OBESITY

AND
METABOLIC SYNDROME

Fabiola MS A - John MF Adam

Division of Endocrinology and Metabolism

Dept. of Internal Medicine, Faculty of Medicine
Hasanuddin University

Makassar 2012
OBESITY
 OBESITY – THE DEFINITION

Obesity is defined as a condition in which

there is an excess of fat accumulation in
adipose tissue, to the extend that health
may be impaired (WHO, 2000)

The operational definition of obesity and over-

weight are based on Body Mass Index
(BMI), which is closely related with body
fatness
 PROPOSED CLASSIFICATION of WEIGHT by
BMI for ASIAN ADULTS

Classification BMI (kg/m2) Risk of co-morbidities

Underweight < 18.5 Low ( but Increased risk
of other clinical problems)
Normal Range 18.5 – 22.9 Average
Overweight > 23
At Risk 23 - 24.9 Increase
Obese I 25 - 29.9 Moderate
Obese II > 30 Severe

Regional Office for the Western Pacific of the World Organization, The International
Association for the Study of Obesity, The International Obesity Task Force. The Asia-Pacific
perspective: Redefining obesity and its treatment. WHO Collaborating Centre for the
epidemiology of Diabetes and Health Promotion for Noncommunicable Disease, Melbourne
2000

JMFA 7
OBESITY –
BODY FAT DISTRIBUTION

“It is not the amount of fat but also its

distribution that determines the risk
associated with obesity” (WHO, 2000)

Android obesity (abdominal or visceral

or central obesity)
Gynoid obesity (gluteal obesity)
 OBESITY and BODY FAT
DISTRIBUTION
In men, fat distribution
tends to accumulate in the
Android obesity upper part of the body or
in the abdominal region
Gynoid obesity (android obesity), while in
women, it tends to
accumulate in the
peripheral part of the body
or gluteofemoral region
(gynoid obesity)

JMFA 9
It is not just the amount of fat,
but the distribution of fat
determines the risk of co-morbidities in obese subjects

Large Insulin-Resistant
Adipocytes Small Insulin-Sensitive
Adipocytes

Android Obesity Gynoid

Obesity

JMFA 10
 OBESITY- MEASUREMENT

1. Body Mass Index

Weight in kg
BMI =
(Height in meters)2

2. Body Fat Distribution

Android type (central obesity = visceral
obesity)
Gineoid type
MEASUREMENT OF CENTRAL
OBESITY

Imaging
Computed tomography scanning (CT-scan)
Magnetic resonance imaging (MRI)
Dual energy x-ray absorptiometry (DEXA)

Anthropometric
Waist-hip ratio (WHR)
Waist circumference
MEASUREMENT OF CENTRAL OBESITY

CT-scanning
MRI
DEXA

Waist circumference
Waist-to-hip ratio
Waist
20 years

Hip

BMI = 24 BMI = 35
Waist = 80 cm Waist = 100 cm
Hip = 100 cm Hip = 125 cm
WH Ratio = 0.80 WH Ratio = 0.80
Desprs JP, dkk. BMJ 2001;322:716-720
 What Causes Obesity?
• Energy imbalance over a long
period of time.
• Energy in > Energy out.
• Excess calories and lack of
physical activity.

• Genetic predisposition

• Disruption in energy balance

• Environmental and social factors

 OBESITY – THE MECHANISM
In simple terms, obesity is a consequence of an
energy imbalance, that is energy intake
exceeds energy expenditure over a
considerable period
The mechanisms of excess energy intake are
multifactorial, genetic and environmental
factors

Most of the obesity is probably due to subtle

alterations in interactions between genetic
and environmental factors that favor the net
deposition of calories as fat (Rosembaum M. N Engl J
Med 1997, 337)
Individual/biological
susceptibility

Dietary and physical

activity patterns

Energy regulation
Intake Expenditure
Fat Activity
TEF
CH
Protein BMR

Body fat stores

 WHY IS OBESITY INCREASE IN THE
DEVELOPING COUNTRIES ?

In the last two decades, obesity is linked to

the adopting of Western lifestyle,
- increased ability of overconsumption of
cheap energy-dense food
- and a shift to decreased physical activity
and more sedentary life
Fast food
Makassar
Eat to

Live to Eat!
Live!
OBESITY -

A DISEASE ?
OBESITY – IS OBESITY A DISEASE ?

There has been a debate if obesity is disease or

just a risk factors for some diseases such as
diabetes, hypertension, dyslipidemia, and
cardiovascular disease
In 1985 The National Institute of Health in US
decided that obesity is a disease
Even though, clinicians are more interest in
the management of the comorbidities related
to obesity such as hypertension, diabetes
mellitus and dyslipidemia than treating
obesity
PROPORTION of DISEASE PREVALENCE
ATTRIBUTABLE to OBESITY

Type 2 diabetes 57%

Gallbladder disease 30%
Hypertension 17%
Coronary heart disease 17%
Osteoarthritis 14%
Breast cancer 11%
Ulterine cancer 11%
Colon cancer 11%
 Men
6
Diabetes
Odds ratio 5 Hypertension
4 Dyslipidemia
Albuminuria
3
2
1
0
22 23 24 25 26 27 28 29 30
BMI (kg/m2)
Women
6
Diabetes
5
Hypertension
Odds ratio

4 Dyslipidemia
Albuminuria
3
2
1
0
22 23 24 25 26 27 28 29
BMI (kg/m2)
BMI and diabetes, hypertension, dyslipidemia and microalbuminuria in China Hongkong. Ko GTC,
Chan JCN, Woo J, Lau E, Yeung VTF, Chow C-C, Wai HPS, LI YKS, So W-Y, Cockram CS. Chinese. Int J
Obes 1997; 21: 995-1001 2.
OBESITY – THE TREATMENT
Should we treat obesity ??
 Moderate High
2.5 Low Risk Risk
2 Risk
1.5
1
0.5
0
20 25 30 35
RelativerRisk of ill health
Body Mass Index
4
3
2
1
0
150 170 200 210 220 230 240 250 290
Cholesterol (mg/dl)
5
4
3
2
1
75 80 85 90 95 100 105 110 115 120
Diastolic Blood Pressure
Relationship of BMI, cholesterol, and blood pressure to risk of ill health. The vertical lines accepted subdivisions
for low, moderate, and high risk. All three curves show a curvilinear increase with increasing level of risk factor

Bray GA, et al. Handbook of obesity, 1998

 Mortality Diabetes
> 20% in total mortality  50% in fasting glucose
> 30% in diabetes – realated deaths Lipids
> 40% in obesity – related cancer deaths  of 10% total cholesterol
Blood Pressure  of 15% LDL
 10 mmHg systolic  of 30% triglycerides
 20 mmHg diastolic  of 8% HDL

Physician’s guide to the management of obesity with Xenical. Xenical Orlistat: p. 13

TREATMENT OF OBESITY

Change of lifestyles
- Diet
- Physical activity
Pharmacotherapy
- Orlistat (Xenical)
Surgery
EXERCISE

Nice try!! But not effective

 PHYSICAL ACTIVITY-

• 60–90 min of daily activity (At least 30 min.) Gradual increases in

physical activity should be encouraged to enhance adherence and
avoid injury.

• Some high-risk patients should undergo formal cardiovascular

evaluation before initiating an exercise program.

• Physical activity could be formal exercise such as jogging, swimming,

or tennis or routine activities, such as gardening, walking, and
housecleaning.
Weight Loss: The Recommendations
-Goal is to reduce body weight by 10% over 6 months
-BMI 27 – 35: 300 – 500 kcal deficit daily  ½ to 1 lb per wk loss
-BMI > 35: 500 – 1000 kcal deficit daily  1 to 2 lb per wk loss
-Low calorie diet with dietary fat < 30% of total calories
-Sustained physical activity recommended.

Fasting for wt loss?

• Fasting is popular because it can provide dramatic
weight-loss but it is primarily water rather than fat
• Lost water is regained quickly when eating is
resumed.
• Prolonged fasting is not recommended and may lead
to nutritional imbalances
• Orlistat (Xenical)
– Inhibitor of pancreatic/intestinal lipase
 increased fecal fat loss
– Dose: 120mg PO TID with meals
– Effects
• Weight loss
• Reduced conversion from IGT to diabetes
• Decrease in HgbA1C
• Decreased LDL

– Adverse effects
• Intestinal borborygmi and cramps
• Flatus +/- discharge
• Steatorrhea
• Bloating
• Oily spotting
• Decreased absorption of fat soluble vitamins
 Mechanisms of Action of Orlistat (continued)

30% of
triglycerid
es
pass
undigested
and are
excreted.

Orlistat prevents the absorption of up to 30% of dietary fat

OBESITY : TREATMENT GUIDELINES FOR BMI

BMI Treatment

18.5 - 24.9 No treatment, diet and exercise to maintain

body weight
25.0 - 29.9
- without disease Hypocaloric diet and exercise to reduce
body weight
25.0 - 29.9 Hypocaloric diet and exercise, anti-obesity
- with disease drug
30.0 - 39.9 Hypocaloric diet and exercise, anti-
obesity drug
> 40 Surgery

Physicians guide to the management of obesity with Xenical (4)

 Sudden death is more common in those
who are naturally fat than in the slender
Hippocrates 410 B.C.

Messerli et al Arch Intern Med 1987; 147: 1725 - 1728 JMFA 4

METABOLIC SYNDROME

Fabiola MS A - John MF Adam

Division of Endocrinology and Metabolism
Dept. of Internal Medicine, Faculty of Medicine
Hasanuddin University

Makassar 2011
 DEFINITION

Metabolic syndrome is a
constellation of lipid and nonlipid
risk factors of metabolic origin.
This syndrome is closely linked
to a generalized metabolic
disorder called insulin resistance
in which the normal actions of
insulin are impaired
 CRITERIA
of METABOLIC SYNDROME
WHO 1999

National Cholesterol Education Program,

Adult Treatment Panel III, 2001
Modified NCEP-ATP III – for Asian, 2001

International Diabetes Federation, 2005

World Health Organization, 1999

COMPONENTS OF THE METABOLIC SYNDROME

Glucose intolerance, impaired glucose tolerance (IGT) or
diabetes mellitus and/or insulin resistance together with
two or more of the following :
Raised arterial pressure
Raised plasma triglycerides
Central obesity
Microalbuminuria

World Health Organization. Definition, diagnosis and classification of diabetes mellitus and
its complication. Part 1: Diagnosis and classification of diabetes mellitus. Department of
Noncommunicable Disease Surveillance, World Health Organization, Geneva 1999
JMFA 22
CLINICAL IDENTIFICATION OF THE METABOLIC
SYNDROME Modified NCEP – ATP III 2001
for Asian Adults

Risk factor Defining level

• Abdominal obesity*
(waist circumference)†
Men > 90 cm
Women > 80 cm
Triglycerides > 150 mg/dl
• High-density lipoprotein
cholesterol
Men < 40 mg/dl
Women < 50 mg/dl
• Blood pressure > 130 / > 85 mmHg
• Fasting glucose > 110 mg/dl

Metabolic syndrome > 3 risk factors

IDF Criteria of Metabolic Syndrome

• Abdominal obesity*
(waist circumference)†
Men > 90 cm
Women > 80 cm
Plus two of the following :
• Triglycerides > 150 mg/dl
• HDL – chol Men < 40 mg/dl
Women < 50 mg/dl
• Blood pressure > 130 / > 85 mmHg
• Fasting plasma glucose > 115 mg/dl
 CENTRAL OBESITY AND
METABOLIC SYNDROME
Diabetes mellitus /
Impaired glucose tolerance

Central
Obesity

Dyslipidaemia Hypertension
(HyperTG, low HDL-C)

JMFA 27
 PREVALENCE OF METABOLIC SYNDROME

USA 22% of adult population, 47 million

In Asian countries as well as other developing
countries metabolic syndrome suggest to be higher
In Makassar,
Adriansjah and Adam (2003) 30,8% among males
Adam and Adriansjah (2003) difference between
two criteria 24,2% NCEP-ATP III, 35,7%
modified NCEP-ATP III
 Age-Specific Prevalence of the Metabolic Syndrome
Among 8,814 US Adults (Age > 20 Years)
(NHANES III, 1988-1994)

Men Women
50
Mean ± SE
40
Prevalence (%)

30

20

10

0
20-29 30-39 40-49 50-59 60-69 >70

Ford ES et al. JAMA 2002; 287: 356-359

 WHY IS METABOLIC SYNDROME
IMPORTANT?

Subjects with metabolic syndrome are high risk for:

- diabetes mellitus
- cardiovascular disease
For these reasons, patients with MetS should be treated

Treatment modalities:
- lifestyle modification, diet and exercise
- treating the risk factors, lipid abnormalities,
hypertension, hyperglycemia
 TREATMENT OF
METABOLIC SYNDROME
TREATMENT OF METABOLIC SYNDROME

Treatment of Diabetes Mellitus

Treatment of Dyslipidemia
LDL-cholesterol, Triglycerides, HDL-
cholesterol

Treatment of Hypertension

Treatment of Obesity
Calorie restriction, Exercise,
Pharmacotherapy
TREATMENT OF METABOLIC SYNDROME

Diabetes Mellitus
Metformin, Thiozolidinedione

Dyslipidemia
Statins, Fibrates

Hypertension
ACE – inhibitor, ARB, Ca – Channel blocker, HCT