidneykidney gallbladdergallbladder pancreaspancreas esophagusesophagus

National Cancer Institute

In 2002, an estimated 41,000 new In 2002, an estimated 41,000 new cases of cancer in the United States cases of cancer in the United States were due to obesity. About 3.2 percent were due to obesity. About 3.2 percent of all new cancers are linked to obesity of all new cancers are linked to obesity (1).(1).

14% of deaths from cancer in men & 14% of deaths from cancer in men & 20% of deaths in women were due to 20% of deaths in women were due to overweight and obesity(2). overweight and obesity(2).

1. Polednak AP. Trends in incidence rates for obesity-associated cancers in the U.S. Cancer Detection and Prevention 2003; 27(6):415–421.

2. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort

of U.S. adults. New England Journal of Medicine 2003; 348(17):1625–1638.

Obesity and CancerObesity and Cancer

Obesity and physical inactivity may Obesity and physical inactivity may account for 25%-30% of cancer of the account for 25%-30% of cancer of the colon, breast (postmenopausal), colon, breast (postmenopausal), endometrial, kidney, and esophagus endometrial, kidney, and esophagus

Preventing weight gain can reduce the Preventing weight gain can reduce the risk of many cancers. Healthy eating risk of many cancers. Healthy eating and physical activity early in life can and physical activity early in life can prevent overweight and obesity. prevent overweight and obesity.

National Cancer Institute

Obesity and CancerObesity and Cancer

Sessions address: Parents as role models of eating and

exercise behavior Nutrition: Moderating Portion Sizes Fruits and Vegetables Family Meals Physical Activity

The Feeding Relationship Mindful Eating Resisting Media Influences Healthy Body Image and Dealing with

Teasing

Adult interventions have had poor outcomes

Treating childhood overweight is an important strategy for the prevention of adult obesity.

1. Physical Activity Intervention monitored, structured physical activity session one

day each week two additional days of physical activity at YMCA

2. Behavioral Intervention intake behavioral specialist bi-weekly, ongoing, structured, same gender

groups homework is assigned and goal monitoring t

3. Nutrition Intervention 30 minute twice-monthly meetings with the

dietitian

Our intervention will incorporate an intensive parental intervention within an established adolescent program (TEENS Program).

بMر اسMاس یMک مطالعMه در آمریکMا کMه در مMردان و زنMان تنMهMا 64M-35چMاMق M،MدMام شMجMان MالMدار 10 سMپای MاهشMک M%BMI زانMیMم Mس، وMنMن، جMسM هMه بMتMبس M،اقMچM رادMفMاM در BMI

M:بودM راهMا نتایج زیر همMاولیه، ب.I) االMون بMار خMا فشMوام بMدگی تMای زنMال هM2/9کاهش س-

نMوع1/2 سMال)M ،MدیMاMبت 2M) کلسMترMول 1/7-0/5 M، سMال) سال)0/3-0/8خون باال (

.II زیMکته مغMروز سMیزان بMزار و 1-13کاهش مMورد درهMم MرMکرونM روقMاری عMول 12-38بیمMار در طMزMورد در هMم

زندگی..III ماه.2-7افزایش امید به زندگی به میزان .IV تیMای بهداشMراقبت هMه مMذکور در 5کاهش هزینMاری مMبیم

دالر.2200-5300طMول زندگی Mبه میMزان

استرالیا)1989(

فرانسه)1992(

انگلستان)2004(

آمریکا)1995(

هزینه اقتصادی

میلیون 395دالر استرالیا

بیلیون 11/89فرانک فرانسه

بیلیون 1/15پوند انگلیس

بیلیون 51/6دالر آمریکا

هزینه مستقیم

بیلیون 2/55پوند انگلیس

بیلیون 47/6دالر آمریکا

هزینه غیر مستقیم

کشورهای توسعه یافته

کشورهای در حال توسعه با

مرگ و میر پایین

کشورهای در حال توسعه با

مرگ و میر باال

جنسیت

مرد9/6%4/2%1/1%

زن11/5%5/6%2%

کشورهای توسعه یافته

کشورهای در حال توسعه با

مرگ و میر پایین

کشورهای در حال توسعه با

مرگ و میر باال

جنسیت

مرد6/9%2/3%0/6%

زن1% 8/1%3/2%

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