Obezite – Lipid semptom yaklaşım Obezite – Lipid semptom yaklaşım

Dr. Mustafa Sahin

Ankara Universitesi Tıp Fakültesi

Endokrinoloji ve Metabolizma Hastalıkları Bilim Dalı Dr. Mustafa Sahin

Ankara Universitesi Tıp Fakültesi

Endokrinoloji ve Metabolizma Hastalıkları Bilim Dalı

Obezite – Lipid semptom yaklaşım

Obezite – Lipid semptom yaklaşım

Nonpharmacological Interventions Nonpharmacological Interventions

COR LOE Recommendations for Nonpharmacological Interventions

I A

Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese.

I A

A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that

facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension.

I A Sodium reduction is recommended for adults with elevated BP or hypertension.

I A

Potassium supplementation, preferably in dietary

modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the

presence of CKD or use of drugs that reduce

potassium excretion.

Nonpharmacological Interventions (cont.) Nonpharmacological Interventions (cont.)

COR LOE Recommendations for Nonpharmacological Interventions

I A

Increased physical activity with a structured

exercise program is recommended for adults with elevated BP or hypertension.

I A

Adult men and women with elevated BP or

hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively.

*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension*

Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension*

  Nonpharmacologi

-cal Intervention Dose Approximate Impact on SBP

Hypertension Normotension Weight loss Weight/body fat Best goal is ideal body weight, but aim

for at least a 1-kg reduction in body weight for most adults who are

overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight.

-5 mm Hg -2/3 mm Hg

Healthy diet DASH dietary

pattern Consume a diet rich in fruits,

vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.

-11 mm Hg -3 mm Hg

Reduced intake of dietary

sodium

Dietary sodium Optimal goal is <1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults.

-5/6 mm Hg -2/3 mm Hg

Enhanced intake of dietary potassium

Dietary

potassium Aim for 3500–5000 mg/d, preferably by consumption of a diet rich in potassium.

-4/5 mm Hg -2 mm Hg

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* (cont.)

Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* (cont.)

  Nonpharmacologica l Intervention

Dose Approximate Impact on SBP Hypertension Normotension Physical

activity  

Aerobic ● 90–150 min/wk

● 65%–75% heart rate reserve

-5/8 mm Hg -2/4 mm Hg Dynamic resistance ● 90–150 min/wk

● 50%–80% 1 rep maximum

● 6 exercises, 3 sets/exercise, 10 repetitions/set

-4 mm Hg -2 mm Hg

Isometric resistance ● 4 × 2 min (hand grip), 1 min rest between exercises, 30%–40%

maximum voluntary contraction, 3 sessions/wk

● 8–10 wk

-5 mm Hg -4 mm Hg

Moderation in alcohol intake

Alcohol consumption In individuals who drink alcohol, reduce alcohol† to:

● Men: ≤2 drinks daily

● Women: ≤1 drink daily

-4 mm Hg -3 mm

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12%

alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

• Effective lifestyle modification may decrease BP as much as a single antihypertensive, combinations achieve more

• Lifestyle intervention may

-decrease pharmacological intervention

-enhance antihypertensive effect of drugs

-reduce need for multiple drug treatment

-positive influence on overall CVD risk

Lifestyle measures that lower blood pressure

• Weight reduction

• Limitation of alcohol consumption

• Increased physical activity

• Increased fruit and vegetable consumption

• Reduced total fat and saturated fat intake

Measures to reduce cardiovascular disease risk

• Cessation of smoking

• Reduced total fat and saturated fat intake

• Replacement of saturated fats with mono-unsaturated fats

• Increased oily fish intake

NICE 2006

• Encourage use of salt substitutes

• Discourage excessive consumption of coffee and other caffeine rich products

• Tell patients about local initiatives that provide support and promote lifestyle change

• Consider relaxation therapies

• Lifestyle advice should be offered initially and then

periodically to patients undergoing assessment or treatment for hypertension

• Offer guidance and written or audiovisual information

Impact of lifestyle

interventions on blood pressure

Impact of lifestyle

interventions on blood pressure

2-4mmHg

Alcohol

4-9mmHg

Exercise

2-8 mmHg

Salt

8-14 mmHg

Dietary

5-10 mmHg per 10kg weight loss

Weight reduction

Expected systolic blood pressure reduction

Intervention

The effect of weight loss on BP The effect of weight loss on BP

• Estimated 24% of the population in the UK have a BMI > 30

• Neter et al (2003):

1mmHg reduction in BP per 1kg weight loss

• Weight reduction has beneficial effects on

associated risk factors i.e. insulin resistance, diabetes, dyslipidaemia and LVH

• Estimated 24% of the population in the UK have a BMI > 30

• Neter et al (2003):

1mmHg reduction in BP per 1kg weight loss

• Weight reduction has beneficial effects on

associated risk factors i.e. insulin resistance,

diabetes, dyslipidaemia and LVH

Clinic measurements Clinic measurements

• Weight

• Height

• BMI

• Waist measurement – midway between lower rib margin and the ileac crest

• Weight

• Height

• BMI

• Waist measurement – midway between

lower rib margin and the ileac crest

BMI and Waist measurements BMI and Waist measurements

BMI Category

<20 Underweight

20-24.9 ^Normal

25-29.9 ^Overweight 30-39.9 ^Obese

>40 ^Severely

Obese

BMI Category

<20 Underweight

20-24.9 ^Normal

25-29.9 ^Overweight 30-39.9 ^Obese

>40 ^Severely

Obese

Abdominal obesity

Men >102cm Women >88cm

Indio Asia decent Men >90cm

Women >80cm

JBS Guidelines 2005

Abdominal obesity

Men >102cm Women >88cm Indio Asia decent Men >90cm

Women >80cm

JBS Guidelines 2005

Long term benefits of weight reduction

Long term benefits of weight reduction

• He et al. (2000) “Beneficial effects are still evident 7 years after study ended.”

• n= 208 high impact weight reduction advice and support

• 7 years later 181 brought back

• Incidence of hypertension:

19% in weight loss group 40% control group

• Effect, despite being an equal amount of weight gain

• He et al. (2000) “Beneficial effects are still evident 7 years after study ended.”

• n= 208 high impact weight reduction advice and support

• 7 years later 181 brought back

• Incidence of hypertension:

19% in weight loss group 40% control group

• Effect, despite being an equal amount of weight gain

Dietary interventions and BP Dietary interventions and BP

DASH – Dietary approach to stop hypertension diet (2000)

Participants with mild hypertension had approx.

11.4mmHg reduction in systolic BP compared to control diet

• Combination of a Mediterranean diet with low fat dairy products

• Low fat, high fibre including increased amounts of potassium, calcium, and magnesium

• Effects potentiated by salt restriction

• Diet better tolerated than salt restrictions

DASH – Dietary approach to stop hypertension diet (2000)

Participants with mild hypertension had approx.

11.4mmHg reduction in systolic BP compared to control diet

• Combination of a Mediterranean diet with low fat dairy products

• Low fat, high fibre including increased amounts of potassium, calcium, and magnesium

• Effects potentiated by salt restriction

• Diet better tolerated than salt restrictions

5 a day (or 7-9 if possible!)

5 a day (or 7-9 if possible!)

• 1 portion of fruit or vegetable represents 80g i.e 1 apple, 1 orange, 1 banana, 2 satsumas, 2 plums, 3 heaped tbsp peas or carrots, 1 bowl of mixed salad

• 1 glass of 100% fruit juice can replace 1 portion

• 1 portion of fruit and vegetables a day lowers CVD risk by 4% (Joshipura et al. 2001)

• Beneficial effects due to array of compound i.e.

vitamins and minerals, phytochemicals, antioxidants

• Individual compounds not enough – supplements

• 1 portion of fruit or vegetable represents 80g i.e 1 apple, 1 orange, 1 banana, 2 satsumas, 2 plums, 3 heaped tbsp peas or carrots, 1 bowl of mixed salad

• 1 glass of 100% fruit juice can replace 1 portion

• 1 portion of fruit and vegetables a day lowers CVD risk by 4% (Joshipura et al. 2001)

• Beneficial effects due to array of compound i.e.

vitamins and minerals, phytochemicals, antioxidants

• Individual compounds not enough – supplements

Physical activity and BP Physical activity and BP

• Aerobic endurance based activities reduce resting BP in adults with normal BP and in those with hypertension

• Places demands on the cardiovascular system

• Reductions in BP last for up to 22hrs after exercise (ACSM, 2004)

• BP reductions are independent of weight loss (Whelton et al. 2002)

• Aerobic endurance based activities reduce resting BP in adults with normal BP and in those with hypertension

• Places demands on the cardiovascular system

• Reductions in BP last for up to 22hrs after exercise (ACSM, 2004)

• BP reductions are independent of weight loss

(Whelton et al. 2002)

Adapted from

Exercise training in the management of and treatment of hypertension

Exercise training in the management of and treatment of hypertension

2.4 4.6

6,805 105

Dickenson et al. 2006

2.4 3.0

3,936 72

Cornelissen and Fagard 2005

2.5 4.0

2,419 54

Whelton et al. 2002

2.4 3.4

2,674 44

Fagard 2001

3.1 4.7

1,553 29

Halbert et al.20 1997

Decrease in DBP (mmHg) Decrease

in SBP (mmHg) Number of

subjects RCTs

included

Meta-analysis

Exercise

Recommendations Exercise

Recommendations

• Frequency –x5, preferably all days of the week

• Intensity – moderate

• Time – 30 minutes or more of continuous activity, alternatively 3 bouts of no less than 10 minutes accumulated during the day

• Type – aerobic exercise using large muscle groups

• Caution if systolic >160mmHg and/or diastolic

>110mmHg

• Frequency –x5, preferably all days of the week

• Intensity – moderate

• Time – 30 minutes or more of continuous activity, alternatively 3 bouts of no less than 10 minutes accumulated during the day

• Type – aerobic exercise using large muscle groups

• Caution if systolic >160mmHg and/or diastolic

>110mmHg

Alcohol and BP Alcohol and BP

• Association seen as long ago as 1917

• Study of trench soldiers

“tres grands buveurs” – hypertensive

“sobres” – normotensive

• Klatsky (1977) n= 84,000 men

3 or more drinks per day – dose dependent relationship

• Beevers (1984) direct pressor effect of alcohol established –observed alcohol

• Association seen as long ago as 1917

• Study of trench soldiers

“tres grands buveurs” – hypertensive

“sobres” – normotensive

• Klatsky (1977) n= 84,000 men

3 or more drinks per day – dose dependent relationship

• Beevers (1984) direct pressor effect of

alcohol established –observed alcohol

• Reduction in alcohol consumption may reduce BP by an average of 3/2 mmHg (Xin 2001)

• Daily drinking and on empty stomach associated with higher BP

• There should be 2 alcohol free days per week

• There are probably no safe alcohol limits

≤ 14 units per week for women and ≤ 21units per week for men

• Binge drinking is now defined as >3 units/day

• ?? Cardioprotective properties……Jackson 2005

argued may be due to confounding

• Assess number of units per week

• Number of alcohol free days

• Binge drinking

• GGT

• 125ml wine

• 1 pub shot of spirit (35ml)

• ½ pint lager / beer / cider

• Assess number of units per week

• Number of alcohol free days

• Binge drinking

• GGT

• 125ml wine

• 1 pub shot of spirit (35ml)

• ½ pint lager / beer / cider

Smoking and BP Smoking and BP

• Cigarette smoking does not appear to be associated with hypertension

• BP does rise acutely during smoking leading to underestimation of BP in regular smokers

• Extensive observational data show that

smoking has a graded adverse effect on risk of cardiovascular complications

• Use of nicotine replacement therapies is safe in hypertensives and doubles smoking

cessation rates

• Cigarette smoking does not appear to be associated with hypertension

• BP does rise acutely during smoking leading to underestimation of BP in regular smokers

• Extensive observational data show that

smoking has a graded adverse effect on risk of cardiovascular complications

• Use of nicotine replacement therapies is safe in hypertensives and doubles smoking

cessation rates

• Assess smoking history - smoker / non smoker - how long given up

- number of years / pack years - method of smoking

- previous attempts at cessation - NRT

- desire to give up

• Smoking cessation clinic / NRT

• Assess smoking history - smoker / non smoker - how long given up

- number of years / pack years - method of smoking

- previous attempts at cessation - NRT

- desire to give up

• Smoking cessation clinic / NRT

Effect on CVD risk Effect on CVD risk

• Age 51

• Gender male

• SBP 156

• Smoker no

• Hx diabetes no

• LVH no

• Cholesterol 5.1

• HDL 1.2

CVD RISK 16 %

• Age 51

• Gender male

• SBP 156

• Smoker no

• Hx diabetes no

• LVH no

• Cholesterol 5.1

• HDL 1.2

CVD RISK 16 %

• Age 51

• Gender male

• SBP 156

• Smoker yes

• Hx diabetes no

• LVH no

• Cholesterol 5.1

• HDL 1.2

CVD RISK 28 %

• Age 51

• Gender male

• SBP 156

• Smoker yes

• Hx diabetes no

• LVH no

• Cholesterol 5.1

• HDL 1.2

CVD RISK 28 %

Effect of Salt on Blood pressure

Effect of Salt on Blood pressure

• Recommended salt intake is 5g/day

• Estimated that average intake is 9.5g/day

• A max of 25% comes from adding at table or cooking

• Na value x 2.5 to gain NaCl value

• DASH Sodium - reduction in blood pressure with lower sodium intake – direct relationship

• Few observational studies and virtually no trial data exist on the effect of sodium intake on subsequent cardiovascular disease

• Recommended salt intake is 5g/day

• Estimated that average intake is 9.5g/day

• A max of 25% comes from adding at table or cooking

• Na value x 2.5 to gain NaCl value

• DASH Sodium - reduction in blood pressure with lower sodium intake – direct relationship

• Few observational studies and virtually no trial data

exist on the effect of sodium intake on subsequent

cardiovascular disease

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