Obesity and Heart Disease

8/20/2019 Obesity and Heart Disease

http://slidepdf.com/reader/full/obesity-and-heart-disease 1/73

Beyond BMI –Beyond BMI –

New Perspectives onNew Perspectives onObesityObesityVirend K. Somers MD, PhDVirend K. Somers MD, PhD





ObesityObesity

• De%ined by the (!O)NI! as an ecess o%De%ined by the (!O)NI! as an ecess o%body %at percenta"e o% *body %at percenta"e o% *

+ - men+ - men

+ /- women+ /- women

• Body %at percenta"eBody %at percenta"e variesvaries important$yimportant$yaccordin" to se, a"e and race.accordin" to se, a"e and race.

http://www.shutterstock.com/pic-48738.html



BMI

(ei"hthei"ht





Bac&"ro'ndBac&"ro'ndObesity De%initionObesity De%inition

• 5$inicians and epidemio$o"ists o%ten5$inicians and epidemio$o"ists o%tenre$y on body mass inde 2BMI4 tore$y on body mass inde 2BMI4 to

dia"nose obesitydia"nose obesity

• BMIBMI 6ow 1 7 89.- &")m6ow 1 7 89.- &")m,, Norma$ 1 89.- : ;.< &")mNorma$ 1 89.- : ;.< &")m,,

Overwei"ht 1 - : <.< &")mOverwei"ht 1 - : <.< &")m,,

Obese 1 /3 : /<.< &")mObese 1 /3 : /<.< &")m,, =treme$y obese 1=treme$y obese 1 ++ ;3 &")m;3 &")m,,



BMI >dvanta"esBMI >dvanta"es

• Simp$e and reprod'cib$eSimp$e and reprod'cib$e

• >ssociated with cardiovasc'$ar 25V4>ssociated with cardiovasc'$ar 25V4ris& %actors ris& %actors

• 6ow and hi"h BMI are associated6ow and hi"h BMI are associatedwith increased morta$ity and 5Vwith increased morta$ity and 5Veventsevents



Do yo' &now yo'r BMI#Do yo' &now yo'r BMI#



BMI Disadvanta"esBMI Disadvanta"es Obesity ParadoObesity Parado

0$e"a$, K. M. et a$. JAMA 33?. @omero:5orra$, >. et a$. Lancet 33A.

enera$enera$

Pop'$ationPop'$ation5>D5>D

Pop'$ationPop'$ation



@es'$ts@es'$ts

• Cnderwei"ht*Cnderwei"ht* BMI 27 34 stron"$y associatedBMI 27 34 stron"$y associatedwith an increased $on":term morta$ity and otherwith an increased $on":term morta$ity and other5V events.5V events.

• Overwei"ht*Overwei"ht* BMI 2BMI 2++- – <.<4 associated with- – <.<4 associated withbetter s'rviva$ and %ewer 5V events.better s'rviva$ and %ewer 5V events.

• Obese*Obese* BMI /3, not si"ni%icant$y associatedBMI /3, not si"ni%icant$y associatedwith $on":term morta$ity and other 5V events inwith $on":term morta$ity and other 5V events inpatients with 5>D.patients with 5>D.





Possib$e =p$anationsPossib$e =p$anations

• 6ow BMI*6ow BMI*

O$der patientsO$der patients

5ancer and other co:morbidities5ancer and other co:morbidities

6ow $ean mass and hi"h body %at6ow $ean mass and hi"h body %at

• =$evated BMI*=$evated BMI*

Fo'n"er Fo'n"er

Better treatment#Better treatment#

Preserved or increased $ean mass ratherPreserved or increased $ean mass rather thanthanecess in body %atecess in body %at



5onc$'sions5onc$'sions

• Mechanisms 'nder$yin" this apparent$yMechanisms 'nder$yin" this apparent$yparadoica$ re$ationship are 'nc$ear, b'tparadoica$ re$ationship are 'nc$ear, b'tthey may re$ate to the de%inition o% obesitythey may re$ate to the de%inition o% obesity

itse$%itse$% 2BMI42BMI4 • BMI 'nab$e to di%%erentiate between B0 BMI 'nab$e to di%%erentiate between B0

and $ean m'sc$e massand $ean m'sc$e mass



New Perspectives on ObesityNew Perspectives on Obesity

• BMI and the obesity paradoBMI and the obesity parado

• !ow "ood is BMI in dia"nosin" obesity#!ow "ood is BMI in dia"nosin" obesity#

• Imp$ications o% centra$ obesityImp$ications o% centra$ obesity

• Does s$eepin" $ess ma&e 's %at#Does s$eepin" $ess ma&e 's %at#

• Mana"ement o% the hi"h ris& obeseMana"ement o% the hi"h ris& obesepatientpatient



ObGectiveObGective

• >ssess the>ssess the dia"nostic per%ormancedia"nostic per%ormance o%o%BMIBMI in detectin" ecess in B0 inin detectin" ecess in B0 in

patients with 5>Dpatients with 5>D H..+ - in men.+ - in men.

+ /- in women.+ /- in women.

Dia"nostic Per%ormance*Dia"nostic Per%ormance* Sensitivity,Sensitivity,

Speci%icity, corre$ation coe%%icients betweenSpeci%icity, corre$ation coe%%icients between

BMI and both, B0 and 6M.BMI and both, B0 and 6M.

H B0 estimated 'sin" air disp$acement p$ethysmo"raphy



MethodsMethods

• > cross:sectiona$ desi"n o%> cross:sectiona$ desi"n o% 8/,A388/,A38 s'bGectss'bGects2a"e 3:?<.< years ;9 men4 %rom the Jhird2a"e 3:?<.< years ;9 men4 %rom the JhirdNationa$ !ea$th and N'trition =aminationNationa$ !ea$th and N'trition =amination

S'rvey 2N!>N=S III4.S'rvey 2N!>N=S III4.

• Bioe$ectrica$ impedance ana$ysis was 'sedBioe$ectrica$ impedance ana$ysis was 'sed

to estimate B0 and 6M. !ei"ht and wei"htto estimate B0 and 6M. !ei"ht and wei"htmeas'rements were 'sed to ca$c'$ate BMImeas'rements were 'sed to ca$c'$ate BMI2&")m2&")m,,4.4.



Body 0at vs. 6ean MassBody 0at vs. 6ean Mass

@omero:5orra$, >. et a$. Int J Obes (Lond) 339.



38A S'perbow$ : Denver Broncos38A S'perbow$ : Denver Broncos

388 M0M=@ L s$ide: 388 M0M=@ L s$ide:

8989




• Obesity de%ined as a BMIObesity de%ined as a BMI ++ /3 &")m/3 &")m missesmissesmore than ha$% more than ha$% o% the patients with 5>D witho% the patients with 5>D withrea$ B0 :obesity.rea$ B0 :obesity.

• >$tho'"h BMI had a "ood corre$ation with>$tho'"h BMI had a "ood corre$ation withB0 it a$so had aB0 it a$so had a "ood corre$ation with"ood corre$ation with$ean mass$ean mass..

• In men BMI corre$ated better with $ean massIn men BMI corre$ated better with $ean mass

than with B0 whi$e in women BMIthan with B0 whi$e in women BMIcorre$ated better with B0 than $ean mass.corre$ated better with B0 than $ean mass.Jhis mi"ht ep$ain theJhis mi"ht ep$ain the better dia"nosticbetter dia"nosticper%ormance o% BMI in womenper%ormance o% BMI in women..




• BMI %ai$s to discriminate between %atBMI %ai$s to discriminate between %atmass and $ean mass in the CSmass and $ean mass in the CSpop'$ation, has a poor dia"nosticpop'$ation, has a poor dia"nostic

per%ormance and poor associationper%ormance and poor associationwith adverse events.with adverse events.

• Other meas'res that discriminateOther meas'res that discriminatebetween %at mass and $ean mass,between %at mass and $ean mass,especia$$y those acco'ntin" %or centra$especia$$y those acco'ntin" %or centra$obesity 2e" (!@4 are needed.obesity 2e" (!@4 are needed.



Variabi$ity o% B0Variabi$ity o% B0in Peop$e within Peop$e with

BMIBMI - &")m- &")m

@an"e* 8/.9 to /-./ @an"e* A. to ;.9

@omero:5orra$, >. et a$. Int J Obes (Lond) 339.

2n 1 -;4 2n 1 -;4

---- AA33 8989



!ypotheses!ypotheses

• S'bGects considered to have norma$S'bGects considered to have norma$body wei"ht based on BMI, co'$d sti$$body wei"ht based on BMI, co'$d sti$$

have a hi"h body %at 2B04 contenthave a hi"h body %at 2B04 content• NNorma$orma$ ((ei"htei"ht OObesity,besity, N(ON(O

• N(ON(O s'bGects have a hi"her preva$ences'bGects have a hi"her preva$enceo% metabo$ic syndrome ando% metabo$ic syndrome andcardiometabo$ic dysre"'$ationcardiometabo$ic dysre"'$ation



De%initionsDe%initions

• NNorma$orma$ ((ei"htei"ht OObesitybesity

• Norma$ BMI 1 89.-:;.<Norma$ BMI 1 89.-:;.< &")m&")m

• B0 B0 + 3+ 3 menmen+ /3+ /3 womenwomen

• Metabo$ic SyndromeMetabo$ic Syndrome• >JP III criteria>JP III criteria

• Jraditiona$ 5V ris& %actorsJraditiona$ 5V ris& %actors• Dys$ipidemia 2N5=P >JP:III4, !JN 2N5 ?4, DM 2>D>4,Dys$ipidemia 2N5=P >JP:III4, !JN 2N5 ?4, DM 2>D>4,

smo&in", 5VD 2MI stro&e4smo&in", 5VD 2MI stro&e4



Preva$ence o% N(OPreva$ence o% N(O

• -?.--?.- in men andin men and -/.--/.- in womenin women

(ei"hted preva$ences(ei"hted preva$ences

-/.

A8.;

?3.;

A8.;





Dose @esponseDose @esponse

H >dG'sted %or a"e and race

Se:Speci%ic $owest 'arti$e 'sed as the re%erence

HH HH



N(O and Metabo$ic SyndromeN(O and Metabo$ic Syndrome

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HH Odds ratio adG'sted %or a"e and raceOdds ratio adG'sted %or a"e and race

[email protected] 28.8A : .;4

HO@18./9 28.3 : 8.9?4



N(O and Metabo$ic SyndromeN(O and Metabo$ic Syndrome

[email protected] 28.A : -.3<4

HH Odds ratio adG'sted %or a"e and raceOdds ratio adG'sted %or a"e and race

[email protected] 2-.;A : ?./4

HO@18.?? 28.89 : .?4

[email protected] 28.3? : .;A4



N(O and 5V Morta$ityN(O and 5V Morta$ity

M=NM=N (OM=N(OM=NBody %at 7 3Body %at 7 3

Body %at + 3Body %at + 3

2N(O42N(O4

Body %at 7 /3Body %at 7 /3

Body %at + /3Body %at + /3

2N(O42N(O4



5o'tinho JE6opeQ:

imeneQ 0, >55

38



Disc'ssionDisc'ssionMain 0indin"sMain 0indin"s

• 8 o't o% s'bGects8 o't o% s'bGects with a norma$ BMI has anwith a norma$ BMI has anecess in B0ecess in B0 2N(O42N(O4

• ;- mi$$ion >mericans ;- mi$$ion >mericans

• N(ON(O associated with cardiometabo$icassociated with cardiometabo$icdysre"'$ation 2MetS4dysre"'$ation 2MetS4

• CnawareCnaware o% increased ris& d'e to theiro% increased ris& d'e to their

norma$ BMInorma$ BMI

• N(ON(O mi"ht be re$ated to increased 5Vmi"ht be re$ated to increased 5Vmorta$ity, especia$$y womenmorta$ity, especia$$y women



















5entra$5entra$vs.vs.

Non:centra$ obesityNon:centra$ obesity

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Viscera$ >dipose Jiss'eViscera$ >dipose Jiss'e

• -:8- o% tota$ body %at-:8- o% tota$ body %at• More metabo$ica$$y activeMore metabo$ica$$y active

than s'bc'taneo's %atthan s'bc'taneo's %at

• >ssociated with hi"her>ssociated with hi"herpreva$ence o%preva$ence o%cardiovasc'$ar andcardiovasc'$ar andmetabo$ic ris& %actorsmetabo$ic ris& %actorsand disordersand disorders

Ve"a et a$., 5$in =ndocrino$ Metab 33AVe"a et a$., 5$in =ndocrino$ Metab 33AMahabadi et a$., ='r !eart 33<Mahabadi et a$., ='r !eart 33<



BMI vs. (!@BMI vs. (!@

F's'%, S. Lancet 33-/AA*8A;3:<.



9:wee&s

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Body composition

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St'dy Desi"n and Pop'$ationSt'dy Desi"n and Pop'$ation

• Do'b$e b$inded @andomiQed contro$$edDo'b$e b$inded @andomiQed contro$$edtria$tria$

• $ean hea$thy h'mans$ean hea$thy h'mans

• @andomiQation : 8 5ontro$*; ainers@andomiQation : 8 5ontro$*; ainersVisit

S$eep st'dy

B$ood draw

Body composition

Visit /

S$eep st'dy

B$ood draw

Body composition

0$ M di t d V di$ t ti0$ M di t d V di$ t ti



0$ow Mediated Vasodi$atation0$ow Mediated Vasodi$atation

Image at baseline

Cuff inflation

5 min

Cuff deflation

15-30 sec

(image acquisition)

5orretti, M5 et a$. JACC 33



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5ase =amp$e5ase =amp$e

Base$ineBase$ine 0o$$ow:'p0o$$ow:'p

? yr ma$e, BMI ;.- &")m

(ei"ht "ainer

Body wei"ht* R ;.-

Viscera$ %at* R ;;

S'bc'taneo's %at* R /-

;:h SBP)DBP)M>P* R -)8)/ mm!"

Viscera$

>dipose Jiss'e

S'bc'taneo's

>dipose Jiss'e



=ndothe$ia$ Dys%'nction by Jerti$es o% Viscera$=ndothe$ia$ Dys%'nction by Jerti$es o% Viscera$0at ain in the 0at ain ro'p0at ain in the 0at ain ro'p

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d ' c t i o n i n b r a c h i a $ a r t e r y

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7 9 cm 9 – 8A.- cm + 8A.- cm

p 1 3.3-

p 7 3.3338

p 1 3.33A

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Viscera$ 0at ain

Potentia$ MechanismsPotentia$ Mechanisms



Potentia$ MechanismsPotentia$ Mechanisms

• Viscera$ %at acc'm'$ation may ca'seViscera$ %at acc'm'$ation may ca'seincrease in BP thro'"h "reater secretion o%*increase in BP thro'"h "reater secretion o%*

• > third %actor may drive increases in both> third %actor may drive increases in bothviscera$ %at and BPviscera$ %at and BP

• !P> ais activation!P> ais activation

0@==:0>JJF

>5IDS

>NIOJ=NSINO=N

P@O:IN06>MM>JO@F

5FJOKIN=S











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Increase o% Me$atonin and Ind'ction o% S$eep by Dar&ness

Krip&e D0, 38







(e are chronica$$y s$eep deprived(e are chronica$$y s$eep deprived: B0B: B0B

McKni"ht:=i$y, >M> 339 Kr'e"er Am. J. Epidemiol 2009; S$eep in >merica 33 >"'iarNationa$ B'rea' o% =conomic @esearch 33A

S$eep Deprivation Ind'ced by theS$eep Deprivation Ind'ced by the



S$eep Deprivation Ind'ced by theS$eep Deprivation Ind'ced by theIn%ormation !i"hwayIn%ormation !i"hway

2388 S$eep in >merica Po$$ %rom the NS042388 S$eep in >merica Po$$ %rom the NS04

• Jwo thirds o% en F 28< to < yrs4 and oneJwo thirds o% en F 28< to < yrs4 and onethird o% en 'se a socia$ networ&in" sitethird o% en 'se a socia$ networ&in" sitebe%ore bedbe%ore bed

• Peop$e who tet be%ore bed 2ha$% o% en F4Peop$e who tet be%ore bed 2ha$% o% en F4are more $i&e$y to be s$eepy and driveare more $i&e$y to be s$eepy and drivewhi$e drowsywhi$e drowsy

• ? o% 83 Brits are tweetin", po&in", s'r%in"? o% 83 Brits are tweetin", po&in", s'r%in"and writin" on wa$$s at ni"ht instead o%and writin" on wa$$s at ni"ht instead o%"oin" to s$eep 2Jrave$od"e S'rvey)raham"oin" to s$eep 2Jrave$od"e S'rvey)rahamones4ones4

=pidemio$o"y o% s$eep d'ration=pidemio$o"y o% s$eep d'ration



=pidemio$o"y o% s$eep d'ration=pidemio$o"y o% s$eep d'ration

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Preva$ence o% s$eep d'ration ?

hrs)day by state

Centers for isease Control and !re"ention#

Morb Mortal $%l& 'ep. 20



an"swisch, S$eep 33-Pate$, >m =pidemio$o"y

33A

N!>N=S I

Short s$eepShort s$eep

d'ration andd'ration andobesityobesity=pidemio$o"ic=pidemio$o"ic

evidenceevidence

8<9;

8<9?

8<<



RATINGS OF HUNGER AND APPETITE

p level % changeHUNGER (cms) 6.0 ± 0.5 7.2 ± 0.4 <0.01 +24%GLOBAL APPETITE (cms) 39.7 ± 3.0 47.7 ± 3.4 0.010 +23%

AFTER 2 DAYS OF4-H BEDTIME

AFTER 2 DAYS OF10-H BEDTIME

GLOBALAPPETITE

HUNGER

9 11 13 15 17 19 21

CLOCK TIME

3.5

5.5

7.5

22

32

42

52

Spiegel et al, Ann Int Med, 141 (2004), 846-850

S$eep Deprivation and =ner"y Ba$anceS$eep Deprivation and =ner"y Ba$ance



S$eep Deprivation and =ner"y Ba$anceS$eep Deprivation and =ner"y Ba$anceDesi"nDesi"n

• Simp$e randomiQation strati%ied by "ender to s$eepin"Simp$e randomiQation strati%ied by "ender to s$eepin" ad libad libor red'ction in time in bed byor red'ction in time in bed by 88 ) )//

• S'bGects awo&en every day at A am b't bedtime based onS'bGects awo&en every day at A am b't bedtime based onrandomiQationrandomiQation

>556IM>JION

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@=5OV=@F

; d)/ n

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acti"raphy

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Jypica$ time in bed* 83*33 pm – A*33 am 1 9 h

Deprived time in bed* 8*;3 am – A*33 am 1 -./ h

S$eep Deprivation and =ner"yS$eep Deprivation and =ner"y



S$eep Deprivation and =ner"yS$eep Deprivation and =ner"yBa$anceBa$ance

Mayo S$eep Monitorin" System 2MSMS4Mayo S$eep Monitorin" System 2MSMS4

• 5'stom:modi%ied s$eep)wa&e monitorin" system5'stom:modi%ied s$eep)wa&e monitorin" systembased on 5omp'medics Siesta 93based on 5omp'medics Siesta 93

• A; channe$s, -8 !Q, 8A bit reso$'tionA; channe$s, -8 !Q, 8A bit reso$'tion

• Mayo 83)3 e$ectroencepha$o"ram 2==4Mayo 83)3 e$ectroencepha$o"ram 2==4

• =$ectro:oc'$o"ram 2=O4=$ectro:oc'$o"ram 2=O4

• =$ectromyo"ram 2=M4=$ectromyo"ram 2=M4

• =$ectrocardio"ram 2=54=$ectrocardio"ram 2=54

• =tensib$e, i.e., easi$y a$$ows addition o% more=tensib$e, i.e., easi$y a$$ows addition o% morechanne$schanne$s

• Specia$iQed e$ectrode p$acement to a$$ow sa%e,Specia$iQed e$ectrode p$acement to a$$ow sa%e,/ ho'r)day monitorin"/ ho'r)day monitorin"

• te$emetry a$$owin" rea$:time monitorin"te$emetry a$$owin" rea$:time monitorin"

• 78 &", wearab$e, 'nobtr'sive78 &", wearab$e, 'nobtr'sive





O'tcomes – ca$oric inta&eO'tcomes – ca$oric inta&e

• main o'tcome ca$oric inta&e per daymain o'tcome ca$oric inta&e per day2&ca$42&ca$4

• %ree access to %ood ;)?%ree access to %ood ;)?

• 5@C Metabo$ic &itchen, SM!5@C Metabo$ic &itchen, SM!ca%eteria, snac& bas&et, o'tside %oodca%eteria, snac& bas&et, o'tside %ood

• dai$y $o" by dieticiansdai$y $o" by dieticians





O'tcomes – ener"y ependit'reO'tcomes – ener"y ependit're

6evine, Science 8<<< 6evine, Science 33- 6evine, >cta Physio$ Scand 33-

si sensors 2$e%t pane$4*

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ha$%:second on two data $o""ers.

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S$eep Deprivation and =ner"y Ba$anceS$eep Deprivation and =ner"y Ba$ance@es'$ts – ca$oric inta&e@es'$ts – ca$oric inta&e

!*3.38 ! 1NS

5a$vin et a$, C+est 38/




S$eep Deprivation and =ner"y Ba$anceS$eep Deprivation and =ner"y Ba$ance@es'$ts – ca$oric inta&e per ho'r @es'$ts – ca$oric inta&e per ho'r

! 13.3

! 13.38(as the increased ca$oric inta&e d'e to more time avai$ab$e to

eat#


S$ D i ti d = B $S$eep Depri ation and =ner" Ba$ance



S$eep Deprivation and =ner"y Ba$anceS$eep Deprivation and =ner"y Ba$ance@es'$ts – ener"y ependit're@es'$ts – ener"y ependit're

! 1NS

=stimated maima$ 2<-4 ener"y chan"e 7-3 &ca$)day





S$eep Deprivation and =ner"y Ba$anceS eep ep at o a d e "y a a ce5onc$'sions5onc$'sions

• Modest s$eep restriction increasedModest s$eep restriction increasedca$oric inta&e by -;< &ca$)dayca$oric inta&e by -;< &ca$)day

• >ctivity ener"y ependit're did not>ctivity ener"y ependit're did notchan"e, tota$ ener"y ependit'rechan"e, tota$ ener"y ependit're$i&e$y chan"es minima$$y$i&e$y chan"es minima$$y



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•Mana"ement o% the hi"h ris& obeseMana"ement o% the hi"h ris& obesepatientpatient



!ow are we doin" with hi"h ris&!ow are we doin" with hi"h ris&obesity#obesity#

@eco"nition, Dia"nosis and@eco"nition, Dia"nosis and



" , "" , "Mana"ement o% Obesity a%ter MIMana"ement o% Obesity a%ter MI

• n 1 A? random$y se$ected patients dischar"edn 1 A? random$y se$ected patients dischar"ed

a%ter MI, between 8)8)38 and 8)/8)3a%ter MI, between 8)8)38 and 8)/8)3

• 0ive teachin" hospita$s0ive teachin" hospita$s

• Overwei"htOverwei"ht 11 BMIBMI - &")m- &")m

• ObeseObese 11 BMIBMI /3 &")m/3 &")m

• Mar&ed$y obeseMar&ed$y obese 11 BMIBMI ;3;3&")m&")m

26opeQ:imeneQ et a$,26opeQ:imeneQ et a$, Int J Obesit& Int J Obesit& 44

@ $t@es $ts



@es'$ts@es'$ts

• Mean BMI 1 /8 T 8/ &")mMean BMI 1 /8 T 8/ &")m : doc'mented in 8;: doc'mented in 8;

• 9/ overwei"ht, -- obese, 9 morbid$y obese9/ overwei"ht, -- obese, 9 morbid$y obese

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Documents

Obesity and Heart Disease