the metabolic syndrome the new idf defintion and the socio-economic burden prof. morsi arab...
TRANSCRIPT
THE METABOLIC SYNDROME
THE NEW IDF DEFINTION
and
THE SOCIO-ECONOMIC BURDEN
Prof. Morsi Arab
University of Alexandria
IDF Chairman EMME Region
THE SIMPLE CONCEPT OF THE METABOLIC SYNDROME ( MTS )
The Metabolic Syndrome is a cluster of the mostdangerous risk factors for heart attack:
- diabetes / raised fasting plasma glucose,+
- abdominal obesity , - high blood pressure
- defective Cholesterol Metab.
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
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
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(
“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?
“Abdominal Obesity “ as measured by waist
circumference is more indicative of the
Metabolic Syndrome profile than increased BMI
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
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
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
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(.
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 (
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 .
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
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)
The new international Diabetes Federation (IDF) definitionAccording 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:
Raised triglycerides
150 mg/dL (1.7 mmol/L )
or specifc treatment for this lipid abnormality.
Reduced HDL Cholesterol
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
Raised blood pressure
Systolic BP 130 or diastolic BP 85 mmHg
Or treatment of previously diagnosed hypertension
Raised fasting plasma glucose
)FPG (100 mg/dL (5.6 mmol/L)
or previously diagnosed type 2 diabetes
Ethnic specific values for waist circumference
Country / Ethnic group Waist circumference
Europids*
In the USA, the ATP III values ( 102 cm male; 88 cm female) are likely to continue to be
used for clinical purposes
Male
Female
94 cm
80 cm
South Asians
Based on a Chinese , Malay and Asian-Indian population
Male
Female
90 cm
80 cm
ChineseMale
Female
90 cm
80 cm
Japanese**Male
Female
90 cm
80 cm
Ethnic South and Central AmericansUse South Asian recommendations until more specific data are available
Sub-Saharan Africans Use European data until more specific
data are available EMME ( Arab) populationsUse South Asian recommendations
until more specific data are available
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
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
The MTS in Young PeopleResearch 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
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.
The IDF definition of the at risk group and metabolic syndrome in children and adolescents
Age group (years)
Obesity*
)WC(
TriglyceridesHDL-CBlood pressure
Glucose (mg/ dl) or known T2DM
6< - 1090Metabolic 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
10 - < 16 90 or adult cut-off if lower
) 150 mg/dL( < )40mg/dL(Syst. 130 diast85mmHg
)100 mg/dL(
]or known T2DM[
16+ Use existing IDF criteria for adults
The Socio economic Burden
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
�ِ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 (
Can we meet the Challenge?
Mean Health Expenditure per person with diabetes ( 2007 ) in ID ( international Dollar) in different regions Africa 180SEA 233EMME (514)SACA 625WP 684NA 1188EUR 1561----------------------------------Global av. 712
Mean Health Expenditure /person with diabetes in different regions
180 233514 625 684
11881561
0
500
1000
1500
2000ID
<200200-600600 -1000 <1000
Afghanistan 56
Iraq 72
Pakistan 99
Sudan 103
Yemen 110
Syria 185
Alger 273
Morocco 285
Egypt 286
Libya 384
Oman 614
Tunisia 637
Jordan 711
Iran 744
Kuwait 806
Saudi Arabia 891
Emirates 929
Bahrain 1047
Lebanon 1050
Qatar 1198
EMME Countries according to The Mean Health Expenditure per person with diabetes in ID (international Dollar) : Diabetes Atlas, 3rd Ed.
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!!
100%120.80%
354% 346%
0%
50%
100%
150%
200%
250%
300%
350%
400%
DM +CVD +R.F. +Diab. Foot
Hospital Treatment 2001 Cost /Day
(Egyptian Study )
55% Medicine & Supp.
45% Basic( Food : 5%
H.C.Team 11%
Others: 29%)
Distribution of Hospital Cost
8.85%
EGYPT
1.9%
QATAR
3.1%
SAUDI ARABIA
Year Cost / percapit. Burden for Human Insulin (40 u /d)
EGYPT
29.9%
Cost Burden of Oral Treatment related to Per capitum
QATAR
4.2%
8.4%
SAUDI ARABIA
Alexandria – Montazah Palace
Thank You