Dr. N. KASIRAJAN, M.D., Consultant Physician & Cardiologist Apollo Speciality Hospitals Madurai – 625 020.

Apollo Speciality Hospitals

Madurai – 625 020.

Health is (Not Simply Absence of Disease) positive sense of Physical, Mental, Social & Spiritual well being W.H.O.

Health is (Not Simply Absence of Disease)

positive sense of Physical, Mental, Social

& Spiritual well being

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DALY = disability-adjusted life years EME = established market economies LAC = Latin America and the Caribbean FSE = formerly socialist economies of Europe MEC = Middle Eastern crescent OAI = other Asia and islands SSA = sub-Saharan Africa Burden of CVD 1990 - 2020 1990 2000 2010 2020 50 40 30 20 10 0 DALYs (millions) India China SSA MEC LAC EME FSE OAI

Observed and Predicted Decline in CHD Mortality: 3 major risk factors explain much of the variation in CVD incidence (men 35 – 64, Finland) Smoking BP Cholesterol CHD predicted (all RF) CHD observed 1970 1975 1980 1985 1990 1995 0 - 10 - 20 - 30 - 40 - 50 - 60 % change (RF, CHD mortality) Vartiainen E, et al. BMJ 1994;309:23-27

Mechanism of Cardiovascular Diseases in Indians Communities surviving on low fat intake and physically demanding work Under nutrition in fetus and infant Adaptations (genetic, metabolic) to survive under food scarcity (optimal physiological functions) Rapid increase in fat intake and sedentariness Adaptations of fetal and infant life turn into maladaptations in adult life Increased genetic and metabolic susceptibility to rapid changes in diet and lifestyle Poor function of pancreas and liver causing inefficient metabolism of energy and fat Hyperglycemia, Hyperinsulinemia, Hyperlipidemia and central obesity even on lower intake of fat Diabetes, Hypertension, CAD and Atherosclerosis

High-Tech increases Body Weight Cellular phones and remote controls deprive us from walking! 20 times daily x 20 m = 400 m Walking distance lost/year 400x365 = 146,000 m 146 km = 25 h of walking 1 h of walking = 113-226 kcal Energy saved =2800-6000 kcal Rössner, 2002  0.4-0.8 kg adipose tissue

Waist circumference measurement technique http://www.postgradmed.com/issues/2004/01_04/metabolic_foldout.pdf last accessed on 18.2.2004

Obesity & Metabolic Syndrome Increased Abdominal Fat Released of Free Fatty Acids Peripheral Insulin Resistance Increased Pancreatic Insulin Secretion Decreased Hepatic Insulin Extraction Hyperinsulinemia Attenuated Vasodilation Increased SNS Activity Sodium Retention Vascular Hypertrophy Adapted from Kaplan NM, Clin Hypertens, 7 th ED., 1998 Lipolysis due to increased SNS activity X

Obesity as a Risk Factor for CAD • The Importance of Abdominal Fat Gynoid Obesity Android Obesity Sharma 2002

Obesity and Metabolic Risk • Abdominal vs. Peripheral Obesity Android Obesity Gynoid Obesity Sharma 2002 Small Insulin-Sensitive Adipocytes Large Insulin-Resistant Adipocytes

Obesity and Metabolic Risk • Abdominal vs. Peripheral Obesity Android Obesity Gynoid Obesity Sharma 2002 Adrenergic Receptors  Adrenergic Receptors 

Abdominal Obesity is associated with Increased Plasma Non-Esterified Fatty Acids Insulin-Mediated Antilipolysis  Catecholamine-Mediated Lipolysis  Plasma Non-Esterified Fatty Acids  Sharma 2002

SYNDROME X : WHY ? Non-esterified (free) fatty acids Interfere with hepatic insulin disposal hyperinsulinemia Interfere with action of insulin hyperglycemia  in blood glucose  in insulin release Insulin not able to transfer glucose from blood to cells  In Blood Glucose Stimulus for further insulin release Liver not able to remove insulin physiologically Hyperglycemia Hyperinsulinemia Hyperglycemia Dr. P. Shyam Sundar. Syndrome X - An Overview Down regulation of insulin receptors

Non-esterified (free) fatty acids

Interfere with hepatic insulin disposal hyperinsulinemia

Interfere with action of insulin hyperglycemia

Obesity and Cardiovascular Risk Hypertension Left ventricular hypertrophy Congestive heart failure Prothrombosis Fibrinogen  PAI-1  Insulin resistance Glucose intolerance Hyperglycaemia Type 2 diabetes Endothelial dysfunction Dyslipidaemia Total-C  • LDL-C  Triglycerides  Apo-B  • HDL-C  Renal Hyperfiltration Albuminuria Inflammatory Response  Visceral Obesity

Thrombogenic and Inflammatory Risk Thrombogenic Factors Tissue Factor  Plasminogen Activator Inhibitor - 1  Fibrinogen  Inflammatory Risk Tumour Necrosis Factor -   Complement  Adiponectin  IL-1, IL-6  Sharma 2002 Vascular Damage

Thrombogenic Factors

Tissue Factor 

Plasminogen Activator Inhibitor - 1 

Fibrinogen 

Inflammatory Risk

Tumour Necrosis Factor -  

Complement 

Adiponectin 

IL-1, IL-6 

Potential Benefits of Moderate (5-10%) Weight Loss Subcutaneous Adipose Tissue 5-10% weight loss ~30% Visceral adipose tissue loss (diet, physical activity, pharmacotherapy) Abdominally Obese (high waist measurement) Reduced Obesity (low waist measurement) Visceral Adipose Tissue Després JP, BMJ 2001;322:716-20 High Low Risk of coronary heart disease   Blood Pressure Deteriorated Improved Lipid profile Impaired Improved Insulin sensitivity Insulinaemia, Glycaemia       Susceptibility to thrombosis   Inflammation markers