代謝症候群案例說明

1. 代謝症候群案例說明 Kuo-Chin Huang MD, PhD Associate Professor Department of Family Medicine National Taiwan University Hospital

2. Metabolic Syndrome Grundy SM. Nat Rev Drug Discov 2006 Apr;5(4):295-309.

3. Metabolic Syndrome Colon cancer ↑1.62 for proximal lesions Grundy SM. Nat Rev Drug Discov. 2006 Apr;5(4):295-309.

4. 代謝症候群與心血管疾病及死亡率 Am J Med. 2006 Oct;119: 812-9

5. 台灣成年人代謝症候群與死亡率 Huang KC Obesity 2008 Mar;16(3):684-9.

6. 台灣老年人代謝症候群與死亡率 CVD mortality All-cause mortality Huang KC, et al. Eur J Clin Invest 2008; 38 (7): 469–475

7. Circulation 2005;112: 285-90 Lancet. 2005 Sep 24;366(9491):1059-62.

8. Circulation 2005;112: 285-90

9. 台灣代謝症候群的定義(>=3個) • 腹部肥胖：腰圍男性>=90 公分，女性>=80公分 • 血壓過高：收縮壓>=130 mmHg and/or 舒張壓>=85mm Hg或是高血藥物治療中 • 空腹血糖過高：空腹血糖值>=100 mg/dL或是糖尿病治療中 • 三酸甘油脂過高：TG >=150 mg/dL • 高密度脂蛋白膽固醇過低：low HDL-C 男性 <40mg/dL, 女性 <50mg/dL 國健局 2006

10. Limitations of BMI: The Y-Y Paradox Yajnik & Yudkin, Lancet 2004

11. 國民健康局, Taiwan 成人腰圍測量方法 • 除去腰部覆蓋衣物，輕鬆站立，雙手自然下垂。 • 以皮尺繞過腰部，調整高度使能通過左右兩側腸骨上緣至肋骨下緣之中間點(如圖)，同時注意皮尺與地面保持水平，並緊貼而不擠壓皮膚。 • 維持正常呼吸，於吐氣結束時，量取腰圍。

12. 腹部肥胖之盛行率 Prevalence of abdominal obesity by region or country 1. Ford ES et al, 2003; 2 Haftenberger M et al, 2002; 3. Kim MH et al 2004; 4. Cameron AJ et al, 2003; 5. Puoane T et al, 2002; 6. Hwang LC et al, 2006

13. 代謝症候群之防制策略 成人健檢或其他健康檢查資料 篩選高危險群 符合診斷標準 量腰圍、量血壓、空腹抽血 確立診斷為代謝症候群 評估心血管疾病風險：Framingham 10年風險指數 處理 國健局 2006

14. 代謝症候群申請支付標準流程圖

16. 表一 不同性別與年齡層的代謝症候群之盛行率(N=124,513)

17. 表二 有無腹部肥胖在不同性別與年齡層的代謝症候群之盛行率(N=124,513)

18. 表三 有無血壓高在不同性別與年齡層的代謝症候群之盛行率(N=124,513)

19. 表四 同時有腹部肥胖與血壓高在不同性別與年齡層的代謝症候群之盛行率

20. 表五 有無肥胖(BMI>=27kg/m2)在不同性別與年齡層的代謝症候群之盛行率

21. 表六 同時有肥胖(BMI>=27kg/m2)與血壓高在不同性別與年齡層的代謝症候群之盛行率

22. 40-55歲

23. 40-55歲

24. 不同情況下代謝症候群絕對風險之比較 Despres et al. Nature 2006; 444: 881-7

25. 代謝症候群之防制策略(續) 處理 A. 減重 B. 增加體力活動 C. 健康飲食 D. 戒菸 • 血脂異常 • 必要時藥物治療，詳見 • http://www.bhp.doh.gov.tw/ • BHP/do/chinese/home 2. 血壓異常 必要時藥物治療，詳見 http://www.bhp.doh.gov.tw/ BHP/do/chinese/home 3. 血糖異常 必要時藥物治療，詳見 http://www.bhp.doh.gov.tw/ BHP/do/chinese/home 定期追蹤、積極處理 預防心血管疾病及糖尿病 國健局 2006

26. 治療式生活形態改變(TLC)之施行步驟 第1次就診 開始TLC 第2次回診 第3次回診 評估達到 治療目標否 第N次回診 評估與監測 …… 6週 6週 每3-6個月 若無 1.評估 2.設立治療目標（TLC目標 及血壓、血脂、血糖 控制目標） 3.鼓勵適度體力運動 4.強調健康飲食 5.轉介給營養師 1.評估及討論 2.補強第1次就診後之缺失 3.轉介給營養師 1.評估及討論 2.再加強TLC 3.考慮使用藥物 國健局 2006

27. Patient Profile: Ron G. • BP 140/94 mmHg, BMI 28 kg/m2, WC 41" • TC: 230 LDL: 138 HDL: 36 TG: 280 mg/dL • Fasting glucose: 114 mg/dL (prediabetes) • Family history of T2DM with complications • No clinically evident disease, but clearly at risk for CVD, T2DM • What is the best treatment for Ron G. within the new treatment paradigm? Data from Prof Jillian Meyer in USA

28. Treatment Comprehensive Management for Disease Prevention Current Treatment Paradigm Treatment HTN, ↑LDL, ↑TG + ↓HDL, IFG, AO AO ± pre-HTN, dyslipidemia CVD/T2DM Delay/prevent? New Treatment Paradigm Data from Prof Jillian Meyer in USA

29. Metabolic Syndrome- a lifestyle disease with genetic predisposition

30. Etiological categories for the metabolic syndrome • Obesity and abnormalities of adipose tissue • Insulin resistance • A constellation of independent factors (eg, molecules of hepatic, vascular and immunological origin) that mediate specific components of the metabolic syndrome (FFA, Cortisol, Estrogen, Leptin, Adiponectin, Resistin, IGF-1, IL-6, TNF-A, PAI-1) Carlson LA. Clinician’s Manual on the Metabolic Syndrome

31. Medications for this patient Blood pressure: 148/ 89 mmHg Diuretics Betablocker ACE-Inhibitors AT1-blockers .... Impaired fasting glucose: AC sugar: 111 mg/dl 2-h OGTT: 180 mg/dl Metformin Acarbose TZD´s LDL-Cholesterol: 140 mg/dl Statin Central obesity: 128 cm Diet, Exercise Orlistat, Sibutramine HDL-Cholesterol: 32 mg/dl Niacin Triglycerides: 288 mg/dl Fibrates Data from Prof. Matthias Blüher in Germany

32. Mr JP • Now 64 year-old retired taxi driver • Type 2 diabetes mellitus since 1998, age 56 • Diagnosed on screening at GP • Fasting glucose 9.2 mmol/L (166 mg/dl) • HbA1c 8.4% • Total Cholesterol 6.1 mmol/L (236 mg/dl) • BP 154/88 mm Hg • Weight 94 kg • BMI 32.4 • Advised on ‘diabetic diet’ (patient description) • Avoid sugar and fatty foods Data from Dr Finer in UK

33. Mr JP • Feb 2000 • HbA1c 9% • Started on Metformin 500 mg bid • Feb 2001 • HbA1c 7.8% • Continues on Metformin • Cholesterol 6.2 mmol/L (240mg/dl): Simvastatin started • Jan 2002 • BP 156/92 mm Hg: Perindopril started • Weight 98 kg, BMI 34 • Oct 2002 • HbA1c 8.5% • Weight 101 kg, BMI 35 Data from Dr Finer in UK

34. Mr JP • What should he do now? • Accept current glycaemic control • Re-advise on diet and exercise • Add 2nd hypoglycaemic drug • Start insulin Data from Dr Finer in UK

35. Clinical Management of Metabolic Syndrome • Lifestyle risk factors Abdominal obesity (7-10% at year 1, BMI<25 kg/m2 finally), physical inactivity (30-60 min, 5-7 d/wk, RT 2d/wk), atherogenic diet (reduced saturated fat, trans fat, and cholesterol), smoking cessation • Metabolic Risk Factors Atherogenic dyslipidemia (1st LDL-C, 2nd non-HDL-C, 3rd HDL-C) Elevated BP Elevated glucose Prothrombotic state Proinflammatory state Circulation 2005;112: 285-90

36. (1)代謝症候群之腹部肥胖的治療

37. 減重的效益 1 1 2 2 3 3 3 3 4 1. Wing RR et al. Arch Intern Med. 1987;147:1749-1753. 2. Mertens IL, Van Gaal LF. Obes Res. 2000;8:270-278. 3. Blackburn G. Obes Res. 1995;3 (Suppl 2):211S-216S. 4. Ditschunheit HH et al. Eur J Clin Nutr. 2002;56:264-270.

38. N Engl J Med 2002;346:393-403 31% 58%

39. Intensive Lifestyle Intervention • The goal is to achieve and maintain a weight reduction of at least 7 % initial BW through a healthy low calorie, low-fat diet and physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week. • A 16-lesson curriculum covering diet, exercise, and behavior modification • one-to-one basis during the first 24 weeks (flexible, culturally sensitive, and individualized) • Subsequent individual sessions (usually monthly) and group sessions with the case managers were designed to reinforce the behavioral changes. N Engl J Med 2002;346:393-403

40. Development and Resolution of the Metabolic syndrome (53%) 38% 53% 23% 18% 47% 38% Development Resolution Ann Intern Med. 2005; 142(8):611-9.

41. XENical in the Prevention of Diabetes in Obese Subjects (XENDOS) Study Diabetes Care 2004; 27: 155-61.

44. N Engl J Med 2004;351:2683-93

45. N Engl J Med 2004;351:2683-93

46. N Engl J Med 2004;351:2683-93

47. 減重手術降低重度肥胖病人的死亡率 29% N Engl J Med 2007;357:741-52

48. (2)代謝症候群之血脂異常的治療

49. Intensive LDL lowering is recommended in ATP III report (2004) High Risk CHD or CHD risk equivalents (10-yr risk >20%) Moderately High Risk ≥ 2 risk factors (10-yr risk 10-20%) Moderate Risk ≥ 2 risk factors (10-yr risk <10%) Lower Risk < 2 risk factors 190 - Target 160 mg/dL 160 - Target 130 mg/dL Target 130 mg/dL LDL-C level 130 - Target 100 mg/dL or optional 100 mg/dL 台灣健保局治療目標 100 - or optional 70 mg/dL＊ 70 - ＊ Patient who had established CVD combine with acute coronary syndromes or multiple risk factors (esp. diabetes) or severe and poorly controlled risk factors (e.g., cigarette smoking) or metabolic syndrome (high TG, low HDL-C) Circulation. 2004;110:227-239

50. Therapeutic Lifestyle Changes（TLC）for Dyslipidemia 　血中膽固醇或壞的膽固醇過高，可藉由改善以下的生活形態，來降低動脈粥樣硬化的危險： • TLC飲食（TLC diet）： • 少吃飽和脂肪 • 少吃膽固醇 • 多攝取水溶性纖維，例如：全穀類、豆莢、種子、蔬菜、水果 • 規律運動 • 維持理想體重