肥胖的并發(fā)癥課件

1、Medical Complications of ObesityMedical Complications of ObesiBMI-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).Addit

2、ional risks:Large waist circumference (men40 in; women 35 in)5 kg or more weight gain since age 18-20 yPoor aerobic fitnessSpecific races and ethnic groupsBMI-Associated Disease RiskClaWeight (lb)23222119181716151525242221201918171627262423212019181729272624232220191831292826242322212033312927262423

3、222135333129272624232237353331292726242339373432302927262441383634323029272643403836343230282745424037353331302847444139373533312949464340383634323051484542403735333253494644413937353355514845434038363457535047444239373559555249464341393763595552484643414066625855524946444170666258555249464474706561

4、585552494678736965615754514912013014015016017018019020021022032034036024025026023027028029038030040064Height (in)6260706866727476Body Mass Index ChartWeight (lb)2325272931333537394Relationship Between BMI and Percent Body Fat in Men and WomenAdapted from: Gallagher et al. Am J Clin Nutr 2000;72:694.

5、Body Fat (%)Body Mass Index (kg/m2)0103040602050WomenMenRelationship Between BMI and PPulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndromeNonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosisCoronary heart disease Diabetes Dyslipidemia HypertensionGynecologic

6、 abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndromeOsteoarthritisSkinGall bladder diseaseCancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostatePhlebitisvenous stasisGoutMedical Complications of ObesityIdiopathic intracranial hypertensionStrokeCataractsSevere pancreati

7、tisPulmonary diseaseNonalcoholic Metabolic SyndromeAbdominal obesityHyperinsulinemiaHigh fasting plasma glucoseImpaired glucose toleranceHypertriglyceridemiaLow HDL-cholesterolHypertensionMetabolic SyndromeAbdominal obEvolution of Metabolic SyndromeIsomaa B et al. Diabetes Care. 2001;24:683-689.AKA:

8、 Insulin Resistance Syndrome; Syndrome X; Dysmetabolic Syndrome; Multiple Metabolic Syndrome1923: Kylin describes clustering of hypertension, gout, and hyperglycemia1988: Reaven describes “Syndrome X” hypertension, hyperglycemia, glucose intolerance, elevated triglycerides, and low HDL cholesterol19

9、98: World Health Organization defines “metabolic syndrome” as clustering of hypertension, low HDL, hypertriglyceridemia, insulin resistance, glucose intolerance or type 2 diabetes, high waist-to-hip ratio, and microalbuminuriaEvolution of Metabolic SyndromAbdominal obesity Glucose intolerance/ Insul

10、in resistance Hypertension Atherogenic dyslipidemiaProinflammatory/Prothrombotic stateCharacteristics of the Metabolic Syndrome: NCEP-ATP IIINational Cholesterol Educational Program (NCEP), Adult Treatment Panel (ATP) III; 2001.DiabetesCVDAbdominal obesity CharacteristClinical Identification of the

11、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) Women88 cm (35 in)TG150 mg/dLHDL-C Men40 mg/dL Women130 / 85 mm HgFasting glucose110 (100*) mg/dLExpert Panel on Detect

12、ion, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.* 2003 New ADA IFG criteria (Diabetes Care)Clinical Identification of theIncreasing Prevalence of NCEP Metabolic Syndrome with Age (NHANES III)Prevalence (%)AgeMen WomenFord E et al. JAMA. 2002;287:356-359.I

13、ncreasing Prevalence of NCEP 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, et al. Diabetes 52: 1210-1214, 200313.9%7.5%19.2%MS/No DMDM/No MSDM/MSPrevalence of CHD by the MetabP

14、revalence 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%Prevalence of the Metabolic SyMetabolic Syndrome: Impact on MortalityMortality Rate (%)Without meta

15、bolic syndromeWith metabolic syndrome*Isomaa B et al. Diabetes Care. 2001;24:683-689.*P 0.001.*Metabolic Syndrome: Impact on Metabolic Syndrome: Impact on Cardiovascular HealthPrevalence (%)Without metabolic syndromeWith metabolic syndrome*P 0.001.Isomaa B et al. Diabetes Care. 2001;24:683-689.*Meta

16、bolic Syndrome: Impact on Elevated 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 diabetesDiabetic atbaseline2.823.715.02Elevated Risk of CVD Prior to

17、 Characteristics 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)BMI (kg/m2)31.534.7F

18、at 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 (H

19、ounsfield U, leg)42.2 + 2.643.6 + 4.8Characteristics of MetabolicalLipids 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 + 0.8

20、7*LDL cholesterol (mmol/L)3.28 + 0.723.00 + 0.85HDL cholesterol (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 M

21、etab. 2001;86:1020-1025.Lipids and Lipoproteins & RestOral Glucose Tolerance in Insulin-Sensitive and Insulin-Resistant 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.

22、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)31.6 + 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

23、 Endocrinol Metab. 2001;86:1020-1025.Oral Glucose Tolerance in InsuWaist Size vs BMI and the Metabolic Syndrome8-y Incidence of Metabolic Syndrome (%)Waist circumference level 2*Han TS et al. Obes Res. 2002;10:923-931.*Level 2 = waist 40 inches in men or 35 inches in women.9.9820.4519.7733.43Waist S

24、ize vs BMI and the MetaBoth Insulin Resistance and Decreased Insulin Secretion Predict the Risk of Developing Type 2 Diabetes: 7-Year IncidencePercentNeitherLowHighHaffner SM et al. Circulation. 2000;101:975-980.Insulin secretionLowLowInsulin resistanceHighHighBothHighLowMetabolic statusHOMA-IR I30-

25、0min/G30-0minBoth Insulin Resistance and DeDistribution 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.Both (54%)(n = 195)Low insulin secretion; insulin sensitive (15.9%)Neither (1.5%)Insulin r

26、esistant;good insulinsecretion (28.7%)Distribution by Metabolic StatInsulin 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 ethnicity, LDL, triglyceride, HDL, systolic b

27、lood 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) 0.0075Insulin Resistance (HOMA-IR QuIntra-Abdominal Fat Mass and CHD Risk in Type 2 Diab

28、etesQuintileWaist 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, hormon

29、e replacement therapy, aspirin intake, saturated fat, and antioxidant score.Rexrode W et al. JAMA. 1998;280:1843-1848.P 0.001 for trend.Intra-Abdominal Fat Mass and CEctopic Lipids and the Metabolic SyndromeMetabolic syndrome reflects failure of intracellular lipohomeostasis, which prevents lipotoxi

30、city in organs of overnourished individualsNormal 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 o

31、r nonresponsiveness to leptin prevents these protective 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.Ectopic Lipids and the MetabolRelationship Betw

32、een BMI and Cardiovascular Disease MortalityRelative Risk of DeathBody Mass index40.0LeanOverweightObeseRelationship Between BMI and CRelationship 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 RiskBod

33、y Mass index (kg/m2)MenWomen222323-23.924-24.925-26.927-28.929-30.931-32.933-34.935+1.02.91.04.31.05.015.84.427.640.354.093.26.711.621.342.1Relationship Between BMI and RWaist-HipRatioTertileAbdominal Fat Distribution Increases the Risk of Coronary Heart DiseaseThe Iowa Womens Health StudyF

34、olsom et al. Arch Intern Med 2000;160:2117.Relative riskBody Mass Index Tertile213321Waist-HipRatioTertileAbdominRelationship Between Weight Gain in Adulthood and Risk of Type 2 Diabetes MellitusRelative RiskWeight Change (kg)Willett et al. N Engl J Med 1999;341:427.-10-505101520MenWomenRelationship

35、 Between Weight GaDirect 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. Med Care. 1999;37:994-1012.*Adjusted to 1995 dollars.ObesityCoronaryHeart DiseaseHyper-tensionStroke$18.1$18.4$38.7$51.6$53

36、.2Direct Cost * of Chronic DiseaEffect 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, hypertension, hypercholesterolemia, strokeAge (y)Thompson et al. Arch Intern Med 1999;159:2177.35-4422.5Effect of Obe

37、sity on Expected Increase 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 visitsPharmacyLaboratory testsAll outpatient servicesAll inpatient servicesTotal healthc

38、areIncrease in Healthcare Costs AEconomic 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.AbsenteeismHealthcareLeanObese*$4,496$6,822$683$1,546Economic Effect of Obesity to Annual Medical Expenditures Attributable to Obesity in USNew study quantifying state-level expendituresModel developed to predict expenditures by combining MEPS and BRFFS dataObesity prevalence for US estimated at 20% of total adult populationPrevalence varies considerably by stateOverall ra