metabolic syndrome, medical doctor, BPJS

1. Cardiometabolic Risk

2. Learning Objectives
• Define cardiometabolic risk and assess the
non-modifiable and modifiable risk factors
• Describe methods for early identification and
management of the following risk factors:
– Obesity
– Dyslipidemia
– Hypertension

3. Why Focus on Cardiometabolic Risk?
• A comprehensive approach to patient care
• Multiple disease pathways and risk factors are
considered to facilitate earlier intervention
• Early assessment and targeted intervention are
needed to treat and prevent all risk factors
associated with cardiovascular diseases (CVD)
and diabetes Daly A, Power MA. Medical Nutrition Therapy.
Diabetes Mellitus and Related Disorders; Medical
Management of Type 2 Diabetes, 7th Edition.
American Diabetes Association, 2012.

4. What is Cardiometabolic Risk?
• A comprehensive picture of a patient’s
health and potential risk for future disease
and complications
– All risks related to metabolic changes
associated with CVD
– Accommodates emerging risk factors
– Focuses clinical on evaluation, education,
disease prevention and treatment
Kahn, et al. The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American Diabetes
Association and the European Association for the Study of Diabetes Diabetes Care. 2005;28 (9)2289-304.

5. Indonesian Cardiometabolic Risk:
CVD Epidemiology
• CVDs are responsible for over 17.3 million
deaths/year and are the leading causes of death
in the world
• Indonesian statistics:
– CVD Mortality Rates: 363-443/100 000 for males
and 181-281/100 000 for females
– Burden of CVD (Disability-adjusted Life Year):
3315-4228/100000 for males and 2584-
3438/100000 females
WHO. Global atlas on cardiovascular disease prevention and control. 2011

6. Direct and Indirect Cost of CVD
and Diabetes (USD)*
2008 statistics from the American Diabetes Association and American Heart Association.
*Note: These figures may not account for potential overlap
Estimated Direct
Medical Costs
Estimated Indirect
Costs (disability, work loss,
premature mortality)
CVD $296 billion $152 billion
Diabetes $116 billion $58 billion
TOTAL $412 billion $210 billion

7. Cardiometabolic
Risk
Global Diabetes/CVD
Risk
Overweight / Obesity
Abnormal Lipid
Metabolism
LDL  ApoB 
HDL  Trigly. 
Age, Race,
Gender,
Family History
Inflammation
HypercoagulationHypertension
Smoking
Physical Inactivity
Unhealthy Eating
?
GlucoseBP Lipids
Age Genetics
Insulin Resistance

8. Risk Factors
Nonmodifiable
• Age
• Race/Ethnicity
• Gender
• Family history
Modifiable
• Overweight
• Abnormal lipid
metabolism
• Inflammation,
hypercoagulation
• Hypertension
• Smoking
• Physical inactivity
• Unhealthy diet
• Insulin resistance

9. Insulin Resistance

10. • Overweight/ Fat distribution
• Age
• Genetic predisposition
• Activity level
• Medications
• Pregnancy
Factors Affecting Insulin Resistance

11. • Impaired Fasting Glucose (IFG):
– A condition in which the blood glucose level
is between 100 mg/dL to 125mg/dL after an
8- to 12-hour fast.
• Impaired Glucose Tolerance (IGT):
– A condition in which the blood glucose level
is between 140 and 199 mg/dL at 2 hours during
an oral glucose tolerance test (OGTT).
Impaired Fasting Glucose &
Glucose Tolerance

12. Proposed Metabolic Observations
in the Natural History of T2DM
Atherogenesis
Euglycemia
Insulin Sensitivity
Insulin Secretion
• Hypertension
• Dyslipidemia
Microvascular
Complications
Age (years) Type 2 Diabetes
Cardiometabolic Risk
ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition, 2009.
Associated Risk Factors
Fasting Blood Glucose

13. Prediabetes and
Diabetes Prevention

14. Prediabetes
• Pre-diabetes is an important risk factor for future
diabetes and CVD
• Recent studies have shown that lifestyle
modifications can reduce the rate of progression
from pre-diabetes to diabetes

15. Impaired Fasting Glucose (IFG) and
Impaired Glucose Tolerance (IGT)
• ADA Consensus Statement:
– Treat IFG and IGT with intensive
lifestyle modification
– For certain patients with both IFG & IGT
and risk factor(s), consider addition of metformin
Nathan D, et al. Impaired Fasting Glucose and Impaired Glucose Tolerance: Implications for Care.
Diabetes Care 2007;30:753-9.

16. Relative Effectiveness of
Interventions in Diabetes Prevention
CumulativeIncidence
ofDiabetes(%)
Years
40
30
20
10
0
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Placebo
Knowler WC, et al. NEJM. 2002;346:393-403.
Metformin
Lifestyle

17. Prevention of T2DM: Recent
Randomized Trial Results
Study Subjects Intervention
Relative Risk
Reduction
Behavior
Finnish
DPS
US DPP
IGT Lifestyle 58%
IGT Lifestyle 58%
Medication
US DPP
STOP-
NIDDM
TRIPOD
XENDOS
DREAM
IGT Metformin 31%
IGT Acarbose 25%
Prior GDM Troglitazone 55%
IGT Orlistat 45%
IGT
Rosiglitazone/
Ramipril
61% NS

18. Screening
• Screening is conducted on those who have
diabetes risks, but do not show any symptoms
of DM.
• Screening seeks to capture undiagnosed DM
or prediabetes so it can be managed earlier
and more appropriately.
• Mass screening is not recommended considering
the costs (usually abnormal results are not
followed-up with an action plan).
PERKENI Guidelines. Diabetes Mellitus National Clinical Practice Guidelines. 2011

19. Standard Values of Random BG and
FBG for Screening and Diagnosis of DM
Note: For high-risk groups which show no abnormal results, the test should be done
every year. For those aged > 45 years without other risk factors, screening can be done
every 3 years.
Non DM
Uncertain
DM
DM
Random Blood
Glucose Level
(mg/dL)
Venous
Plasma
<100 100-199 ≥200
Capillary
Blood
<90 90-199 ≥200
Fasting Blood
Glucose Level
(mg/dL)
Venous
Plasma
<100 100-125 ≥126
Capillary
Blood
<90 90-99 ≥100
PERKENI Guidelines. Diabetes Mellitus National Clinical Practice Guidelines. 2011

20. Diabetes Prevention
− Medical Nutritional
Therapy
− Physical activity
− Weight reduction
Not yet
recommended
− Hypertension
− Dyslipidemia
− Physical
health
− Body weight
control
− If overweight,
reduce body
weight by 5-10%
− Physical exercise
for 30 minutes,
5x/week
2-hour OGTT is the most
sensitive method for early
detection and a recommended
screening test procedure
High-risk population at
<30-year old
− Family history of DM
− Cardiovascular disorder
− Overweight
− Sedentary life style
− Known IFG or IGT
− Hypertension
− Elevated Triglyseride,
low HDL or both
− History of Gestational
DM
− History of give birth >
4000g
− PCOS
Life Style
Changes
Early
Detection
Pharmacology
Therapy
Periodic
Blood
Glucose
and Risk
Factor
Monitoring
PERKENI Guidelines. Diabetes Mellitus National Clinical Practice Guidelines. 2011
Management

21. Early Detection
High risk population at the age < 30 years old
• Family history of diabetes
• Cardiovascular abnormalities
• Overweight
• Sedentary life
• History of IFG or IGT
• Hypertension
• Increase of TG / Decrease of HDL or Both
• History of Gestational Diabetes
• History of delivering infant > 4000 g
• Polycystic Ovary Syndrome
OGTT is the most sensitive
method for early detection
and the recommended
screening tool
PERKENI Guidelines. Diabetes Mellitus National Clinical Practice Guidelines. 2011

22. Prediabetes, management
• Target lifestyle changes and use adjunct
pharmacologic treatment for specific priorities
eg, hypertension1
• The decision to start pharmacologic treatment
must be based on a risk-benefit analysis2
– Metformin and acarbose: safe & effective
– Thiazolidinedione (TZD): associated risk of
congestive heart failure and fracture should be
given attention.
1.Saewonder & Pramono. Prevalence, characteristics, and predictors of pre-diabetes in Indonesia. Med J Indones 2011; 20: 283-94.
2. Buku Panduan Pengelolaan dan Pencegahan Prediabetes. 2010 (Guideline book on Management and Prevention of Prediabetes)

23. Prediabetes, management
• Dyslipidemia: Statin is recommended
• Hypertension: ACE-I or ARB is recommended,
Calcium channel blocker, second choice.
• All prediabetes subjects who do not have
risk of gastrointestinal bleeding, intracranial
bleeding or other risk of bleeding, may be given
low dose aspirin.
Buku Panduan Pengelolaan dan Pencegahan Prediabetes. 2010 (Guideline book on Management and Prevention of Prediabetes)

24. Overweight/Obesity

25. Obesity in Indonesia: Double Burden
Nutrition Problems
• Despite general improvements in food
availability, health and social services, hunger
and malnutrition exist in some form in almost
every district
• In 2003, 27.5 percent of children under five
were moderately and severely underweight
Amarita, 2005

26. IFLS Results: Overweight Population
• Increasing prevalence among people >18 years old
• Prevalence women>men
Indonesia Family Life Survey, 1993, 1997, 2000, 2007
IFLS-1
(1993)
IFLS-2
(1997)
IFLS-3
(2000)
IFLS-4
(2007)
% Overweight
Men 20.78 - 24.86 31.14
Women 32.28 39.55 - 48.67

27. Results: RISKESDAS 2007 & 2010
Overweight Population
• Over 3 years, the obesity prevalence increased in all
children’s age groups, with the largest increase in the
15-18 year old female group
RISKESDAS 2010
2007 2010
% Overweight
Toddlers 12.2 14.0
6-12 year old females 6.4 7.7
6-12 year old males 9.5 10.7
15-18 year old females 23.8 26.9
15-18 year old males 13.9 16.3
>18 year olds 10.3 11.7

28. BMI and DM
<17.9 18 – 22.9 23 – 26.9 >27
3.7%
4.4%
7.3%
9.1%
PrevalenceofDM
(RISKESDAS 2007
BMI

29. Clinical Obesity Measurements
• Body mass index (BMI)
– Calculated as (Weight in pounds / Height in inches2) x 703
– Direct correlation with risk of adverse health outcomes
and mortality
• Waist circumference
– A surrogate marker of body fat distribution
– Measurement may not affect clinical management
when BMI and other cardiometabolic risk factors are
already determined
BMI (kg/m2) = Weight in kilograms
Height in meters2
Klein S, et al. Diabetes Care. 2007;30:1647-52.

30. Measuring Waist Circumference
• Locate upper hip bone and
top of the right iliac crest
• Place a measuring tape in a
horizontal plane around the
abdomen at iliac crest
• Tape should be snug,
parallel to the floor, and not
compress the skin
• Measurement at end of
normal expiration
High-Risk Waist Circumference
Women: > 80 cm
Men: > 90 cm
International Diabetes Federation. Consensus worldwide definition of the metabolic syndrome. www.idf.org

31. Abdominal Obesity is Associated
With Increased Risk of CHD
• Waist circumference is independently associated with
increased age-adjusted risk of CHD, even after adjusting
for BMI and other CV risk factors.
0.0
0.5
1.0
1.5
2.0
2.5
3.0
1 2 3 4 5
1.27
2.08
2.31
2.44
P for trend = .007 (women)
P for trend = .001 (men)
RelativeRisk
Quintiles of Waist Circumference
1.00 1.01
1.34 1.26
1.60
1.00
Rexrode KM, et al. JAMA. 1998;280:1843-8.
Rexrode KM, et al. Int J Obes (Lond). 2001;25:1047-56.

32. Multiple Factors Associated With Obesity
Give Rise to Increased Risk of CVD
Intravascular
Pathology
Clinical
Event
CVD
Atherosclerosis
Hypercoagulability
• Coronary arteries
• Carotid arteries
• Cerebral arteries
• Aorta
• Peripheral arteries
Hypertension
Dyslipidemia
Hyperinsulinemia
Hyperglycemia
Inflammation
Impaired
Fibrinolysis
Endothelial
Dysfunction
Insulin
Resistance
Overnutrition
Primary
Metabolic
Disturbance
Intermediate
Vascular Disease
Risk Factor
Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-87.

33. Obesity Practice Guidelines:
Indonesia
• Summary of recommendations:
– Clinical evaluation of overweight and
obese patients
– Weight management programs and
support for weight loss maintenance
• Lifestyle modification
• Behavioral modification
• Pharmacological Treatment
• Surgery
Purnamasari D et al. Identification, Evaluation and treatment of overweight and obesity in adults: Clinical
Practice Guidelines of the Obesity Clinic, Wellness Cluster Cipto Mangunkusumo Hospital, Jakarta, Indonesia

34. Risk Management:
Weight Loss Recommendations
• Weight loss therapy is recommended for:
– BMI ≥25 kg/m2
– BMI 23-24.9 kg/m2 + 2 risk factors
– High-risk waist circumference + 2 risk factors
(comorbidities)
• Weight management programs should include
lifestyle modification and behavioral
management
Purnamasari D et al. Identification, Evaluation and treatment of overweight and obesity in adults: Clinical
Practice Guidelines of the Obesity Clinic, Wellness Cluster Cipto Mangunkusumo Hospital, Jakarta, Indonesia

35. Recommendations:
Lifestyle Modification
• Dietary intervention
– Reduce intake by 500–1000 kcal/day from total
daily intake
• Increased physical activity
– Moderate activity 30-45 mins/day, 3-5 times/week
– Overweight and obese individuals: Moderate
activity 45-60 mins/day 5 times/week .
Purnamasari D et al. Identification, Evaluation and treatment of overweight and obesity in adults: Clinical
Practice Guidelines of the Obesity Clinic, Wellness Cluster Cipto Mangunkusumo Hospital, Jakarta, Indonesia

36. Is There One “Best” Weight Loss Diet?
ADA Recommendations
• For weight loss, either low-carbohydrate or
low-fat calorie-restricted diets may be effective in
the short term (up to 1 year)
• Ability to adhere to a diet, rather than its
composition, is the primary determinant of
successful weight loss

37. Look AHEAD: Benefits of Weight Loss
• “Magnitude of weight loss at 1 year was strongly
(P<0.0001) associated with improvements in glycemia,
blood pressure, triglycerides and HDL cholesterol but not
with LDL cholesterol”
• Improvement was greater with weight loss of 10-15%
• Conclusions:
– Even modest weight loss of 5-10% is associated with
significant improvements in cardiometabolic risk factors
Wing RR et al. Benefits of modest weight loss in improving cardiovascular risk factors
in overweight and obese individuals with Type 2 Diabetes. Diabetes Care. 34: 2011.

38. Risk Management:
Pharmacologic Treatment
• Consider pharmacologic treatment in patients
with:
– BMI 25 kg/m2 with comorbidities
– BMI 30
• Decide based on an individual case basis
and risk/benefit assessment
• Include as part of comprehensive lifestyle
intervention
Purnamasari D et al. Identification, Evaluation and treatment of overweight and obesity in adults: Clinical
Practice Guidelines of the Obesity Clinic, Wellness Cluster Cipto Mangunkusumo Hospital, Jakarta, Indonesia

39. Abnormal Lipid
Metabolism

40. Dyslipidemia in Indonesia
• International Diabetes Management Practices
Study (IDMPS)
– Study of 674 patients with T2DM
• 53.5% had dyslipidemia
– 44.5% were receiving treatment
• Demonstrated that the metabolic control
of diabetes is not good enough to prevent
complications
Current practice in the management of type 2 diabetes in Indonesia. Results from IDMPS. J Indon Med Assoc 2011

41. Abnormal Lipid Metabolism
Increased:
• Triglycerides
• Very-low-density
lipoprotein (VLDL)
• LDL and small dense LDL
• Apolipoprotein B
Decreased:
• HDL
• Apolipoprotein A-I
American Diabetes Association. Diabetes Care. 2007;30:S4-41.

42. Cholesterol management
• Cigarette smoking
• Hypertension (≥140/90 mm Hg or on
antihypertensive medication)
• Low HDL-C (<40 mg/dL)
• Family history of early heart disease
• Age (men ≥45 years; women ≥55 years)
Major Risk Factors Affecting Lipid Goals

43. Cholesterol Management
LDL-C Goal
Category of Risk LDL-C Goal
0-1 risk factor* < 160 mg/dL or lower
Multiple (2+) risk factors* < 130 mg/dL or lower
People with coronary heart
disease or risk equivalent
(e.g., diabetes)
< 100 mg/dL or lower
Known CAD and DM
< 70 mg/dL or lower
may be ideal

44. Risk Management: Abnormal Lipids
• Lifestyle Modification
– Increased physical activity
– Diet: reduced saturated fat, trans fat,
and cholesterol
– Weight loss, if indicated
American Diabetes Association. Diabetes Care. 2007;30:S4-41.

45. • Pharmacologic Treatment:
– Primary goal is LDL lowering
– Without overt CVD: If >40 yrs of age, statin to
achieve 30-40% LDL reduction
– With overt CVD: All patients, statin to achieve 30-
40% LDL reduction
– Lowering TG and raising HDL with a fibrate
is associated with fewer cardiovascular events
in patients with clinical CVD, low HDL, and
near-normal LDL
Risk Management: Abnormal Lipids in DM
American Diabetes Association. Diabetes Care. 2007;30:S4-41.

46. Classes of Medications for
Lipid Pharmacology
• Statins: Work by increasing hepatic LDL-C removal
from the blood
• Resins: Bind to bile acids in the intestines and
prevent their reabsorption, leading to increased
hepatic LDL-C removal from the blood
• Cholesterol absorption inhibitors help lower LDL-C
by reducing the amount of cholesterol absorbed in
the intestines
– Increases LDL receptor activity

47. Classes of Medications for
Lipid Pharmacology (cont’d)
• Fibrates: Activate an enzyme that speeds
the breakdown of triglyceriderich lipoproteins
while also increasing HDL-C
• Niacin: Reduces the livers ability to produce
very low density lipoprotein (VLDL)
– When given at high doses, it can also
increase HDL-C

48. Screening for Dyslipidemia
• Persons without diabetes
– Test at least every 5 years, starting at age 20,
including adults with low-risk values
• Persons with diabetes
– In adults, test at least annually
– Lipoproteins: measure after initial BG control
is achieved as hyperglycemia may alter results

49. Hypertension

50. Hypertension in Indonesia
• International Diabetes Management Practices
Study (IDMPS)
– Study of 674 patients with T2DM
• 47.6% had hypertension
– 44.3% were receiving treatment
• The high prevalence of hypertension was likely
a contributing factor in the high rate of
complications found in the study
Current practice in the management of type 2 diabetes in Indonesia. Results from IDMPS. J Indon Med Assoc 2011

51. Hypertension:
Evaluation and Screening
Persons without
Diabetes:
• At each regular visit or at
least once /2 years if BP
<120/80 mmHg
• Measured seated after 5
min rest in office
Persons with Diabetes:
• Measured at each
regular visit
• Measured seated after
5 min rest in office
• Patients with ≥130 or
≥80 mmHg should have
BP confirmed on a
separate day
Preventing Cancer, Cardiovascular Disease, and Diabetes A Common Agenda for the American Cancer
Society, the American Diabetes Association, and the American Heart Association. Circulation.
2004;109:3244-55. American Diabetes Association. Diabetes Care. 2007;30:S4-41.

52. Management of Hypertension
• Nonpharmacologic:
– Reduce salt intake
– Physical activity
– Weight loss, if applicable

53. Management of Hypertension
• Pharmacologic:
– Drug therapy indicated if BP ≥140/ ≥90 mmHg
– Combination therapy often necessary
– Treatment should include angiotensin
converting enzyme inhibitor (ACE) or
angiotensin receptor blocker (ARB)
– Thiazide diuretic may be added to reach goals
– Monitor renal function and serum potassium

54. Summary: Cardiometabolic Risk
• Assessing a patient’s cardiometabolic risk is
important in the prevention of CVD and T2DM
• Identification of risk factors such as obesity,
dyslipidemia and hypertension allow for
the initiation of appropriate risk management
strategies
– Lifestyle modification
– Addition of pharmacologic agents in some
clinical scenarios

55. Thank you