clinical spectrum, comorbidities and outcomes in patients with obesity
TUSHARA CH THESIS
INTRODUCTION:
TITLE
CLINICAL SPECTRUM, COMORBIDITIES AND OUTCOMES IN PATIENTS WITH OBESITY.
INTRODUCTION:
Obesity is one of the most serious public health challenges of the 21st century. The problem is global and is steadily affecting many low and middle income countries, particularly in urban settings. The prevalence has increased at an alarming rate. Overweight and obese patients are more likely to develop diseases like diabetes and cardiovascular diseases at a younger age, the risks depend partly on the age of onset and on the duration of obesity. Obese patients suffer from both short-term and long-term health consequences.
The most significant health consequences of overweight and obesity are:
cardiovascular diseases (mainly heart disease and stroke);
Diabetes;
Musculoskeletal disorders, especially osteoarthritis; and
Certain types of cancer (endometrial, breast and colon).
The fundamental cause of overweight and obesity is an energy imbalance between calories consumed and calories spent.
Global increases in overweight and obesity are attributable to a number of factors including:
• A global shift in the diet towards increased intake of energy-dense foods that are high in fat and sugars but low in vitamins, minerals and other healthy micronutrients;
• A trend towards decreased physical activity levels due to the increasing sedentary nature of many forms of recreation time, changing modes of transportation, and increasing urbanization.
*Metabolic syndrome:*
Metabolic syndrome is also known as metabolic syndrome X, syndrome X, insulin resistance syndrome, Reaven's syndrome is a combination of medical disorders that increase the risk of developing cardiovascular diseases and diabetes.
Although the pathophysiology of this syndrome is incompletely understood, insulin resistance and abdominal obesity are central to many of the metabolic perturbations. Based on existing estimates the metabolic syndrome affects- nearly 1/4th of the populations in developed countries. Prevalence of the metabolic syndrome is increasing in developing countries, including India.
Insulin resistance and resulting hyperinsulinemia have been implicated in the development of glucose intolerance (and progression to type 2 diabetes), hypertriglyceridemia, hypertension, polycystic ovary syndrome, hypercoagulability and vascular inflammation, as well as the eventual development of atherosclerotic cardiovascular disease manifested as myocardial infarction, stroke and myriad end organ diseases.
There are other concerns as well that should be mentioned. Metabolic syndrome is associated with fat accumulation in the liver (fatty liver), resulting in inflammation and the potential for cirrhosis. The kidneys can also be affected, as there is an association with microalbuminuria the leaking of protein into the urine, a subtle but clear indication of kidney damage.
Other problems associated with metabolic syndrome include obstructive sleep apnea, polycystic ovary syndrome, increased risk of dementia with aging, and cognitive decline in the elderly.
Conversely, treatment and consequent improvement of insulin resistance have been shown to result in better outcomes in virtually all of these conditions.
*Criteria of Metabolic Syndrome:*
NCEP The US National Cholesterol Education Program Adult Treatment Panel III (2001) requires at least three of the following:
• Central obesity: waist circumference ≥ 102 cm or 40 inches (male), ≥ 88 cm or 36 inches(female)
• Dyslipidemia: TG ≥ 1.7 mmol/L (150 mg/dl)
• Dyslipidemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female)
• Blood pressure ≥ 130/85 mmHg
• Fasting plasma glucose ≥ 6.1 mmol/L (110 mg/dl)
If BMI is >30kg/m², central obesity can be assumed and waist circumference does not need to be measured.
Obesity is considered to be a disease of epidemic proportion. Metabolic syndrome is increasing in prevalence with obesity and sedentary lifestyles. Patients with metabolic syndrome frequently progress to type 2 DM and have increased risk for mortality and morbidity from cardiovascular diseases.
The most significant health consequences of overweight and obesity are:
cardiovascular diseases (mainly heart disease and stroke);
Diabetes;
Musculoskeletal disorders, especially osteoarthritis; and
Certain types of cancer (endometrial, breast and colon).
The fundamental cause of overweight and obesity is an energy imbalance between calories consumed and calories spent.
Global increases in overweight and obesity are attributable to a number of factors including:
• A global shift in the diet towards increased intake of energy-dense foods that are high in fat and sugars but low in vitamins, minerals and other healthy micronutrients;
• A trend towards decreased physical activity levels due to the increasing sedentary nature of many forms of recreation time, changing modes of transportation, and increasing urbanization.
*Metabolic syndrome:*
Metabolic syndrome is also known as metabolic syndrome X, syndrome X, insulin resistance syndrome, Reaven's syndrome is a combination of medical disorders that increase the risk of developing cardiovascular diseases and diabetes.
Although the pathophysiology of this syndrome is incompletely understood, insulin resistance and abdominal obesity are central to many of the metabolic perturbations. Based on existing estimates the metabolic syndrome affects- nearly 1/4th of the populations in developed countries. Prevalence of the metabolic syndrome is increasing in developing countries, including India.
Insulin resistance and resulting hyperinsulinemia have been implicated in the development of glucose intolerance (and progression to type 2 diabetes), hypertriglyceridemia, hypertension, polycystic ovary syndrome, hypercoagulability and vascular inflammation, as well as the eventual development of atherosclerotic cardiovascular disease manifested as myocardial infarction, stroke and myriad end organ diseases.
There are other concerns as well that should be mentioned. Metabolic syndrome is associated with fat accumulation in the liver (fatty liver), resulting in inflammation and the potential for cirrhosis. The kidneys can also be affected, as there is an association with microalbuminuria the leaking of protein into the urine, a subtle but clear indication of kidney damage.
Other problems associated with metabolic syndrome include obstructive sleep apnea, polycystic ovary syndrome, increased risk of dementia with aging, and cognitive decline in the elderly.
Conversely, treatment and consequent improvement of insulin resistance have been shown to result in better outcomes in virtually all of these conditions.
*Criteria of Metabolic Syndrome:*
NCEP The US National Cholesterol Education Program Adult Treatment Panel III (2001) requires at least three of the following:
• Central obesity: waist circumference ≥ 102 cm or 40 inches (male), ≥ 88 cm or 36 inches(female)
• Dyslipidemia: TG ≥ 1.7 mmol/L (150 mg/dl)
• Dyslipidemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female)
• Blood pressure ≥ 130/85 mmHg
• Fasting plasma glucose ≥ 6.1 mmol/L (110 mg/dl)
If BMI is >30kg/m², central obesity can be assumed and waist circumference does not need to be measured.
Obesity is considered to be a disease of epidemic proportion. Metabolic syndrome is increasing in prevalence with obesity and sedentary lifestyles. Patients with metabolic syndrome frequently progress to type 2 DM and have increased risk for mortality and morbidity from cardiovascular diseases.
Hence there is a vital need for early identification of patients with this syndrome and modification of risk factors to prevent further progression.
AIM:
To assess the clinical spectrum,co morbidities and outcomes with obesity
OBJECTIVES:
• To identify patients of obesity with and without comorbidities.
• To document associated comorbidities in patients with obesity in different age groups.
• To document outcomes in patients with patients.
STUDY DESIGN:
A Prospective Observational Study
STUDY PERIOD: 2 YEARS
PLACE OF STUDY: Department of General Medicine, Kamineni Institute of medical sciences Narketpalli.
SAMPLE SIZE: 5O PATIENTS
METHODOLOGY:
This is an observational study done in the department of general medicine where patients were screened for obesity with BMI, and those who satisfy the inclusion criteria were enrolled in the study after informing the nature of the study to the patients. Written informed consent was obtained from patients or guardian. Complete physical examination along with anthropometric measurements was done.
Family history of obesity, DM, hypertension (HT), cerebrovascular events, coronary artery disease, dyslipidemia (DL).
Anthropometry: Body weight was measured to the nearest 0.1 kg with a balance scale , and height was measured to the nearest 0.1 cm with stadiometer with subjects lightly dressed and without shoes. Body mass index (BMI) was calculated as weight (kg) divided by height square (m2).
Laboratory investigations: Blood glucose, serum insulin and lipid levels were determined from blood samples taken after an overnight fast.
Biochemical analysis and definition: Hyperinsulinemia is defined if fasting insulin >15mu/L, HOMA IR > 3.5 HOMA IR is calculated as product of fasting plasma insulin in mu/L and the fasting glucose in mg/dl, divided by 405.Score of >3.5 is taken as insulin resistance and score < 3.5 as insulin sensitive. Fasting glucose >110mg/dl is considered abnormal and >140mg/dl is taken as having Diabetes mellitus Triglycerides >100mg/dl, HDL < 40 mg/dl is considered cut off. Metabolic syndrome was considered if three or more of the following criteria were present: BMI > 95th percentile, triglyceride >40mg/dl, HDL <40mg/dl, fasting glucose >110mg/dl, systolic or diastolic BP >90th percentile.
Family history of obesity, DM, hypertension (HT), cerebrovascular events, coronary artery disease, dyslipidemia (DL).
Anthropometry: Body weight was measured to the nearest 0.1 kg with a balance scale , and height was measured to the nearest 0.1 cm with stadiometer with subjects lightly dressed and without shoes. Body mass index (BMI) was calculated as weight (kg) divided by height square (m2).
Laboratory investigations: Blood glucose, serum insulin and lipid levels were determined from blood samples taken after an overnight fast.
Biochemical analysis and definition: Hyperinsulinemia is defined if fasting insulin >15mu/L, HOMA IR > 3.5 HOMA IR is calculated as product of fasting plasma insulin in mu/L and the fasting glucose in mg/dl, divided by 405.Score of >3.5 is taken as insulin resistance and score < 3.5 as insulin sensitive. Fasting glucose >110mg/dl is considered abnormal and >140mg/dl is taken as having Diabetes mellitus Triglycerides >100mg/dl, HDL < 40 mg/dl is considered cut off. Metabolic syndrome was considered if three or more of the following criteria were present: BMI > 95th percentile, triglyceride >40mg/dl, HDL <40mg/dl, fasting glucose >110mg/dl, systolic or diastolic BP >90th percentile.
INCLUSION CRITERIA:
• Patients above 18 YEARS
• Patients presenting to our hospital with waist circumference >102cm in men and >88cm in women.
• Patients with BMI greater than or equal to 25.
EXCLUSION CRITERIA:
• Patients less than 18 yrs
• Patients with waist circumference <102cms in men and <88cms in women
• Patients who doesnt want to be a part of study.
• Mentally not competent to give consent.
OUTCOMES:
Morbidity
Mortality
Case proforma
PATIENT DETAILS
Name
Age
Sex
Occupation
Residence
OP/IP number
HISTORY
Biopsychosocial history
Past history:
Personal history:
Bowel and bladder
Diet
Addictions
Allergies
Family history:
General examination
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema
Height
Body weight
BMI
ABDOMINAL FAT
Waist-Hip circumference
Investigations (in selected patients)
CBP
CUE
FBS
PPBS
HBA1C
LFT
RFT
THYROID PROFILE
FASTING LIPID PROFILE
ECG
2D ECHO
CHEST X RAY
ULTRASOUND
Name
Age
Sex
Occupation
Residence
OP/IP number
HISTORY
Biopsychosocial history
Past history:
Personal history:
Bowel and bladder
Diet
Addictions
Allergies
Family history:
General examination
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema
Height
Body weight
BMI
ABDOMINAL FAT
Waist-Hip circumference
Investigations (in selected patients)
CBP
CUE
FBS
PPBS
HBA1C
LFT
RFT
THYROID PROFILE
FASTING LIPID PROFILE
ECG
2D ECHO
CHEST X RAY
ULTRASOUND
CONSENT
I/WE, relative of the patient have read and understood the information provided in the patient information sheet and have been informed the purpose of the evaluation in the language I understand.
I am aware of the fact that I may not derive any benefit from the evaluation and that I deserve the right to opt out of the study at any point of time.
I willingly agree to participate in this study
Patients sign/thumb impression/ witness sign/thumb impression:
I/WE, relative of the patient have read and understood the information provided in the patient information sheet and have been informed the purpose of the evaluation in the language I understand.
I am aware of the fact that I may not derive any benefit from the evaluation and that I deserve the right to opt out of the study at any point of time.
I willingly agree to participate in this study
Patients sign/thumb impression/ witness sign/thumb impression:
Name:
Date:
Residents sign:
Date:
Residents sign:
Resident name:
Date:
REFERENCES:
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