Transcript Obesity and cardiovascular disease

“Overweight” and CardioVascular
diseases
22nd December 2015
Peringatan Hari Ibu (ke-87),
Dharma Wanita Persatuan KJRI
Osaka, Jepang
Hokusetsu General Hospital
Edhi Sudjono Gunawan. M.D., Ph.D.
(医学博士 黄俊 貴文）
Obesity, a growing problem in the nation
• Elly Burhaini Faizal, The Jakarta Post, Jakarta |
National | Thu, April 05 2012, 10:17 AM
• Undernutrition in early life
– Increases the risk of overnutrition in later life
• Children with undernutrition in their early lives
are more susceptible to infectious diseases, which
may lead to death
Obesity trends and determinants in Indonesia
• Department of Agricultural Economics and Rural
Development, Georg-August-University of Goettingen,
Platz der Goettinger Sieben 5, 37073 Goettingen,
Germany
• Over the past 20 years, obesity has increased remarkably in
Indonesia across all population groups, including rural and
low income strata
• The problem is particularly severe among women
• Nutrition awareness and education campaigns, combined
with programs to support leisure time exercise especially
for women, seem to be most promising to contain the
obesity pandemic
IRIN humanitarian news and analysis
• JAKARTA, 5 June 2013 (IRIN) –
• The Indonesian Ministry of Health reports
– Non-communicable diseases
• Strokes, hypertension and diabetes
• Replaced communicable diseases
• As the leading cause of death in the country
• Deaths from non-communicable diseases
– 41% (1995)
– 60% (2007)
• Communicable disease
– An infectious disease transmissible
– Direct contact
– Indirect contact (vector)
• Noncommunicable diseases (NCDs)
– Chronic diseases, are not passed from person to person.
– Long duration and slow progression
– The 4 main types of noncommunicable diseases
• Cardiovascular diseases (like heart attacks and stroke)
• Cancers
• Chronic respiratory diseases (chronic obstructed pulmonary
disease and asthma)
• Diabetes
• Dr. Elvina Karyadi, the director for the
Micronutrient Initiative in Indonesia
– People in Jakarta don't have time to exercise and people
go by car
– People also like junk food and snacking
– They say they don't have time to prepare healthy food
– Starting from childhood, parents give children money
• They can buy their own food instead of preparing
them a meal
– This is a change of lifestyle
Effects of obesity on women's health
• Overweight and obesity are associated with elevated
mortality from all causes in both men and women
– The risk of death rises with increasing weight
• Obesity, especially abdominal obesity, is central to the
metabolic syndrome and is strongly related to polycystic
ovary syndrome (PCOS) in women
• Obese women are particularly susceptible to diabetes, and
diabetes, in turn, puts women at dramatically increased risk
of cardiovascular disease (CVD).
• Obesity increases the risk of several major cancers in
women
– Postmenopausal breast cancer and endometrial cancer
Obesity and cardiovascular disease
• Overweight may develop
– Hypertension, diabetes and atherosclerosis.
– These conditions
• High risk of cardiovascular disease
– Central obesity/Abdominal obesity
CardioVascular ? Disease
Cardiovascular disease
• A diseases that involve the heart or blood vessels
• Includes coronary artery diseases (CAD)
– Angina (penyempitan pembuluh darah jantung)
– Myocardial infarction (heart attack)
• Other CVDs
– Stroke, hypertensive heart disease, rheumatic heart
disease, cardiomyopathy, atrial fibrillation, congenital
heart disease, endocarditis, aortic aneurysms, peripheral
artery disease and venous thrombosis
CardioVascular ? Disease
The underlying mechanisms
• Depending on the disease
• Coronary artery disease, stroke, and peripheral
artery disease, aneurysm involve atherosclerosis.
– Caused by high blood pressure, smoking, diabetes, lack
of exercise, obesity, high blood cholesterol, poor diet,
and excessive alcohol consumption
• Rheumatic heart disease may follow
untreated streptococcus throat infection
Cardiovascular disease and Sudden death
1.
2.
3.
4.
5.
Coronary disease
Aortic Aneurysm
Cerebrovascular disease
Perpheral artery disease
Thrombosis/Embolism
Sudden death Causes
• Coronary artery disease is the leading
cause of sudden cardiac arrest
• Many other
– Cardiac
– Non-cardiac conditions
Sudden death
• Cardiac
– Coronary artery disease
– Myocardial infarction
– Non-ischemic heart disease
• Cardiomyopathy, cardiac rhythm disturbances (arrythmia)
• Hypertensive heart disease (Tekanan darah tinggi)
• Congestive heart failure (Gagal Jantung)
• Non Cardiac
– Bleeding
• Gastrointestinal bleeding, aortic rupture, or intracranial
hemorrhage
– Overdose, drowning and pulmonary embolism
– Cardiac arrest can also be caused by poisoning
Cardiovascular disease and Sudden death
1.
2.
3.
4.
5.
Coronary disease
Aortic Aneurysm
Cerebrovascular disease
Peripheral artery disease (PAD)
Thrombosis/Embolism
1. Coronary artery disease ⇒MI
Therapy of Coronary artery disease
Stent
(PCI = percutaneous coronary
intervention)
PCI = percutaneous coronary intervention
Unstable Angina Clinical Presentation
• Ischemic pain
• heaviness, tightness, aching, fullness, or burning of the
chest, epigastrium, or arm or forearm (usually the left)
• Involve the lower jaw, neck, or shoulder
• Associated symptoms :
– dyspnea, generalized fatigue, diaphoresis, nausea and vomiting
– flulike symptoms, lightheadedness or abdominal pain
• The intensity of pain does not correlate with diagnosis or
prognosis
• Elderly and female patients are more likely to present with
atypical signs and symptoms
2. Aortic aneurysm
Aneurysm
• An aneurysm or aneurism
– from Greek:"dilation", "to dilate“
– localized
– Blood-filled balloon-like bulge in the wall of
a blood vessel
• Risk factors
– Diabetes, obesity, hypertension, tobacco use,alcoholism,
high cholesterol, copper deficiency, increasing age, and
tertiary syphilis and TBC infection
Therapy
Abdominal aneurysm
Case Study
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Oct 12th 2015, 21p.m.
Chest discomfort
chest pain
Emergency unit
– Lab:Normal limit
– BP 185/102
• Chest Rontgent
• Inpatient recommended
– Rejected
Aortic aneurysm rupture
• Oct 13th, 07 a.m.
• Brushing teeth
• She felt down suddenly
(Collaps)
• Emergency services called
and Cardiopulmonary
resuscitation start
• 08:14 a.m. confirmed
death
• R-1, R-2, R-3
Aortic aneurysm Symptoms
• Many aneurysms do not have symptoms
• Detected during a routine physical exam or
– X-ray evaluation for another disorder
• Symptoms occur
– When the aneurysm grows/disrupts the wall of the aorta
• Symptoms depend on the size and location
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Pain in the abdomen or in the lower back
Constant pain occurring over hours or days
Sudden onset of severe stabbing pain
Unusual sensation of pulsing in the abdomen
Cough, shortness of breath (thoracic aortic aneurysm)
Fainting, Chest pain
3. Cerebrovascular disease
Subarachnoid haemorahge
• 66 years old man
• 2 days ago
– Headeche
– Vomit
– General malaise
• Walking to Hospital
• BP 207/85
• Concious
• SAH.wmv
SAH (Subarachnoid haemorrhage)
• acute nontraumatic headache
– maximum intensity within 1 hour
– “Worst headache of my life"
• 30-40% of patients are at rest at the time of
SAH
• The remaining 60-70% of cases
– Physical or emotional strain
– Defecation, coitus, and head trauma
SAH Prodromal events
• Signs and symptoms
– Ruptured cerebral aneurysm (10-50% of cases.)
– 10-20 days prior to rupture
• The most common symptoms
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Headache (48%)
Dizziness (10%)
Orbital pain (7%)
Diplopia (4%), Visual loss (4%)
Sensory or motor disturbance (6%)
Seizures (4%), Dysphasia (2%), Ptosis (3%)
• Prodromal signs and symptoms
– Sentinel leaks
• Headaches, nausea, vomiting, photophobia, malaise, neck pain.
• These symptoms may be ignored by the physician
– Mass effect (aneurysm expansion)
– Emboli
Cerebrovascular disease (head injury)
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92 years old woman
Fall down, Head injury
Headeache, nausea, vomiting
Right Intracranial haemorrhage
(Epidural hematoma)
Sarcopenia
Cerebrovascular disease,
Cerebrovascular infarct (Stroke)
• 47 years old woman
• Past history : Iron Defficiency Anemia
• 28th Oct 2015
– Suddenly fall down and feel dysarthria
• 29th Oct 2015 night
– Numbness left hand and leg
• 30th Oct 2015 Emergency department
– No sign of paralysis, walking to hospital
– BP 182/104
– Head MRI exam
– 脳梗塞（DWI).wmv 脳梗塞（MRA 1）.wmv
– 脳梗塞（MRA-2).wmv 脳梗塞（頚動脈－１）.wmv
Internal carotid artery oclusion
4. Peripheral artery disease (PAD)
• Narrowing of the arteries
– Other than the heart or brain
• classic symptom
– Leg pain when walking, resolves with rest
– Intermittent claudication
• Other symptoms
– Skin ulcers, bluish skin, cold skin, or poor nail and hair
growth in the affected leg
– Complications
• Infection or tissue death
• May require amputation
• 50% are without symptoms
Symptom
Screening
Therapy of Peripheral artery disease
Peripheral artery disease
• 72 Years old Man (Inpatient caused by Osteomyelitis)
– Diabetes Mellitus
– Hypercholesterol, Hyperlipidemia
– Hypertension
• Bilateral Leg PAD
5. Pulmonary embolism
• Inhospital caused by
lower extremities
infection
• Oct 6th 22 p.m.
– Suddenly
– Chest pain, dyspnea
– Cold sweat
• ECG: look like Angina
or MI
• PE-造影０１.wmv
• PEー造影２.wmv
• PEー造影３D.wmv
A former minister for health in Indonesia,
• The rates of infectious diseases have gone down,
while non-communicable diseases have gone up
tremendously
• The non-communicable diseases are not included
in our health insurance schemes
90% of CVD : preventable
• Prevention of atherosclerosis by decreasing risk factors
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Healthy eating, exercise
Avoid tobacco smoke
Limiting alcohol intake
Treating high blood pressure and diabetes
Treating people who have strep throat with antibiotics can
decrease the risk of rheumatic heart disease
– Avoid or reduce exposure to air pollution
Cardiovascular disease = Obesity only?
1. Visceral fat (abdominal fat)
–
–
Body fat that exists in the abdomen
Surrounds the internal organs
2. Cholesterol Ratio
–
L/H Ratio
3. Air Pollution
Cardiovascular disease = Obesity only?
Air Pollution ＝ PM2.5
Air pollution
• Currently, PM2.5 is the major focus
• short- and long-term exposure
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Increased rate of atherosclerosis and inflammation
Effects on cardiovascular disease
Estimated 8–18% CVD mortality risk
Women had a higher relative risk coronary artery
disease than men did
5 days of exposure, a rise in Blood pressure
Irregular heart rhythm, reduced heart rate variability,
and heart failure
Artery thickening
Increased risk of acute myocardial infarction
Respiratory system
Others effects PM2.5
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Irritation of the eyes, nose and throat
Coughing, chest tightness and shortness of breath
Reduced lung function
Irregular heartbeat
Asthma attacks
Lung Cancer
Premature death in people with heart or lung
disease
Reduce exposure to PM2.5
• When outdoor levels of PM2.5 are elevated,
– Going indoors
• Limit indoor and outdoor activities that produce
fine particles
– Burning candles indoors/open burning outdoors
– Avoid strenuous activity in areas where fine particle
levels are high
– Tobacco (Passive smoking)
• Air purifier
PM
2.5
Concentration expected
1. Visceral fat, or abdominal fat
Has significant impact on metabolism
• Affects blood pressure; blood lipid levels, cardiac rhythm
• Interferes with ability to use insulin effectively, disturb
neurohormonal function ect
2. Cholesterol
Fat
TG
Liver
Intestine
TG
HDL
1. “Scour" the walls of blood vessels
2. Cleaning out excess cholesterol (plaques that cause CAD)
3. Carried to the liver
•
Processed into bile
•
Secreted into the intestines and out of the body
3. Cholesterol ratio
• Total cholesterol
• High-density lipoprotein, HDL (good cholesterol),
• + Low-density lipoprotein, LDL (bad cholesterol),
• + 20 percent of triglycerides
• a type of fat carried in blood
• Cholesterol ratio
• Total cholesterol/HDL
Total Cholesterol/HDL Ratio (U.S.A)
LDL/HDL Ratio (Japan)
Cholesterol ratio : Total cholesterol/HDL
• An optimal ratio 3.5～1
• A higher ratio : a higher risk of heart disease
• Non-HDL cholesterol
– Total cholesterol ー HDL cholesterol
– All the "bad" types of cholesterol
– Higher numbers mean a higher risk of heart disease
• Ratio of 5 ：average risk of heart disease for men
– Ratio 9.6 : double the risk
• Women, a 4.4 ratio ： average risk for heart disease
– A ratio 3.3 : roughly half the average risk
– Ratio 7 : double the risk for heart disease
– Because their HDL levels are often higher
Cholesterol ratio : Total cholesterol/HDL
• HDL ＜ 40 mg/dL
– Increased risk of CAD
– Normal total cholesterol and LDL cholesterol levels
• HDL 40 ― 60 mg/dL ： considered "normal"
– Do not very much affect the risk of CAD
• HDL ＞ 60 mg/dL
– Reduced risk of heart disease
L/H ratio
– <1.5 Good condition
– >2.0 accumulation of cholesterol, Probability of
atherosclerosis
– >2.5 Risk for Plaque and CardioVascular disease
Target HDL cholesterol level
At risk
Desirable
Men
＜ 40 mg/dL
(1.0 mmol/L)
≧60 mg/dL
(1.6 mmol/L)
Women
＜ 50 mg/dL
(1.3 mmol/L)
≧60 mg/dL
(1.6 mmol/L)
How can We Increase Our HDL Levels?
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Aerobic exercise
Lose weight
Stop smoking
Cut out the trans fatty acids
Alcohol : one or two drinks /day
Increase the Monounsaturated Fats In Your Diet
Add soluble fiber to your diet
Other dietary means to increasing HDL
What About A Low-Fat Diet?
What About Drugs?
Trans fatty acid
• Made through the chemical process of
hydrogenation of oils
• Margarine, crackers, cookies, and snack
foods
• Abundance in many deep-fried foods
• Raise the 'bad' (LDL) cholesterol
• Lower the 'good' (HDL) cholesterol levels
• Increase the risk of heart disease
Increase in HDL levels
• Removing trans fatty acids
• Monounsaturated fats : canola oil, avocado oil, olive oil
– Without increasing the total cholesterol
• Soluble fibers : fruits, vegetables
– Reduction in LDL cholesterol
– Increase HDL cholesterol
• Cranberry juice
• Fish and other foods containing omega-3 fatty acids
– Increase HDL levels. In postmenopausal women
– (but not, apparently, in men or pre-menopausal women)
Regular aerobic exercise increase your HDL level
• Walking, jogging or bike riding
• duration ＞ intensity
– At least 20 minutes (though 40 would be better)
– At least 3 ~ 4 times/week
• Raises your heart rate for 20 to 30 minutes at a time
– THR (Target heart zone)
Low-fat diet
• Reduces HDL - rather than increases - HDL levels
– Not specifically caused by “not enough fat”
– But, is caused by consuming too many carbohydrates
• The American Heart Association and the American
College of Cardiology
– Stopped recommending low-fat diets for heart disease
prevention
• Low-carb diets - and not low-fat diets –
– Can increase HDL levels
• Drug therapy for raising HDL cholesterol levels
• Disappointment
• Statins
– Has proven highly successful in reducing LDL
– Not very effective at increasing HDL levels
• Niacin : drug therapy for raising HDL levels.
– One of the B vitamins
– The amount of niacin needed are so high
– Raising HDL levels with niacin
• No improvement in cardiovascular outcomes
– Treatment with niacin
• Increased risk of stroke, diabetic complications
Healty eating and exercise = Lose weight
• BMI : (kg/m2)
– weight (kilograms) : the square of height in meters
• BMI score
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Underweight ：＜ 18.5
Healthy weight ：18.5 ー 24.9
Overweight：25 ー 29.9
Obese ：30 ー 39.9
Severely obese ＞40
Waist circumference
Another indicator of your risk of developing health problems
• USA
– Men > 94cm
– Women > 80cm
• Japan
– Men > 85cm
– Women > 90cm
Lose weight too fast ⇒ Rebound
• Lose weight at a safe rate of 0.5kg to 1kg / week
• A daily calorie : 1,900kcal for men
– 1,400kcal for women
• Losing weight faster
– Increase the risk of health problems
– Malnutrition, gallstones, feel tired and unwell
• 1 Kg = ? Calories = ?cm waist circumference
• Caloric needs (simple guide)
– Body weight (Kg)×２５〜３０ Kcal
– Adult women ±１５００ Kcal/day
Caloric needs (simple guide)
• Calorie need/kg
– Desk work (Low active) 25~30 kcal
– Standing work or work outside
• (Moderate active) 30~35 kcal
– Hard work (Active) 35~40 kcal
Conclusion = Live well
Live well
• Eat well
– Good fats
• Monounsaturated fats :avocados, nuts and seeds
• Polyunsaturated fats, including Omega-3s, : fatty fish
• Good vegetarian sources of polyunsaturated fats : walnuts
– Bad fats
• Trans fats, margarines, candies, cookies, snack foods, fried foods
• Exercise
• Avoid / reduce polution
– PM2.5 of 880 ug/m3 (city with high pollution)
– Smoking area 700 ~ 800 ug/mg3
Fat composition recommnded
Unsaturated fat
Saturated fat
Trans fat
Monounsaturated
Polyunsaturated
Omega-3
Omega-6
Source
Animal fat
Meat, milk
Chemical process
Olive oil
avocados
Fish, salmon
Beans,sardine
Vegetable
oil, nuts
intake
Limit
consumtion
Avoid, do not eat
“hydorogenated oil”
Recommneded
Bad Chol↓
Good chol ↑
Good fat
Brain health
Help
metabolism
Good fat
Over
consumed
caused
health
problem
Food composition
Case 1
2014/8/6
2014/11/12
2015/6/10
2015/10/20
T-Chol
209
228
254
123
T-G
550
261
351
186
HDL
37
40
41
27
LDL
120
149
166
57
Tchol/HDL
5.6
5.7
6.2
4.5
L/H ratio
3.2
3.7
4.0
2.1
Case 2
2012/4/19
2014/10/17
2015/10/13
T-Chol
305
272
272
T-G
223
162
79
HDL
48
68
74
LDL
221
181
186
Tchol/HDL
6.4
4
3.6
L/H ratio
4.6
2.6
2.5
Case 1 & 2
2014/8/6
T-Chol
T-G
HDL
LDL
2014/11/12
2015/6/10
2015/10/20
123
272
186
79
27
74
209
305
550
223
37
48
228
272
261
162
40
68
254
120
221
149
181
166
351
41
57
186
Case 1 take madication Statin
2014/8/6
2014/11/12
2015/6/10
2015/10/20
HDL
37
40
41
27
Tchol/HDL
L/H ratio
5.6
3.2
5.7
3.7
6.2
4.0
4.5
2.1
Case 2 didn’t take madication
2012/4/19
2014/10/17
2015/10/13
HDL
48
68
74
Tchol/HDL
L/H ratio
6.4
4.6
4
2.6
3.6
2.5
3 ~ 4 times/week exercise + Low carb diet
Metabolic syndrome
• Waist circumference
– Man > 85cm Women > 90cm
• Trigliceride・HDL Cholesterol
– TG >150mg/dl
– HDL<40mg/dl
– One or both
• Blood pressure
– Systolic blood pressure >130mｍHg
– Diastolic blood pressure > 85mｍHg
– One or both
• Blood Sugar
– Fasting blood sugar >110mg/dl
Conclusion
BMR is the number of calories you would burn with NO activity
Effect on BMR
BMR (Simple guide)
(Kcal)
Years/gender
Man
woman
50~69 old
21.5 x weight
20.7 x weight
30~49 old
22.3 x weight
21.7 x weight
18~29 old
24.0 x weight
23.6 x weight
15~17 old
27.0 x weight
25.3 x weight
Conclusion
Meal
TEF
(% of calories consumed)
Protein
20~30 %
Carbohydrates
5 ~10 %
Fat
0~3 %
Exercise THR (Target heart zone)
• First step ： resting heart rate (RHR)
• Before get out of bed in the morning,
– Take pulse for 1 full minute
– Beats per minute (bpm)
• For a more accurate measurement
– Take pulse for 3 mornings and take an average
– A normal RHR for adults is between 60-100
• Use this number to find target heart rate zones
– Karvonen formula
• Calculate a THR zone between 50% and 85%
– Heart rate reserve
Exercise
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Low Intensity - 50-60%
Moderate Intensity - 60-70%
Vigorous or High Intensity - 75-85%
The Talk Test and Perceived Exertion
– Can speak comfortably
• Around the low-middle range of THR zone
To calculate the low end THR zone
• 50% of heart rate reserve
• Max Heart Rate (MaxHR) =
206.9 - (0.67 x age)
• Heart Rate Reserve (HRR)
= MaxHR - (resting heart
rate)
• HRR x 50% = training
range %
• Training range % + resting
heart rate = low end of THR
zone
• 35-year-old RHR of 60/m
• 206.9 - (0.67 x 35) = 183.45
183.45 - 60 = 123.45
123.45 x 50%= 62%
62 + 60 = 122 bpm
• For this person,
– The low end THR starts
at 122 bpm,
– A light, warm up pace
calculating the high end (85%) of THR zone
• 85% of heart rate reserve
• Max Heart Rate (MaxHR) =
206.9 - (0.67 x age)
• Heart Rate Reserve (HRR) =
MaxHR - (resting heart rate)
• HRR x 85% = training
range %
• Training range % + RHR =
high end of your THR zone
• 35 year old RHR 60 bpm
• 206.9 - (0.67 x 35) = 183.45
(MaxHR)
• 183.45 - 60 = 123.45 (HRR)
• 123.45 x 85%= 105 (training
range % )
• 105 + 60 = 165 bpm (high
end of THR zone )
• Training heart rate zone : 120-180 beats per minute
Terima Kasih
Cardiac rhythm