肥胖的并发症-课件.ppt

1、Medical Complications of ObesityBMI-Associated Disease RiskClassificationBMI(kg/m2)RiskUnderweight40Extremely highClinical Guidelines on the Identification,Evaluation,and Treatment of Overweight and Obesity in AdultsThe Evidence Report.Obes Res 1998;6(suppl 2).Additional risks:Large waist circumfere

2、nce(men40 in;women 35 in)5 kg or more weight gain since age 18-20 y Poor aerobic fitness Specific races and ethnic groupsWeight(lb)2322211918171615152524222120191817162726242321201918172927262423222019183129282624232221203331292726242322213533312927262423223735333129272624233937343230292726244138363

3、432302927264340383634323028274542403735333130284744413937353331294946434038363432305148454240373533325349464441393735335551484543403836345753504744423937355955524946434139376359555248464341406662585552494644417066625855524946447470656158555249467873696561575451491201301401501601701801902002102203203

4、40360240250260230270280290380300400Height(in)Body Mass Index Chart010203040506070Relationship Between BMI and Percent Body Fat in Men and WomenAdapted from:Gallagher et al.Am J Clin Nutr 2000;72:694.Body Fat(%)Body Mass Index(kg/m2)0103040602050WomenMenMedical Complications of ObesityMetabolic Syndr

5、omeAbdominal obesityHyperinsulinemiaHigh fasting plasma glucoseImpaired glucose toleranceHypertriglyceridemiaLow HDL-cholesterolHypertensionEvolution of Metabolic SyndromeIsomaa B et al.Diabetes Care.2001;24:683-689.AKA:Insulin Resistance Syndrome;Syndrome X;Dysmetabolic Syndrome;Multiple Metabolic

6、Syndrome1923:Kylin describes clustering of hypertension,gout,and hyperglycemia1988:Reaven describes“Syndrome X”hypertension,hyperglycemia,glucose intolerance,elevated triglycerides,and low HDL cholesterol1998:World Health Organization defines“metabolic syndrome”as clustering of hypertension,low HDL,

7、hypertriglyceridemia,insulin resistance,glucose intolerance or type 2 diabetes,high waist-to-hip ratio,and microalbuminuriaAbdominal obesity Glucose intolerance/Insulin resistance Hypertension Atherogenic dyslipidemiaProinflammatory/Prothrombotic stateCharacteristics of the Metabolic Syndrome:NCEP-A

8、TP IIINational Cholesterol Educational Program(NCEP),Adult Treatment Panel(ATP)III;2001.Clinical Identification of the Metabolic Syndrome*:NCEP-ATP III*Diagnosis is established when 3 of these risk factors are presentRisk FactorDefining LevelAbdominal obesity(Waist circumference)Men102 cm(40 in)Wome

9、n88 cm(35 in)TG150 mg/dLHDL-C Men40 mg/dL Women130/85 mm HgFasting glucose110(100*)mg/dLExpert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA.2001;285:2486-2497.*2003 New ADA IFG criteria(Diabetes Care)0510152025303540455020-70+20-2930-3940-4950-5960-6970Increas

10、ing Prevalence of NCEP Metabolic Syndrome with Age(NHANES III)Prevalence(%)AgeMen WomenFord E et al.JAMA.2002;287:356-359.0%5%10%15%20%25%Prevalence of CHD by the Metabolic Syndrome and Diabetes in the NHANES Population Age 50+CHD PrevalenceNo MS/No DM8.7%of Population=54.2%28.7%2.3%14.8%Alexander C

11、,et al.Diabetes 52:1210-1214,200313.9%7.5%19.2%MS/No DMDM/No MSDM/MS010203040MenWomenPrevalence of the Metabolic Syndrome Varies by Sex and Race/Ethnicity(NHANES III)Prevalence(%)AgeFord E et al.JAMA.2002;287:356-359.WhiteAfrican-AmericanMexican-AmericanOther25%16%28%21%23%26%36%20%Metabolic Syndrom

12、e:Impact on Mortality0510152025All-cause MortalityCardiovascular MortalityMortality Rate(%)Without metabolic syndromeWith metabolic syndrome*Isomaa B et al.Diabetes Care.2001;24:683-689.*P 0.001.*Metabolic Syndrome:Impact on Cardiovascular Health0510152025CHDMIStrokePrevalence(%)Without metabolic sy

13、ndromeWith metabolic syndrome*P 0.001.Isomaa B et al.Diabetes Care.2001;24:683-689.*0123456Elevated Risk of CVD Prior to Clinical Diagnosis of Type 2 DiabetesRelative Risk1.00Nondiabeticthroughoutthe studyHu FB et al.Diabetes Care.2002;25:1129-1134.Prior todiagnosisof diabetesAfter diagnosisof diabe

14、tesDiabetic atbaseline2.823.715.02Characteristics of Metabolically Normal Obese and Metabolically Abnormal Obese SubjectsPostmenopausal women.*P=0.03;*P=0.0001.LBM=lean body mass.AT=adipose tissue.Brochu M et al.J Clin Endocrinol Metab.2001;86:1020-1025.InsulinSensitive(n=17)InsulinResistant(n=26)BM

15、I(kg/m2)31.534.7Fat mass(kg)37.339.0Lean body mass(kg)43.848.1*Body fat(%)45.244.8Total Energy Expenditure(cal/d)29553051Glucose disposal(mg/min x kg LBM)11.25.7*Subcutaneous AT(cm2,L4-L5)447+144434+130Visceral AT(cm2,L4-L5)141+53211+85*Subcutaneous AT(cm2,leg)208+64187+82Muscle attenuation(Hounsfie

16、ld U,leg)42.2+2.643.6+4.8Lipids and Lipoproteins&Resting BP in Insulin-Sensitive and Insulin-Resistant Obese SubjectsInsulinSensitive(n=17)InsulinResistant(n=26)Total cholesterol(mmol/L)5.14+0.804.84+0.91Triglycerides(mmol/L)1.50+0.852.02+0.87*LDL cholesterol(mmol/L)3.28+0.723.00+0.85HDL cholesterol

17、(mmol/L)1.16+0.470.91+0.31*TC/HDL cholesterol5.0+1.85.7+1.8Systolic BP(mm Hg)137.2+14.5139.7+14.8Diastolic BP(mm Hg)72.5+11.175.6+8.2Postmenopausal women.Data are mean SD.*P=0.01.Brochu M et al.J Clin Endocrinol Metab.2001;86:1020-1025.Oral Glucose Tolerance in Insulin-Sensitive and Insulin-Resistan

18、t Obese SubjectsInsulinSensitive(n=17)InsulinResistant(n=26)Fasting glucose(mmol/L)4.78+0.305.21+0.61*Fasting insulin(pmol/L)55.2+14.3136.3+88.2*2 hr glucose(mmol/L)6.02+2.317.28+1.672 hr insulin(pmol/L)250.4+98.3955.7+754.8*Glucose area(mmol/L x 10-3)0.79+0.140.91+0.17Insulin area(pmol/L x 10-3)31.

19、6+16.5108.3+4.6*Postmenopausal women.n=12,sensitive;n=23,resistant.Data are mean SD.*P=0.01;*P=0.005;*P=0.001.Brochu M et al.J Clin Endocrinol Metab.2001;86:1020-1025.01020304050BMI 30Waist Size vs BMI and the Metabolic Syndrome8-y Incidence of Metabolic Syndrome(%)Waist circumference level 2*Han TS

20、 et al.Obes Res.2002;10:923-931.*Level 2=waist 40 inches in men or 35 inches in women.9.9820.4519.7733.4305101520253035Both Insulin Resistance and Decreased Insulin Secretion Predict the Risk of Developing Type 2 Diabetes:7-Year IncidencePercentNeitherLowHighHaffner SM et al.Circulation.2000;101:975

21、-980.Insulin secretionLowLowInsulin resistanceHighHighBothHighLowMetabolic statusHOMA-IR I30-0min/G30-0minDistribution by Metabolic Status Among Converters to Type 2 Diabetes(83%of Prediabetic Subjects are Insulin Resistant)Haffner SM et al.Circulation.2000;101:975-980.Low insulin secretion;insulin

22、sensitive(15.9%)Neither(1.5%)Insulin resistant;good insulinsecretion(28.7%)012345Qt 2Qt 3Qt 4Qt 5012345Qt 2Qt 3Qt 4Qt 5Insulin Resistance(HOMA-IR Quintiles)are Related to CV Disease:San Antonio Heart StudyIncreasing Insulin ResistanceA:adjusted for age,sex,and ethnicityB:adjusted for age,sex,and eth

23、nicity,LDL,triglyceride,HDL,systolic blood pressure,fasting glucose,smoking,alcohol consumption,and leisure time exerciseHanley A et al.Diabetes Care.2002;25:1177-1184.AHOMA IRBOdds Ratio(95%CI)Increasing Risk of CVDP(trend)0.0001P(trend)0.0075Intra-Abdominal Fat Mass and CHD Risk in Type 2 Diabetes

24、QuintileWaist Circumference(in)Relative Risk for CHD115.0 to 27.51.0227.5 to 29.21.27329.2 to 31.22.08431.2 to 34.02.31534.0 to 54.72.44Adjusted for BMI,age(continuous),age2,smoking,parental history of myocardial infarction,alcohol consumption,physical activity,menopausal status,hormone replacement

25、therapy,aspirin intake,saturated fat,and antioxidant score.Rexrode W et al.JAMA.1998;280:1843-1848.P 0.001 for trend.Ectopic Lipids and the Metabolic SyndromeMetabolic syndrome reflects failure of intracellular lipohomeostasis,which prevents lipotoxicity in organs of overnourished individualsNormal

26、individuals:lipohomeostasis(ie,lipid overload confined to white adipocytes,designed to store surplus calories)Obese individuals:adipocytes increase leptin secretion in an attempt to enhance oxidation of surplus lipid in nonadipocytesDeficiency or nonresponsiveness to leptin prevents these protective

27、 events and results in ectopic accumulation of lipidsPancreatic-cells and myocardiocytes are“cellular victims”leading to type 2 diabetes and lipotoxic cardiomyopathyUnger RH.Endocrinology.2003.0.61.01.41.82.22.63.0Relationship Between BMI and Cardiovascular Disease MortalityRelative Risk of DeathBod

28、y Mass index40.0LeanOverweightObese0255075100Relationship Between BMI and Risk of Type 2 DiabetesChan J et al.Diabetes Care 1994;17:961.Colditz G et al.Ann Intern Med 1995;122:481.Age-Adjusted Relative RiskBody Mass index(kg/m2)222323-23.924-24.925-26.927-28.929-30.931-32.933-34.935+1.02.91.04.31.05

29、.01.58.12.215.84.427.640.354.093.26.711.621.342.100.511.522.5Waist-HipRatioTertileAbdominal Fat Distribution Increases the Risk of Coronary Heart DiseaseThe Iowa Womens Health StudyFolsom et al.Arch Intern Med 2000;160:2117.Relative riskBody Mass Index Tertile2133210123456Relationship Between Weight

30、 Gain in Adulthood and Risk of Type 2 Diabetes MellitusRelative RiskWeight Change(kg)Willett et al.N Engl J Med 1999;341:427.-10-5051015200102030405060Direct Cost*of Chronic Diseases in the United StatesDirect Cost($Billions)Type 2DiabetesWolf AM,Colditz GA.Obes Res.1998;6:97-106.Hodgson TA,Cohen AJ

31、.Med Care.1999;37:994-1012.*Adjusted to 1995 dollars.ObesityCoronaryHeart DiseaseHyper-tensionStroke$18.1$18.4$38.7$51.6$53.2010000200003000040000Effect of Obesity on Expected Lifetime Medical Care Costs*in MenCosts($)*Body Mass Index(kg/m2)32.527.537.555-6445-54*Total cost of CHD,type 2 DM,hyperten

32、sion,hypercholesterolemia,strokeAge(y)Thompson et al.Arch Intern Med 1999;159:2177.35-4422.5020406080100Increase in Healthcare Costs Among Obese Compared with Lean(BMI 35 kg/m2Quesenberry CP Jr et al.Arch Intern Med.1998;158:466-472.*HMO Setting:Northern California Kaiser Permanente.Healthcare visit

33、sPharmacyLaboratory testsAll outpatient servicesAll inpatient servicesTotal healthcare$0$2,000$4,000$6,000$8,000$0$400$800$1,200$1,600Economic Effect of Obesity to Business:3-Year Costs to First Chicago NBDBurton et al.J Occup Environ Med 1998;40:786.*BMI 27.8 kg/m2 in men;27.3 kg/m2 in women.Absent

34、eeismHealthcare$4,496$6,822$683$1,546Annual Medical Expenditures Attributable to Obesity in USNew study quantifying state-level expenditures Model developed to predict expenditures by combining MEPS and BRFFS dataObesity prevalence for US estimated at 20%of total adult populationPrevalence varies co

35、nsiderably by state Overall range:15%(CO)25%(WV)Finkelstein,et al Obes Res.2004;12:18-24.MEPS=1998 Medical Expansion SurveyBRFSS=Behavioral Risk Factor Surveillance SystemAnnual Medical Expenditures Attributable to Obesity in US6%total adult medical expenditures are attributable to obesity Range:4%(

36、AZ,CT)7%(AK)7%Medicare expenditures Range:4%(AZ)10%(DE)11%adult Medicaid expenditures Range:8%(RI)16%(IN)Finkelstein,et al Obes Res.2004;12:18-24.Annual Medical Expenses Attributable to Obesity in Selected StatesTotalMedicareMedicaidState%(millions$)%(millions$)%(millions$)AK6.7(195)7.7(17)8.2(29)AZ

37、4.0(752)3.9(154)13.5(242)CA5.5(7,675)6.1(1,738)10.0(1,713)GA6.0(2,133)7.1(405)10.1(385)NY5.5(6,080)6.7(1,391)9.5(3,539)TX6.1(5,340)6.8(1,209)11.8(1,177)Finkelstein,et al Obes Res.2004:12 18-24In the US as a whole,obesity attributable medical expenditures are estimated at$75 billion with$17 billion financed by Medicare and$21 billion financed by Medicaid.