THE METABOLIC SYNDROME THE NEW IDF DEFINTION and

THE METABOLIC SYNDROME THE NEW IDF DEFINTION and THE SOCIO-ECONOMIC BURDEN Prof. Morsi Arab University of Alexandria IDF Chairman EMME Region

THE SIMPLE CONCEPT OF THE METABOLIC SYNDROME ( MTS ) The Metabolic Syndrome is a cluster of the most dangerous risk factors for heart attack : - diabetes / raised fasting plasma glucose, + - abdominal obesity , - high blood pressure - defective Cholesterol Metab.

GLOBAL SIZE OF THE ( MTS ) PROBLEM 20 -25 % of the world adult population have the metabolic syndrome ( MTS) , and these are : - twice likely to die - 3 times likely to have a heart attack or stroke - 5 times at risk to develop diabetes type 2

THE CV RISK IN DIABETES AND IN THE METABOLIC SYNDROME ( MTS) Diabetes is the leading cause of CVD The existence of Metabolic Syndrome confers an additional risk for CVD The more components of MTS the higher the CVD risk and mortality The MTS , even before the diagnosis of diabetes , increases the risk and mortality of CVD

Causative Factors in the Metabolic Syndrome The Two significant factors : ( Insulin Resistance ) and ( Central Obesity ) Other possible Factors : - Genetics - physical inactivity - aging - a pro inflammatory state - a hormonal state (These may play variable roles in different ethnic groups)

“Obesity” is always involved , or associated with all elements of the Metabolic Syndrome : Obesity is associated with Insulin Resistance Obesity contributes to hypertension – high holesterol – low HDL Cholesterol hyperglycemia and type 2 diabetes Obesity is associated with a high CVD risk But Which type of Obesity ?

“ Abdominal Obesity “ as measured by waist circumference is more indicative of the Metabolic Syndrome profile than increased BMI

Historical Context : o , Morgagni : associated visceral ob. ac. obstruct. sleep apena. -1947 Vague ( France ) : Android obesity. -1960 : Plurimetabolic Syndrome ( ob+ diab + bld lipids + risk CHD. ) -1980 : Syndrome X : glucose & insulin metab + + obesity + HT + dyslipidemia Insulin sensitivity - risk CHD insulin resistance

Historical ( cont. ) - 1998 : WHO definition - : EGIR Definition ( European Group Study of Insulin Resistance ) - 2001 : NCEP Definition ( National Cholesterol Education Program ) ATP III (Adult Treatment Panel ) - 2005/6 : The IDF Definition

The WHO Definition : 1998 I- Criteria : [ Type 2 diabetes or IGT ] * 1 - Hypertension 2 - Blood fat 3 - Obesity ( BMI) ** 4 - micro albuminuria + 2 out of 4 : - * In case of normal glucose tolerance , evidence of diminished insulin sensitivity (by Euglycemic clamp or HOMA) aist/ hip ratio

Draw backs in the WHO Definition 1 - BMI is not a reliable measure to obesity 2 - Microalbuminuria is very rarely found in absence of diabetes. 3 - Euglyc. clamp is not practically applicable (clinically or epidem. )

he ATP III ( Adult Treatment Panel ) Definition, 2001 …… by The US National Cholesterol Education Program Revised Criteria = at least 3 out of 5 : M F 1 - Visceral Obesity Waist circumference: 102 88 2 - TG ……………. above 150 mg 3 - HDL Cholesterol …………. below 40 50 4 - Hypertension …………. . ( 130 / 85 ) 5 - Fasting glucose : 100 mg/dl ( if diabetes or IGT is not already diagnosed)

The ATP III Definition 2001( cont. ) + Optional - C-reactive protein ( marker of inflammation ) - Fibrinogen ( marker of prothrombolic state ) Draw back bsence of ethnic consideration in the cut-off points.

Confusion results from different definitions Why ? differences in 1 - the components of the MTS 2 - the cut- off points This causes difficulties in : 1 - identifying the MTS i. e. diagnosing 2 - interpretation of its causation 3 - comparing its burden in different populations

Therefore : A new IDF Definition is needed …. why ? e a set of criteria for use, both demiologically and in clinical practice, e MTS ( i. e. Diagnosis ) 2 - can better define the nature of MTS ( Pathogenesis ) 3 - to focus on …………… appropriate ( management ) 4 - so as to contribute to long term reduction of risk to CVD and type 2 diabetes ( Prevention)

The new international Diabetes Federation (IDF) definition According to the new IDF definition , for a person to be defined as having the metabolic syndrome he/she must have : Central Obesity ( defined as waist circumference * with ethnicity specific values ) plus any two of the following four factors : Raised triglycerides 150 mg/d. L (1. 7 mmol/L ) or specifc treatment for this lipid abnormality. Reduced HDL Cholesterol 40 mg/dl ( 1. 03 mmol/L ) in males 50 mg/d. L (1. 29 mmol/L) in females or specific treatment for this lipid abnormality Raised blood pressure Systolic BP 130 or diastolic BP 85 mm. Hg Or treatment of previously diagnosed hypertension Raised fasting plasma glucose ( FPG) 100 mg/d. L (5. 6 mmol/L) or previously diagnosed type 2 diabetes

Ethnic specific values for waist circumference Waist circumference Country / Ethnic group Male 94 cm Female 80 cm Male Female 90 cm 80 cm Chinese Male Female 90 cm 80 cm Japanese** Male Female 90 cm 80 cm Ethnic South and Central Americans Use South Asian recommendations until more specific data are available Europids* In the USA, the ATP III values ( 102 cm male; 88 cm female) are likely to continue to be used for clinical purposes South Asians Based on a Chinese , Malay and Asian-Indian population Sub-Saharan Africans Use European data until more specific data are available EMME ( Arab) populations Use South Asian recommendations until more specific data are available

Characteristic features of the IDF definition - Single, universally accepted - Simple to use clinically ut-off points, considering different ethnic groups - Central obesity is the core, and waist circumference is the proxy. - Open to additional criteria for research , and - Open to areas for further studies

The IDF Definition does not have the final word : 1 - more research will possibly reveal more accurate predictive indices. 2 - other major risk factors for CVD ( e. g. smoking & LDL cholesterol ) must be taken in consideration

The MTS in Young People Research studies so far denote : 1. Prevalence ? probably 30 % in overweight adolescents (US sample) 2. A high BMI in childhood is predictive of MTS in adult life. 3. CV risk factors in ( LDH & BMI ) are present in childhood , and are predictive of CHD in adulthood

MTS in the young ( cont. ) There are no established criteria for diagnosis in the young There is urgent need to decide : 1. The cut -off values in children. mg/dl fasting glucose is correct. he proper method to assess central obesity by accurate measuring waist circumference.

The IDF definition of the at risk group and metabolic syndrome in children and adolescents Age group (years) Obesity * ( WC ) Triglycerides HDL-C 6 - <10 90 10 - < 16 90 or adult cut-off if lower 16 + Use existing IDF criteria for adults Blood Glucose pressure (mg/ dl) or known T 2 DM Metabolic syndrome cannot be diagnosed , but further measurements should be made if there is a family history of metabolic syndrome, T 2 DM , dyslipidemia, cardiovascular disease , hypertension and/or obesity ( 150 mg/d. L) 130 diast 85 mm. Hg ( < 40 mg/d. L) Syst. (100 mg/d. L) [ or known T 2 DM ]

The Socio economic Burden

World wide = 3. 2 millions die from complications associated with diabetes In the ME : ( with high prev. of diab. ) one in 4 deaths in adults 35 -64 years is related to diabetes

t The EMME Region. A Prevalence of Diabetes is 9. 2 % (age 20 -79) Prevalence of IGT ……. is 8. 1 % 24. 5 millions with Diabetes & 22. 4 with IGT out of the top 10 highest diabetes prevalence rate countries 6 are EMME countries Estimated death due to DM as % of all deaths is 11. 5% ( 11. 1% in Europe and 11. 8 % in NA )

Can we meet the Challenge ?

Mean Health Expenditure person with diabetes ( 2007 ) in ID ( international Dollar) in different regions Africa 180 SEA 233 EMME (514) SACA 625 WP 684 NA 1188 EUR 1561 -----------------Global av. 712

EMME Countries according to The Mean Health Expenditure person with diabetes in ID (international Dollar) : Diabetes Atlas, 3 rd Ed. > 200 Afghanistan 56 Iraq 72 Pakistan 99 Sudan 103 Yemen 110 Syria 185 200 -600 Alger Morocco Egypt Libya 273 285 286 384 600 - 1000 > 1000 Oman 614 Bahrain 1047 Tunisia 637 Lebanon 1050 Jordan 711 Qatar 1198 Iran 744 Kuwait 806 Saudi Arabia 891 Emirates 929

Cost of DM in relation to funds available (Egyptian Study) DIRECT COST OF TREATMENT OF DM AVAILABLE GOVERNMENT EXPENDITURE ON HEALTH L. E. 235. 2 m L. E. 351. 8 m 2/3!!

Hospital Treatment 2001 Cost /Day (Egyptian Study )

Distribution of Hospital Cost 55% Medicine & Supp. 45% Basic ( Food : 5% H. C. Team 11% Others: 29%)

Year Cost / percapit. Burden for Human Insulin (40 u /d) 8. 85% EGYPT 1. 9% QATAR 3. 1% SAUDI ARABIA

Cost Burden of Oral Treatment related to Per capitum 4. 2% 29. 9% EGYPT QATAR 8. 4% SAUDI ARABIA

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