The Wxyz Of Cardiodiab Risk

THE WXYZ OF THE WXYZ OF CARDIODIAB CARDIODIAB

RISKRISKDR.RISHIKESAN K.VDR.RISHIKESAN K.V

VENNIYIL MED .CENTRE VENNIYIL MED .CENTRE

SHARJAHSHARJAH

DIABETES EPIDEMICDIABETES EPIDEMIC

EARLY RECOGNITION OF EARLY RECOGNITION OF RISK FACTORSRISK FACTORS

ENABLES THE CONTROL OF THE ENABLES THE CONTROL OF THE PROGRESSION OF THESE PROGRESSION OF THESE FACTORS BY LIFE STYLE CHANGE FACTORS BY LIFE STYLE CHANGE AND OR MEDICATIONSAND OR MEDICATIONS

LIFE STYLE CHANGES TARGET LIFE STYLE CHANGES TARGET WEIGHT LOSS AND INCREASED WEIGHT LOSS AND INCREASED PHYSICAL ACTIVITYPHYSICAL ACTIVITY

THE MNEMONIC WXYZTHE MNEMONIC WXYZ

W = THE WEIGHT/WAIST FACTORW = THE WEIGHT/WAIST FACTOR X = THE METABOLIC SYNDROME X = THE METABOLIC SYNDROME

(SYNDROME X ) ASSOCIATED (SYNDROME X ) ASSOCIATED WITH CENTRAL OVERWT.WITH CENTRAL OVERWT.

Y = WHY THE PARTICULAR Y = WHY THE PARTICULAR PERSON DEVELOPS THE PERSON DEVELOPS THE METABOLIC SYNDROMEMETABOLIC SYNDROME

Z = SLEEP APNOEA, NOT GETTING Z = SLEEP APNOEA, NOT GETTING ENOUGH SLEEPENOUGH SLEEP

W – THE WEIGHT/WAIST W – THE WEIGHT/WAIST FACTORFACTOR

EACH YEAR OUR WEIGHT AND WAIST EACH YEAR OUR WEIGHT AND WAIST GET BIGGER BOTH AS INDIVIDUALS GET BIGGER BOTH AS INDIVIDUALS AND AS A POPULATION.AND AS A POPULATION.

THERE ARE MANY FACTORS – BUT THE THERE ARE MANY FACTORS – BUT THE BIG TWO ARE _ HIGH ENERGY FOODBIG TWO ARE _ HIGH ENERGY FOOD

_ LOW ENERGY LIFE _ LOW ENERGY LIFE STYLESTYLE

FACTORS INCREASING FACTORS INCREASING WT.&WAISTWT.&WAIST

THE BIG TWOTHE BIG TWO

* EATING * EATING MOREMORE

* WALKING * WALKING LESSLESS

POSSIBLE OTHER POSSIBLE OTHER FACTORSFACTORS

*NOT ENOUGH SLEEP *NOT ENOUGH SLEEP *CLIMATE CONTROL*CLIMATE CONTROL*LESS SMOKING*LESS SMOKING*MEDICATIONS*MEDICATIONS*MATURE MUMS*MATURE MUMS*PRENATAL EFFCTS*PRENATAL EFFCTS*POLLUTION *POLLUTION *LIKE MARRYING LIKE*LIKE MARRYING LIKE*FAT EQUALS FECUND*FAT EQUALS FECUND

GLOBESITYGLOBESITY

Obesity is Obesity is becoming a global becoming a global problem.problem.

The prevalence of The prevalence of obesity is increasing obesity is increasing in Europe, Japan, & in Europe, Japan, & ChinaChina..

10% of Chinese 10% of Chinese children are obese. children are obese.

W FACTORW FACTOR

MEN AND WOMEN ARE GETTING MEN AND WOMEN ARE GETTING HEAVIER AND FATTERHEAVIER AND FATTER

WOMEN ARE GAINING .6 KG PER WOMEN ARE GAINING .6 KG PER EVERY YEAR AND MEN GAIN .4 KG EVERY YEAR AND MEN GAIN .4 KG PER YEAR.PER YEAR.

THIS W FACTOR CAN BE ASSESSED THIS W FACTOR CAN BE ASSESSED BY WAIST CIRCUMFERENCE.BY WAIST CIRCUMFERENCE.

> 88 CM. FOR WOMEN; > 102 CM > 88 CM. FOR WOMEN; > 102 CM FOR MENFOR MEN

TeleologyTeleology

Early humans Early humans evolved powerful evolved powerful mechanisms for mechanisms for storing & saving storing & saving energy.energy.

They ate as much They ate as much as possible when as possible when they had the they had the chance, stored it as chance, stored it as fat. They were fat. They were energy efficient. energy efficient.

We Are Victims We Are Victims Of Our SuccessOf Our Success

We still possess the adaptive We still possess the adaptive traits of our Paleolithic ancestors. traits of our Paleolithic ancestors. We are programmed to eat as We are programmed to eat as much as we can & store it as fat. much as we can & store it as fat. We are still energy efficient. If we We are still energy efficient. If we had not developed these traits we had not developed these traits we would have become extinct, would have become extinct,

but we have changed our but we have changed our environment!environment!

Why Have We GainedWhy Have We GainedSo Much Weight? So Much Weight?

The current epidemic of obesity is The current epidemic of obesity is not an epidemic of lack of character. not an epidemic of lack of character.

Obesity is a “complex multifactorial Obesity is a “complex multifactorial chronic disease that develops from chronic disease that develops from an interaction of genotype & an interaction of genotype & environment…it involves the environment…it involves the integration of social, behavioral, integration of social, behavioral, cultural, physiologic, metabolic & cultural, physiologic, metabolic & genetic factors” genetic factors”

Starvation Is No Longer A Starvation Is No Longer A ThreatThreat

We can produce We can produce large quantities of large quantities of cheap, convenient, cheap, convenient, tasty, high calorie tasty, high calorie foodfood

We are extremely We are extremely good at marketing good at marketing this food to adults this food to adults and to childrenand to children..

THE BIG TWOTHE BIG TWO

THE BIG TWO OF – HIGH ENERGY THE BIG TWO OF – HIGH ENERGY FOOD AND LOW ENERGY LIFE FOOD AND LOW ENERGY LIFE STYLE: FOR Eg :FAST FOOD , STYLE: FOR Eg :FAST FOOD , TELEVISION AND COMPUTER TELEVISION AND COMPUTER

WE LIVE IN AN ENVIRONMENT WE LIVE IN AN ENVIRONMENT DISPOSING TOWARDS OBESITYDISPOSING TOWARDS OBESITY

HEALTHY LIFESTYLE CHOICES HEALTHY LIFESTYLE CHOICES ARE HARD CHOICES ARE HARD CHOICES

We Don’t Have ToWe Don’t Have ToExpend Much EnergyExpend Much Energy

We have created We have created conditions that conditions that allow us to avoid allow us to avoid exertion at work, exertion at work, in travel, & in in travel, & in entertainment.entertainment.

We do little to We do little to promote exercise promote exercise at school or in at school or in our communities.our communities.

Our Diet Has ChangedOur Diet Has Changed

There are more There are more two wage earner two wage earner families & less families & less time to cook food time to cook food at home. at home.

We eat more fast We eat more fast food.food.

Fast food has been Fast food has been heavily marketed heavily marketed to children.to children.

OTHER SYSTEMATIC OTHER SYSTEMATIC FACTORS LEADING TO WT. FACTORS LEADING TO WT.

GAINGAIN SMOKING LESS AND SLEEPING LESS SMOKING LESS AND SLEEPING LESS

SEEM TO PREDISPOSE TO WT.GAINSEEM TO PREDISPOSE TO WT.GAIN

THE SUCCESS OF QUIT CAMPAIGN MAYTHE SUCCESS OF QUIT CAMPAIGN MAY

BE AT THE PRICE OF A FATTER BE AT THE PRICE OF A FATTER

POPULATION IN MANY COUNTRIESPOPULATION IN MANY COUNTRIES

*Heating and *Heating and Airconditioning in Airconditioning in

homes and workplaces homes and workplaces havehave

reduced the need for reduced the need for body energy expenditure body energy expenditure

to keep warm or cold.to keep warm or cold.*Overwt.people tend to *Overwt.people tend to have overwt.childrenhave overwt.children

* WOMEN ARE * WOMEN ARE DELAYING DELAYING

HAVING CHILDREN AND HAVING CHILDREN AND

OLDER MOTHERS TEND OLDER MOTHERS TEND TOTO

HAVE FATTER HAVE FATTER CHILDRENCHILDREN

* PEOPLE TEND TO BE * PEOPLE TEND TO BE ATTRACTED TO THOSE ATTRACTED TO THOSE WHO ARE LIKE THEMWHO ARE LIKE THEM

FAT PERSON LIKELY TO MARRY FAT FAT PERSON LIKELY TO MARRY FAT

PERSON , POSSIBLY AMPLIFYING PERSON , POSSIBLY AMPLIFYING

INCREASES IN OBESITYINCREASES IN OBESITY

EXPOSURE TO EXPOSURE TO CHEMICALS,CHEMICALS,

ENVIRONMENTALENVIRONMENTAL

POLLUTANTS ANDPOLLUTANTS AND

SOME OF THESE SOME OF THESE

CAN LEAD TOCAN LEAD TO

WEIGHT GAINWEIGHT GAIN

SOME GROUPS OF SOME GROUPS OF PEOPLE ARE FATTER PEOPLE ARE FATTER

THAN OTHERSTHAN OTHERSOVER THE LAST 40 YEARS OUR SOCIETYOVER THE LAST 40 YEARS OUR SOCIETY

HAS CHANGED IN MANY WAYS THAT HAS CHANGED IN MANY WAYS THAT

MAKE IT MORE AND MORE DIFFICULTMAKE IT MORE AND MORE DIFFICULT

TO CONTROL THE W FACTORTO CONTROL THE W FACTOR

WT.AND CVDWT.AND CVD

EFFECT OF EFFECT OF WT.REDUCTIONWT.REDUCTION

X = METABOLIC X = METABOLIC XYNDROMEXYNDROME

OROR

SYNDROME XSYNDROME X

X= SYNDROME XX= SYNDROME X

CRITERIA WHO/NCEPCRITERIA WHO/NCEP

MANY DEFINITIONS MANY DEFINITIONS BUT ALL CONTAIN 3 BUT ALL CONTAIN 3

COMPONENTSCOMPONENTS

ALL DEFINITIONS HAVE ALL DEFINITIONS HAVE 3 COMPONENTS3 COMPONENTS

* OVERWT/WAIST * OVERWT/WAIST

* CARDIOVASCULAR * CARDIOVASCULAR RISKRISK

* ABNORMAL * ABNORMAL GLUCOSE GLUCOSE

METABOLISM METABOLISM

Some Types of Fat Some Types of Fat Are Worse Than OthersAre Worse Than Others

Fat can be Fat can be distributed all over distributed all over the body or the body or primarily in the primarily in the abdomen- visceral abdomen- visceral fatfat

Visceral fat is Visceral fat is associated with the associated with the metabolic syndrome: metabolic syndrome: high blood lipids, high blood lipids, high blood pressure, high blood pressure, & insulin resistance.& insulin resistance.

THE TREATABLE THE TREATABLE COMPONENTS ARE COMPONENTS ARE BLOODPRESSURE, BLOODPRESSURE, BLOOD GLUCOSE, BLOOD GLUCOSE, BLOOD FATS AND BLOOD FATS AND PROTHROMBOSISPROTHROMBOSIS

THE MAJOR FEATURE THE MAJOR FEATURE OF METABOLIC SYN.OF METABOLIC SYN.

PROGRESSIVE NATURE OF OVER PROGRESSIVE NATURE OF OVER WT. AND ASSOCIATED PROBLEMSWT. AND ASSOCIATED PROBLEMS

EPIDEMIOLOGICAL STUDIES EPIDEMIOLOGICAL STUDIES SHOW A CONTINUUM OF SHOW A CONTINUUM OF CARDIOVASCULAR RISK .CARDIOVASCULAR RISK .

THERE IS A PROGRESSIVE RISK THERE IS A PROGRESSIVE RISK WITH INCREASING BP , BLOOD WITH INCREASING BP , BLOOD SUGAR AND BLOOD FATSSUGAR AND BLOOD FATS

PATHOPHYSIOLOGY PATHOPHYSIOLOGY METABOLIC SYNDROMEMETABOLIC SYNDROME

CNS SEEMS TO CNS SEEMS TO PLAY A ROLE IN PLAY A ROLE IN THE RELEASE THE RELEASE OF FAT FROM OF FAT FROM VISCERAL FAT VISCERAL FAT DEPOT VIA DEPOT VIA SYMP. NS. LIVER SYMP. NS. LIVER & Ms BECOME & Ms BECOME INSULIN INSULIN RESISTANTRESISTANT

CHD PREVALENCECHD PREVALENCE

MAJOR MAJOR FOCUSSHOULD BE FOCUSSHOULD BE ON BEHAVIOURAL ON BEHAVIOURAL THERAPYTHERAPY

WT.LOSS REDUCES WT.LOSS REDUCES THE INCIDENC OF THE INCIDENC OF

CVD CVD

BEHAVTHAN BEHAVTHAN METFORMIN .METFORMIN .

THE FULL TYPE 2 THE FULL TYPE 2 TABLETSTABLETS

IT IS NOT IT IS NOT CURRENTCURRENT

PRACTICE TO PRACTICE TO

PRESCRIBE FULL PRESCRIBE FULL

TYPE 2 TAB TYPE 2 TAB

(METFORMIN , ACEI , (METFORMIN , ACEI ,

STATIN , & ASPIRIN )STATIN , & ASPIRIN )

FOR PEOPLE WITH FOR PEOPLE WITH

METSY.METSY.

Y = WHY THE Y = WHY THE PARTICULAR PERSON PARTICULAR PERSON

AT HIGH RISKAT HIGH RISK THE ‘ F ” WORDS ACCOUNT FOR THE ‘ F ” WORDS ACCOUNT FOR

MOST CASES OF METSY. & ITS MOST CASES OF METSY. & ITS COMPONENTSCOMPONENTS

*** FORTY : AGE OVER 40 YEARS*** FORTY : AGE OVER 40 YEARS

**** FAMILY H/o TYPE 2 DM IN A 1o **** FAMILY H/o TYPE 2 DM IN A 1o RELATIVE ( RISK INCREASING TWO RELATIVE ( RISK INCREASING TWO FOLD WITH ONE 1o RELATIVE AND FOLD WITH ONE 1o RELATIVE AND THREE FOLD WITH TWO OR MORE )THREE FOLD WITH TWO OR MORE )

**** FAT – OVER WEIGHT / WAIST**** FAT – OVER WEIGHT / WAIST

NURSES HEALTH STUDY NURSES HEALTH STUDY

AS FOR MANY OTHER CHRONIC AS FOR MANY OTHER CHRONIC DISEASES , AGE EMERGED AS A MAJOR DISEASES , AGE EMERGED AS A MAJOR RISK FACTOR.RISK FACTOR.

DIABETES RISK INCREASES 10 FOLD DIABETES RISK INCREASES 10 FOLD BETWEEN THE AGES OF 20 – 60 YEARS.BETWEEN THE AGES OF 20 – 60 YEARS.

LIFE TIME RISK , IF NO F H/o DIABETES LIFE TIME RISK , IF NO F H/o DIABETES IS 10%.IS 10%.

THOSE WITH DIABETES THOSE WITH DIABETES ARE RESPONSIBLE FOR ARE RESPONSIBLE FOR THEIR OWN DIABETESTHEIR OWN DIABETES

THEY ARE THE LAZY GLUTTONS THEY ARE THE LAZY GLUTTONS WHO ARE SUFFERING FROM WHO ARE SUFFERING FROM THEIR SELF INDULGENCE .THEIR SELF INDULGENCE .

IT IS TRUE THAT AGE AND GENES IT IS TRUE THAT AGE AND GENES ARE FIXED AND THE FATNESS TO ARE FIXED AND THE FATNESS TO SOME DEGREE UNDER THE SOME DEGREE UNDER THE INDIVIDUALs CONTROLINDIVIDUALs CONTROL

Z = SLEEP APNOEAZ = SLEEP APNOEA

SLEEP APNOEA & LACK OF ZZZ….sSLEEP APNOEA & LACK OF ZZZ….s

IS OFTEN ASSOCIATED WITH OTHER IS OFTEN ASSOCIATED WITH OTHER

CARDIO DIAB FACTORS . CARDIO DIAB FACTORS .

OSA CAN PREDISPOSE TO INCREASINGOSA CAN PREDISPOSE TO INCREASING

WEIGHT AND WAIST AND TO THE WEIGHT AND WAIST AND TO THE

WORSENING OF THE METABOLIC WORSENING OF THE METABOLIC

ABNORMALITIES ASSOC. WITH ABNORMALITIES ASSOC. WITH

SYNDROME XSYNDROME X

OSAOSA OSA CAUSES SLEEP DISTURBANCEOSA CAUSES SLEEP DISTURBANCE RESULTS IN ACTIVTION OF HPA RESULTS IN ACTIVTION OF HPA

AXIS AND THE SYMPATHETIC AXIS AND THE SYMPATHETIC RESPONSE .RESPONSE .

DISTURBED SLEEP CAN LEAD TO DISTURBED SLEEP CAN LEAD TO DAY TIME SLEEPINESS .DAY TIME SLEEPINESS .

THE COMBINTION OF NOCTURNAL THE COMBINTION OF NOCTURNAL HORMONE DISTURBANCE AND HORMONE DISTURBANCE AND DAYTIME LETHARGY AGGRAVATES DAYTIME LETHARGY AGGRAVATES ADVERSE RISK FACTOR PROFILEADVERSE RISK FACTOR PROFILE

LACK OF ZZZ…….LACK OF ZZZ…….

WORSENS THE METABOLIC PROFILEWORSENS THE METABOLIC PROFILE AGGRAVATES DAYTIME SLEEPINESSAGGRAVATES DAYTIME SLEEPINESS REDUCES THE MOTIVATIONREDUCES THE MOTIVATION REDUCES THE CAPACITY FOR LIFE REDUCES THE CAPACITY FOR LIFE

STYLE CHANGESSTYLE CHANGES NECK CIRCUMFERENCE (> 42 CM . ) NECK CIRCUMFERENCE (> 42 CM . )

OR A HIGH EPWORTH SLEEPINESS OR A HIGH EPWORTH SLEEPINESS SCORE IDENTIFY THE PERSON AT SCORE IDENTIFY THE PERSON AT RISKRISK

EPWORTH SLEEPINESS EPWORTH SLEEPINESS SCALESCALE

HOW LIKELY ARE YOU TO DOZE OFF / HOW LIKELY ARE YOU TO DOZE OFF / FALL ASLEEP IN CERTAIN SITUATIONSFALL ASLEEP IN CERTAIN SITUATIONS

MEASURE DAY TIME SLEEPINESS.MEASURE DAY TIME SLEEPINESS.

DISTINGUISH NORMAL SUBJECTS FROM DISTINGUISH NORMAL SUBJECTS FROM PATIENTS WITH VARIOUS CONDITIONS PATIENTS WITH VARIOUS CONDITIONS LIKE * OSA , * NARCOLEPSY ,LIKE * OSA , * NARCOLEPSY ,

* IDIOPTHIC HYPERSOMNIA* IDIOPTHIC HYPERSOMNIA

ESS SCORE ESS SCORE ILLUSTRATEDILLUSTRATED

0 - 10 NORMAL 0 - 10 NORMAL RANGERANGE

10 - 12 10 - 12 BORDERLINEBORDERLINE

12 - 24 12 - 24 ABNORMALABNORMAL

OSA AND CPAPOSA AND CPAP

CPAP CAN DO WONDERS IN PEOPLE CPAP CAN DO WONDERS IN PEOPLE HAVING OSA.HAVING OSA.

RESULTS DRAMATIC – RESULTS DRAMATIC –

WEIGHT AND WAIST LOSSWEIGHT AND WAIST LOSS

REDUCES BP & BLOOD REDUCES BP & BLOOD SUGARSUGAR

LOSS OF BLOOD FATSLOSS OF BLOOD FATS

INCREASES IN WELL INCREASES IN WELL BEINGBEING

CONCLUSIONSCONCLUSIONS

EARLY RECOGNITION OF THE RISK EARLY RECOGNITION OF THE RISK FACTORS ENABLES CONTROL OF FACTORS ENABLES CONTROL OF THE PROGRESSION OF THESE THE PROGRESSION OF THESE FACTORS BY LIFE STYLE CHANGES FACTORS BY LIFE STYLE CHANGES , MEDICATIONS OR BOTH ., MEDICATIONS OR BOTH .

THE MNEMONIC WXYZ PROVIDES A THE MNEMONIC WXYZ PROVIDES A USEFUL APPROACH WHEN USEFUL APPROACH WHEN CONSIDERING THESE CARDIODIAB CONSIDERING THESE CARDIODIAB RISKS. RISKS.