肥胖的并发症-课件

MedicalComplicationsofObesity

MedicalComplicationsofObesi1BMI-AssociatedDiseaseRiskClinicalGuidelinesontheIdentification,Evaluation,andTreatmentofOverweightandObesityinAdults—TheEvidenceReport.ObesRes1998;6(suppl2).Additionalrisks:Largewaistcircumference(men>40in;women>35in)5kgormoreweightgainsinceage18-20yPooraerobicfitnessSpecificracesandethnicgroupsBMI-AssociatedDiseaseRiskCli2Weight(lb)23222119181716151525242221201918171627262423212019181729272624232220191831292826242322212033312927262423222135333129272624232237353331292726242339373432302927262441383634323029272643403836343230282745424037353331302847444139373533312949464340383634323051484542403735333253494644413937353355514845434038363457535047444239373559555249464341393763595552484643414066625855524946444170666258555249464474706561585552494678736965615754514912013014015016017018019020021022032034036024025026023027028029038030040064Height(in)6260706866727476BodyMassIndexChartWeight(lb)23252729313335373943RelationshipBetweenBMIandPercentBodyFatinMenandWomenAdaptedfrom:Gallagheretal.AmJClinNutr2000;72:694.BodyFat(%)BodyMassIndex(kg/m2)0103040602050WomenMenRelationshipBetweenBMIandP4PulmonarydiseaseabnormalfunctionobstructivesleepapneahypoventilationsyndromeNonalcoholicfattyliverdiseasesteatosissteatohepatitiscirrhosisCoronaryheartdisease

DiabetesDyslipidemiaHypertensionGynecologicabnormalitiesabnormalmensesinfertilitypolycysticovariansyndromeOsteoarthritisSkinGallbladderdiseaseCancerbreast,uterus,cervixcolon,esophagus,pancreaskidney,prostatePhlebitisvenousstasisGoutMedicalComplicationsofObesityIdiopathicintracranialhypertensionStrokeCataractsSeverepancreatitisPulmonarydiseaseNonalcoholic5MetabolicSyndromeAbdominalobesityHyperinsulinemiaHighfastingplasmaglucoseImpairedglucosetoleranceHypertriglyceridemiaLowHDL-cholesterolHypertensionMetabolicSyndromeAbdominalob6EvolutionofMetabolicSyndromeIsomaaBetal.DiabetesCare.2001;24:683-689.AKA:InsulinResistanceSyndrome;SyndromeX;DysmetabolicSyndrome;MultipleMetabolicSyndrome1923:Kylindescribesclusteringofhypertension,gout,andhyperglycemia1988:Reavendescribes“SyndromeX”–hypertension,hyperglycemia,glucoseintolerance,elevatedtriglycerides,andlowHDLcholesterol1998:WorldHealthOrganizationdefines“metabolicsyndrome”asclusteringofhypertension,lowHDL,hypertriglyceridemia,insulinresistance,glucoseintoleranceortype2diabetes,highwaist-to-hipratio,andmicroalbuminuriaEvolutionofMetabolicSyndrom7AbdominalobesityGlucoseintolerance/InsulinresistanceHypertensionAtherogenicdyslipidemia

Proinflammatory/ProthromboticstateCharacteristicsoftheMetabolicSyndrome:NCEP-ATPIIINationalCholesterolEducationalProgram(NCEP),AdultTreatmentPanel(ATP)III;2001.DiabetesCVDAbdominalobesityCharacterist8ClinicalIdentificationoftheMetabolicSyndrome*:NCEP-ATPIII*Diagnosisisestablishedwhen>3oftheseriskfactorsarepresentExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.**2003NewADAIFGcriteria(DiabetesCare)ClinicalIdentificationofthe9IncreasingPrevalenceofNCEPMetabolicSyndromewithAge(NHANESIII)Prevalence(%)AgeMenWomenFordEetal.JAMA.2002;287:356-359.IncreasingPrevalenceofNCEP10PrevalenceofCHDbytheMetabolicSyndromeandDiabetesintheNHANESPopulationAge50+CHDPrevalenceNoMS/

NoDM8.7%%of

Population=54.2% 28.7% 2.3% 14.8%AlexanderC,etal.Diabetes52:1210-1214,200313.9%7.5%19.2%MS/

NoDMDM/

NoMSDM/

MSPrevalenceofCHDbytheMetab11PrevalenceoftheMetabolicSyndromeVariesbySexandRace/Ethnicity(NHANESIII)Prevalence(%)AgeFordEetal.JAMA.2002;287:356-359.WhiteAfrican-AmericanMexican-AmericanOther25%16%28%21%23%26%36%20%PrevalenceoftheMetabolicSy12MetabolicSyndrome:ImpactonMortalityMortalityRate(%)WithoutmetabolicsyndromeWithmetabolicsyndrome*IsomaaBetal.DiabetesCare.2001;24:683-689.*P<0.001.*MetabolicSyndrome:Impacton13MetabolicSyndrome:ImpactonCardiovascularHealthPrevalence(%)WithoutmetabolicsyndromeWithmetabolicsyndrome**P<0.001.IsomaaBetal.DiabetesCare.2001;24:683-689.**MetabolicSyndrome:Impacton14ElevatedRiskofCVDPriortoClinicalDiagnosisofType2DiabetesRelativeRisk1.00Nondiabetic

throughout

thestudyHuFBetal.DiabetesCare.2002;25:1129-1134.Priorto

diagnosis

ofdiabetesAfter

diagnosis

ofdiabetesDiabeticat

baseline2.823.715.02ElevatedRiskofCVDPriorto15CharacteristicsofMetabolicallyNormalObeseandMetabolicallyAbnormalObeseSubjects††Postmenopausalwomen.

*P=0.03;**P=0.0001.

LBM=leanbodymass.

AT=adiposetissue.BrochuMetal.JClinEndocrinolMetab.2001;86:1020-1025.CharacteristicsofMetabolical16LipidsandLipoproteins&RestingBPinInsulin-SensitiveandInsulin-ResistantObeseSubjects††Postmenopausalwomen.

DataaremeanSD.

*P=0.01.BrochuMetal.JClinEndocrinolMetab.2001;86:1020-1025.LipidsandLipoproteins&Rest17OralGlucoseToleranceinInsulin-SensitiveandInsulin-ResistantObeseSubjects††Postmenopausalwomen.

‡n=12,sensitive;n=23,resistant.

Dataaremean

SD.*P=0.01;**P=0.005;***P=0.001.BrochuMetal.JClinEndocrinolMetab.2001;86:1020-1025.OralGlucoseToleranceinInsu18WaistSizevsBMIandtheMetabolicSyndrome8-yIncidenceofMetabolicSyndrome(%)Waistcircumference<level2*Waistcircumference>level2*HanTSetal.ObesRes.2002;10:923-931.*Level2=waist40inchesinmenor35inchesinwomen.9.9820.4519.7733.43WaistSizevsBMIandtheMeta19BothInsulinResistanceandDecreasedInsulinSecretionPredicttheRiskofDevelopingType2Diabetes:7-YearIncidencePercentNeither

Low

HighHaffnerSMetal.Circulation.2000;101:975-980.Insulinsecretion

Low

LowInsulinresistance

High

HighBoth

High

LowMetabolicstatus

HOMA-IR

I30-0min/G30-0minBothInsulinResistanceandDe20DistributionbyMetabolicStatusAmongConverterstoType2Diabetes

(83%ofPrediabeticSubjectsareInsulinResistant)HaffnerSMetal.Circulation.2000;101:975-980.Both(54%)(n=195)Lowinsulinsecretion;insulinsensitive(15.9%)Neither(1.5%)Insulinresistant;

goodinsulin

secretion(28.7%)DistributionbyMetabolicStat21InsulinResistance(HOMA-IRQuintiles)areRelatedtoCVDisease:SanAntonioHeartStudyIncreasingInsulinResistanceA:adjustedforage,sex,andethnicityB:adjustedforage,sex,andethnicity,LDL,triglyceride,HDL,systolicbloodpressure,fastingglucose,smoking,alcoholconsumption,andleisuretimeexerciseHanleyAetal.DiabetesCare.2002;25:1177-1184.AHOMAIRBOddsRatio(95%CI)IncreasingRiskofCVDP(trend)<0.0001P(trend)<0.0075InsulinResistance(HOMA-IRQu22Intra-AbdominalFatMassandCHDRiskinType2DiabetesAdjustedforBMI,age(continuous),age2,smoking,parentalhistoryofmyocardialinfarction,alcoholconsumption,physicalactivity,menopausalstatus,hormonereplacementtherapy,aspirinintake,saturatedfat,andantioxidantscore.RexrodeWetal.JAMA.1998;280:1843-1848.P<0.001fortrend.Intra-AbdominalFatMassandC23EctopicLipidsandtheMetabolicSyndromeMetabolicsyndromereflectsfailureofintracellularlipohomeostasis,whichpreventslipotoxicityinorgansofovernourishedindividualsNormalindividuals:lipohomeostasis(ie,lipidoverloadconfinedtowhiteadipocytes,designedtostoresurpluscalories)Obeseindividuals:adipocytesincreaseleptinsecretioninanattempttoenhanceoxidationofsurpluslipidinnonadipocytesDeficiencyornonresponsivenesstoleptinpreventstheseprotectiveeventsandresultsinectopicaccumulationoflipidsPancreatic-cellsandmyocardiocytesare“cellularvictims”–leadingtotype2diabetesandlipotoxiccardiomyopathyUngerRH.Endocrinology.2003.EctopicLipidsandtheMetabol24RelationshipBetweenBMIandCardiovascularDiseaseMortalityRelativeRiskofDeathBodyMassindex<18.5

MenWomenCalleetal.NEnglJMed1999;341:1097.18.5

–

20.420.5

–

21.922.0

–23.423.5

–24.925.0

–26.426.5

–

27.928.0

–29.930.0

–31.932.0

–

34.935.0

–39.9>40.0

LeanOverweightObeseRelationshipBetweenBMIandC25RelationshipBetweenBMIandRiskofType2DiabetesChanJetal.DiabetesCare1994;17:961.ColditzGetal.AnnInternMed1995;122:481.Age-AdjustedRelativeRiskBodyMassindex(kg/m2)MenWomen<22<2323-23.924-24.925-26.927-28.929-30.931-32.933-34.935+1.02.91.04.31.05.01.58.12.215.84.427.640.354.093.26.711.621.342.1RelationshipBetweenBMIandR26Waist-Hip

Ratio

TertileAbdominalFatDistributionIncreasestheRiskofCoronaryHeartDisease

TheIowaWomen’sHealthStudyFolsometal.ArchInternMed2000;160:2117.RelativeriskBodyMassIndexTertile213321Waist-Hip

Ratio

TertileAbdomin27RelationshipBetweenWeightGaininAdulthoodandRiskofType2DiabetesMellitusRelativeRiskWeightChange(kg)Willettetal.NEnglJMed1999;341:427.-10-505101520MenWomenRelationshipBetweenWeightGa28DirectCost*ofChronicDiseasesintheUnitedStatesDirectCost($Billions)Type2

DiabetesWolfAM,ColditzGA.ObesRes.1998;6:97-106.HodgsonTA,CohenAJ.MedCare.1999;37:994-1012.*Adjustedto1995dollars.ObesityCoronary

HeartDiseaseHyper-tensionStroke$18.1$18.4$38.7$51.6$53.2DirectCost*ofChronicDisea29EffectofObesityonExpectedLifetimeMedicalCareCosts*inMenCosts($)*BodyMassIndex(kg/m2)32.527.537.555-6445-54*TotalcostofCHD,type2DM,hypertension,hypercholesterolemia,strokeAge(y)Thompsonetal.ArchInternMed1999;159:2177.35-4422.5EffectofObesityonExpected30IncreaseinHealthcareCostsAmongObeseComparedwithLean(BMI<25kg/m2)Patients*IncreaseinCostComparedwithLeanSubjects(%)BMI30-34kg/m2BMI>35kg/m2QuesenberryCPJretal.ArchInternMed.1998;158:466-472.*HMOSetting:NorthernCaliforniaKaiserPermanente.HealthcarevisitsPharmacyLaboratorytestsAlloutpatientservicesAllinpatientservicesTotalhealthcareIncreaseinHealthcareCostsA31EconomicEffectofObesitytoBusiness:3-YearCoststoFirstChicagoNBDBurtonetal.JOccupEnvironMed1998;40:786.*BMI>27.8kg/m2inmen;>27.3kg/m2inwomen.AbsenteeismHealthcareL