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

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 most
dangerous 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 ] *
1- Hypertension
2- Blood fat
3- Obesity ( BMI) **
4- micro albuminuria
+ 2 out of 4 :-
* 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)
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 :
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
Waist circumference
Country / Ethnic group
Male
94 cm
Female
80 cm
Male
South Asians
Based on a Chinese , Malay and Asian-Indian Female
population
90 cm
80 cm
Chinese
Male
Female
90 cm
80 cm
Japanese**
Male
Female
90 cm
80 cm
Ethnic South and Central Americans
Use South Asian recommendations until
more specific data are available
Europids*
In the USA, the ATP III values ( 102 cm male;
88 cm female) are likely to continue to be
used for clinical purposes
Sub-Saharan Africans
Use European data until more specific
data are available
EMME ( Arab) populations
Use 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 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
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 )
Triglycerides
6 - <10
90
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
10 - < 16
90 or adult
cut-off if
lower
( 150 mg/dL)
16 +
HDL-C
( < 40mg/dL)
Use existing IDF criteria for adults
Blood
pressure
Syst. 130
diast85
mmHg
Glucose
(mg/ dl) or
known T2DM
(100 mg/dL)
[ or known
T2DM ]
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 Regionِ
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
180
SEA
233
EMME
(514)
SACA
625
WP
684
NA
1188
EUR
1561
---------------------------------Global av.
712
Mean Health Expenditure /person
with diabetes in different regions
ID
2000
1561
1500
1188
1000
684
514 625
180 233
500
EU
R
NA
P
W
SE
A
EM
M
E
SA
C
A
Af
r
ic
a
0
EMME Countries according to The Mean Health
Expenditure per person with diabetes in ID
(international Dollar) : Diabetes Atlas, 3rd Ed.
> 200
Afghanistan 56
Iraq
72
Pakistan
99
Sudan
103
Yemen
110
Syria
185
200-600
Alger
Morocco
Egypt
Libya
273
285
286
384
600- 1000
> 1000
Oman
614
Tunisia
637
Jordan
711
Iran
744
Kuwait
806
Saudi Arabia 891
Emirates
929
Bahrain 1047
Lebanon 1050
Qatar
1198
Cost of DM in relation to funds available
(Egyptian Study)
DIRECT COST
OF TREATMENT
OF DM
AVAILABLE
GOVERNMENT
EXPENDITURE ON
HEALTH
L.E.235.2m
L.E. 351.8m
2/3!!
Hospital Treatment 2001 Cost /Day
(Egyptian Study )
400%
354%
350%
346%
300%
250%
200%
150%
100%
100%
120.80%
50%
0%
DM
+CVD
+R.F.
+Diab. Foot
Distribution of Hospital Cost
55%
Medicine
& Supp.
45%
Basic
( Food : 5%
H.C.Team 11%
Others: 29%)
Year Cost / percapit. Burden for Human Insulin (40 u /d)
8.85%
EGYPT
1.9%
QATAR
3.1%
SAUDI ARABIA
Cost Burden of Oral Treatment related to Per capitum
4.2%
29.9%
EGYPT
QATAR
8.4%
SAUDI ARABIA
Alexandria – Montazah Palace
Thank You