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Resiko metabolik
This document discusses cardiometabolic risk, which refers to the risks associated with metabolic changes that can lead to cardiovascular disease. It defines cardiometabolic risk and identifies both non-modifiable and modifiable risk factors such as obesity, dyslipidemia, hypertension, smoking, and physical inactivity. The document emphasizes the importance of early identification and management of risk factors through comprehensive patient assessment and targeted intervention to prevent diseases like cardiovascular disease and diabetes.
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Resiko metabolik
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- 2. Learning Objectives • Definecardiometabolic 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 onCardiometabolic 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 CardiometabolicRisk? • 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: CVDEpidemiology • 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 IndirectCost 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 ? GlucoseBP 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
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- 10. • Overweight/ Fatdistribution • Age • Genetic predisposition • Activity level • Medications • Pregnancy Factors Affecting Insulin Resistance
- 11. • Impaired FastingGlucose (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 inthe 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
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- 14. Prediabetes • Pre-diabetes isan 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 Interventionsin 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 isconducted 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 ofRandom 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 − MedicalNutritional 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 riskpopulation 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 • Targetlifestyle 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)
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- 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: OverweightPopulation • 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 <17.918 – 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 isAssociated 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 AssociatedWith 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 LossRecommendations • 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 • Dietaryintervention – 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: Benefitsof 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
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- 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 • Cigarettesmoking • 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 Categoryof 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: AbnormalLipids • 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 Medicationsfor 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 Medicationsfor 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
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- 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 Personswithout 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
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Editor's Notes
- #3 Speaker Notes
- #4 Speaker Notes References: Slide Daly A, Power MA. Medical Nutrition Therapy. Diabetes Mellitus and Related Disorders. Medical Management of Type 2 Diabetes, 7th Edition. American Diabetes Association, 2012.
- #5 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)2289-2304.
- #6 WHO. Global atlas on cardiovascular disease prevention and control. 2011
- #8 Cardiometabolic risk identifies individuals at high risk for cardiovascular disease (CVD) Risk factors include traditional CVD risk factors such as abnormal LDL cholesterol but also include metabolic factors such as abdominal adiposity, insulin resistance, metabolic dyslipidemia (hypertriglyceridemia, low levels of HDL, small dense LDL), hypertension, prothrombic state and proinflammatory state Identification of these components helps patients make lifestyle changes needed to decrease their risk of developing CVD and diabetes Reference: ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition, 2009.
- #9 From ADA slide
- #13 As prediabetes develops into T2DM, the continued output of glucose and glucose from the intestinal tract leads to hyperglycemia (increased FBG). Simultaneously, insulin resistance is increased (decreased insulin sensitivity) and insulin secretion is reduced T2DM is an independent risk factor for CVD in addition to coexisting conditions like hypertension, dyslipidemia and obesity which are risk factors in themselves Reference: ADA. Therapy for Diabetes Mellitus and Related Disorders. 5th Edition, 2009.
- #16 Lifestyle modification: 5-10% weight loss and moderate intensity physical activity approx 30 mins/day Risk factors include: <60 yrs of age BMI≥ 35 kg/kg2 Family history of diabetes in first-degree relatives Elevated triglycerides Reduced HDL cholesterol Hypertension A1C>6.0%
- #17 METHODS: 3234 andomly assigned nondiabetic persons with elevated FBG and PPG to placebo, metformin (850 mg twice daily), or a lifestyle-modification program Goals: at least 7 percent weight loss and at least 150 minutes of physical activity/week. RESULTS: The average follow-up was 2.8 years. The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle groups, respectively. The lifestyle intervention reduced the incidence by 58% and metformin by 31%, as compared with placebo Lifestyle intervention was significantly more effective than metformin. To prevent one case of diabetes during a period of three years, 6.9 persons would have to participate in the lifestyle-intervention program, and 13.9 would have to receive metformin. CONCLUSIONS: Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk Lifestyle intervention was more effective than metformin. Reference: Knowler WC, et al. NEJM. 2002;346:393-403
- #19 Perkeni Guidelines. Diabetes Mellitus National Clinical Practice Guidelines. 2011
- #22 OGTT=Oral glucose tolerance test
- #23 References: Saewonder & Pramono. Prevalence, characteristics, and predictors of pre-diabetes in Indonesia. Med J Indones 2011; 20: 283-94. Buku Panduan Pengelolaan dan Pencegahan Prediabetes. 2010 (Guideline book on Management and Prevention of Prediabetes, 2010).
- #24 Statin is recommended to reach LDL target of <100 mg/dL, non HDL target of <130 mg/dL and apolipoprotein B of <90mg/dL. If there is associated hypertension, ACE-I or ARB is the recommended treatment choice, while Ca chanel blocker as second treatment choice. * Need further discussion
- #26 Despite general improvements in income per capita, food availability, infra structure, health and social services, hunger and malnutrition still exist in some form in almost every district in Indonesia. By improving country economics, undernutrition would decrease but still persist and obesity would appear among population.
- #27 Data of IFLS-1 until IFLS-4 showed that the prevalence of adult obesity in Indonesia continued increasing since 1993, in both genders. The prevalence was greater in women compared to men By increasing income per capita in Indonesia, lifestyle changed. More time was spent watching television, playing videogame or using a computer At the same time, food habits of people changed to fast food or high density calorie food Obesity is becoming a serious issue in Indonesia. Obesity for adult age >18 increased from 20.78% in 1993 to 24.86% in 2000
- #28 Indonesia Basic Health Survey was conducted by MOH in 33 provinces. First IBHS was conduct in 2007 while IBHS-2 in 2010 IBHS-1 covered of 258.366 household and IBHS-2 covered of 69.875 household IBHS-2007 and IBHS-2010, showed that during 3 years the obesity prevalence in Indonesia was increased in all age groups by 1.8% in toddlers, 2.5% in group of 6-12 years old, and 5.5% in the group of 15-18 years old. In adults 18 years the obesity prevalence’s was increased by 1.4% (from 10.3% to 11.7%) while overweight among adult also increased from 8.8% to 10.7%. The results of IFLS and IBHS demonstrate that prevalence of obesity in Indonesia has been increasing since 1993 and the id greater in females
- #29 The real problem with obesity arises from its many complications and it is well known to be the risk factors for many diseases including CVD, respiratory diseases, and endocrine conditions. Such a health risk does not only occur in adults, but also in children and adolescents Data from IBHS 2007, showed that increasing BMI is related to increasing prevalence of diabetes mellitus Directorate of Noncommunicable Disease of Ministry of Health developed several programs to prevent increases in prevalence of noncommunicable diseases in 2006 to be implemented by early 2010 Included: CVD, DM and metabolic disease, cancer, degenerative disease and trauma or traffic accident. Classification Used for BMI (kg/m2) Underweight <18.5 Normal 18.5 – 22.9 Overweight 23.0 – 24.9 Obese >25.0 References: WHO Expert Consultation, Lancet 363:157, 2004 The International Association for the study of Obesity and the International Obesity Task Force. The Asia-Pacific perspective, 2000
- #30 Klein S, et al. Diabetes Care. 2007;30:1647-1652
- #32 Rexrode KM, et al. JAMA. 1998;280:1843-1848. p 1847, T3, model 1. (women) from the Nurses’ Health Study: During 8 years of follow-up 320 CHD events (251 myocardial infarctions and 69 CHD deaths) were documented. Higher WHR and greater waist circumference were independently associated with a significantly increased age-adjusted risk of CHD. After adjustment for reported hypertension, diabetes, and high cholesterol level, a WHR of 0.76 or higher or waist circumference of 76.2 cm (30 in) or more was associated with more than a 2-fold higher risk of CHD. Rexrode KM, et al. Int J Obes (Lond). 2001;25:1047-1056. p 1051, T4, model 1. (men) from the Physicians’ Health Study Among the 16 164 men who reported anthropometric measurements and were free from prior CHD, stroke or cancer, a total of 552 subsequent CHD events occurred during an average follow-up of 3.9 y. After adjusting for age, randomized study agent, smoking, physical activity, parental history of myocardial infarction, alcohol intake, multivitamin and aspirin use, men in the highest WHR quintile (>or=0.99) had a relative risk (RR) for CHD of 1.50 (95% CI 1.14-1.98) compared with those in the lowest quintile (<0.90).
- #33 Metabolic syndrome is associated with an increased risk of T2DM &CVD Metabolic syndrome is screened via waist circumference, circulating TG and HDL, FPG and blood pressure. Cardiometabolic risk is the overall risk of CVD resulting from the presence of metabolic syndrome and/or traditional risk factors: dyslipidemia, hypertension, diabetes, age, male gender, smoking, etc. Whether metabolic syndrome is an independent factor that adds significantly to the global CVD risk is uncertain. Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887.
- #36 Recommended total daily intake: 1000-1200 kcal/day for women 1200-1600 kcal/day for men
- #41 Current practice in the management of type 2 diabetes in Indonesia. Results from IDMPS. J Indon Med Assoc 2011 NOTE: Waiting for int’l IDMPS data
- #42 American Diabetes Association. Diabetes Care. 2007;30:S4-41.
- #44 Risk factors include: 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)
- #47 Statins also called HMG-CoA reductase inhibitors Resins also called bile acid sequestrants
- #48 Fibrates also called fibric acid derivatives Niacin also called nicotinic acid
- #51 Note: Waiting for IDMPS inter’l data
- #52 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;109:3244-3255. American Diabetes Association. Diabetes Care. 2007;30:S4-41.