Calculating insulin resistance in the primary care setting: why should we worry about insulin levels in euglycemic patients?

PURPOSE: To describe measures that would determine which patients are insulin resistant and at risk for the metabolic syndrome and its sequelae cardiovascular diseases (CVD) and to analyze methods to determine the presence of insulin resistance and the advantages or disadvantages of each. DATA SOURCES: Review of the multidisciplinary clinical and research literature. CONCLUSIONS: Insulin resistance occurs early in the trajectory of the metabolic syndrome, making it a prime candidate for timely interventions to reduce risk for both type 2 diabetes and CVD. Therefore, prompt recognition of insulin resistance prior to the development of the full metabolic syndrome, type 2 diabetes, and/or CVD may assist in the prevention of morbidity and premature mortality. Likewise, because many insulin-resistant patients belong to minority racial groups (i.e., African American, Hispanic, Native American, or Pacific Islanders), early identification may have a positive impact on the reduction of cardiovascular health disparities. IMPLICATIONS FOR PRACTICE: Documenting the presence of insulin resistance will assist the practitioner to determine if a low-risk patient is in jeopardy for development of type 2 diabetes and/or CVD. Early cardiovascular risk identification is important to clinical practice as it allows more time for the practitioner to counsel patients for the essential planning needed to make lifestyle changes.     

体检人群代谢综合征患病情况及危险因素调查与分析

目的调查体检人群代谢综合征的发生率,并分析其危险因素,为早期干预提供参考。方法对深圳市8 884名体检者的体重指数、血压、空腹血糖及血脂的指标进行调查分析。结果代谢综合征的患病率为15.89%,其中男性和中年组患病率较高(P<0.01);空腹血糖、甘油三酯、性别、收缩压、舒张压和体重指数、高密度脂蛋白是代谢综合征相关因素。结论深圳市体检人群代谢综合征总患病率处于较高水平,医务人员应及早对该人群进行干预,以预防和减少心脑血管疾病的发生,提高生活质量。     

The correlation between waist circumference and ESC cardiovascular risk score: data from the German metabolic and cardiovascular risk project (GEMCAS)

Background  Identification of patients with high cardiovascular risk, an immanent task of primary care physicians, is laborious, cost intensive and thus difficult to perform. Waist circumference (WC), given its association with multiple risk factors, is an easy to use tool for initial assessment of cardiovascular risk, but its predictive validity in primary care has not been assessed. Patients and methods  In 2005 a nationwide sample of 35,869 unselected patients visiting a primary care physician was screened. The global cardiovascular risk using the SCORE Score of the European Society of Cardiology was assessed in 10,323 men (aged 35–65) and 18,852 women (45–65). Logistic regressions and Spearman correlations were used to evaluate the interdependence of WC and cardiovascular risk factors as well as the estimated cardiovascular risk. Results  Of these unselected patients 21.9% had an increased WC (women >80–88, men >94–102 cm) and further 36.5% had a high WC (women >88, men >102 cm). The proportion of patients with a low HDL-cholesterol was higher in high WC compared to normal WC (prevalence rate ratio (PRR) 1.88 [95%CI 1.74–2.02] in men and 2.97 [2.75–3.21] in women). The same applied to elevated triglycerides (PRR 1.72 [1.62–1.84] and 2.57 [2.36–2.80], respectively), impaired fasting glucose (PRR 2.30 [2.13–2.49] and 3.66 [3.29–4.06]), and elevated blood pressure (PRR 1.27 [1.23–1.30] and 1.57 [1.52–1.62]), respectively. The estimated risk to die from cardiovascular events within 10 years based on the SCORE scoring scheme increased with increasing WC (age adjusted ρ 0.18 in women and 0.19 in men). A SCORE score of more than 5% was observed in 24.12% of men (age adjusted PRR 1.27, 95%CI 1.12; 1.44) and 3.19% of women (age adjusted PRR 1.77, 95%CI 1.26;2.49) with a high WC as compared to 10.88% of men and 0.95% of women with a normal WC. Particularly, in the age groups 50–59 years (men, 11.1%) and 60–65 years (women, 10.2%) a high WC identified more frequently patients with a SCORE result necessitating action (>5% risk) than in lean men (3.52%, P < 0.0001) and women (4.32%, P < 0.0001). Conclusions  Routine measurement of waist circumference in primary care attendees is a suitable screening tool to identify patients with high cardiovascular risk in which a further diagnostic workup is necessary. Current cut-off values reflect a higher risk threshold in men than in women. Future research should identify new thresholds based on cardiovascular risk burden.     

The epidemic of violence in America

Abstract

Background: Osteoarthritis (OA) and cardiovascular disease (CVD) share age and obesity as risk factors, but may also be linked by pathogenic mechanisms involving metabolic abnormalities and systemic inflammation. This study compared the prevalence of OA and metabolic syndrome (MetS) in subjects with OA versus the general population without OA to determine whether having OA predicts increased cardiovascular risk. Methods: National Health and Nutrition Examination Survey III data were used as a representative sample of the general US population. Subjects included adults aged ≥ 18 years with records of history, physical, radiographic, and laboratory data adequate to assess for diagnoses of MetS and OA. Logistic regression was used to examine the association between MetS and population-weighted variables. Results: The general population sample included 7714 subjects (weighted value representing 174.9 million population), of whom 975 subjects had OA (weighted value 17.5 million) and 6739 did not (weighted value 157.4 million). Metabolic syndrome was prevalent in 59% of the OA population and 23% of the population without OA. Each of the 5 cardiovascular risk factors that comprise MetS was more prevalent in the OA population versus the population without OA: hypertension (75% vs 38%), abdominal obesity (63% vs 38%), hyperglycemia (30% vs 13%), elevated triglycerides (47% vs 32%), and low high-density lipoprotein cholesterol (44% vs 38%). Metabolic syndrome was more prevalent in subjects with OA regardless of sex or race. The association between OA and MetS was greater in younger subjects and diminished with increasing age. Having OA at age 43.8 years (mean age of the general population) was associated with a 5.26-fold (SE = 1.58, P < 0.001) increased risk of MetS. This association remained strong when obesity was controlled for in additional regression models. Conclusions: Osteoarthritis is associated with an increased prevalence of MetS, particularly in younger individuals. Global cardiovascular risk should be assessed in individuals aged ≤ 65 years with OA, and should be considered when prescribing analgesics for OA patients.     

Systematic screening for metabolic syndrome in consumers with severe mental illness

The high prevalence of metabolic syndrome (MetS) in people with a mental illness has been reported recently in the literature. Gaps have emerged in the widespread use of systematic screening methods that identify this collection of critical risk factors for cardiac and metabolic disorders in people with severe mental illness. A sample (n = 103) of consumers with severe mental illness was screened for MetS using the Metabolic Syndrome Screening Tool and compared to a sample (n = 72) of consumers who were not receiving a systematic approach to screening for MetS. The results demonstrated ad hoc screening of consumers for MetS in the comparison group, potentially leaving patients at risk of cardiac and metabolic disorders being untreated. Mental health nurses are well placed to show leadership in the screening, treatment, and ongoing management of MetS in people with severe mental illness. A potential new speciality role entitled the ‘cardiometabolic mental health nurse’ is proposed as a means leading to improved outcomes for consumers who have both the complication of physical health problems and a severe mental illness.     

Adiposopathy and thyroid disease: tracing the pathway to cardiovascular risk

Adiposopathy, defined as functionally disturbed adipose tissue mainly composed of large adipocytes and induced by chronic excess of food intake, has been associated with immune, metabolic and endocrine derangements promoting inflammation and, eventually, cardiovascular disease. Adiposopathy may positively influence thyrotropin-stimulating hormone, by raising leptin levels, and triggering autoimmunity. In this regard, it is hypothesized that the increased thyrotropin-stimulating hormone is independent of the negative regulation of the thyroid hormone, thereby constituting a secondary phenomenon and not a causal effect. Replacement therapy with thyroid hormones should therefore be applied following strict individualized consideration. Leptin is involved in the immune response and neuroendocrine appetite regulation, while leptin resistance may further promote autoimmune disease. The lipid derangement in adiposopathy may be aggravated in the presence of hypothyroidism and thus considerably augment cardiovascular risk. Lifestyle-modification counselling, including low-fat dietary intake and regular physical exercise, is today the cornerstone of adiposopathy treatment. Meanwhile, new drug formulations, such as leptin and leptin analogs, 5-HT2C-receptor agonist, and potent thyromimetics, currently comprise a promising armamentarium against adiposity and adiposopathy.     

Rimonabant: endocannabinoid inhibition for the metabolic syndrome

Rimonabant is the first drug to target the endocannabinoid (CB) pathway by inhibiting the actions of anandamide and 2-archidonyl-glycerol on CB1 receptors. This review gives an overview of rimonabant and the CB system and how this system relates to obesity. Rimonabant blocks the central effects of this neurotransmitter pathway involved in obesity and weight control and also blocks the direct effects of CBs on adipocyte and hepatocyte metabolism. Blockade of CB1 receptors leads to a decrease in appetite and also has direct actions in adipose tissue and the liver to improve glucose, fat and cholesterol metabolism so improving insulin resistance, triglycerides and high-density lipoprotein cholesterol (HDL-C) and in some patients, blood pressure. The Rimonabant in Obesity (RIO) trials have shown that rimonabant induces weight loss > 5% in 30-40% of patients and > 10% in 10-20% above both a dietary run-in and long-term hypocaloric management over a 2 year period with a low level of drug-related side effects. Rimonabant therapy is associated with an extra 8-10% increase in HDL-C and a 10-30% reduction in triglycerides and improvements in insulin resistance, glycaemic control in patients with diabetes and also adipokines and cytokines including C-reactive protein over hypocaloric diet therapy. In addition rimonabant abolishes the weight gain associated with smoking cessation and improves the chances of quitting smoking. Thus rimonabant has major effects on both the metabolic syndrome and cardiovascular risk factors thus has the potential to reduce the risks of type 2 diabetes and cardiovascular disease associated with the cardiometabolic phenotype.     

Systemic hemodynamics in young adults with the metabolic syndrome: The Cardiovascular Risk in Young Finns Study

Abstract

Objective. We conducted the present study to examine associations of three different metabolic syndrome (MetS) definitions and their components to arterial stiffness, systemic vascular resistance, and left ventricular function at population level. In addition, the objective of the study was to examine associations of spontaneous recovery from MetS over 6 years’ follow-up to systemic hemodynamics.

Methods. The study population consisted of 1,741 Finnish young adults (aged 30–45 years) who had complete MetS risk factor and hemodynamic data available at 2007. Associations of spontaneous recovery from MetS to systemic hemodynamics was studied on a subpopulation of 1,391 subjects who had also complete MetS risk factor data available at 2001. Hemodynamic measurements were performed using a whole-body impedance cardiography device.

Results. MetS and increasing number of MetS components were associated with lower stroke index (P < 0.001) and higher systemic vascular resistance index (P < 0.005) and arterial pulse wave velocity (P < 0.005). In MetS persistent group, stroke index was lower (P = 0.024), and pulse wave velocity was higher (P = 0.003) compared to MetS recovery group.

Conclusion. All current MetS definitions identify young adults with altered systemic hemodynamics, and recovery from MetS is associated with a favorable hemodynamic profile.     

Self-rated health and risk factors for metabolic syndrome among middle-aged men

OBJECTIVES: To examine lifestyle and clinical risk factors for metabolic syndrome (MBO) and compare their significance between levels of self-rated health among middle-aged men. DESIGN: A cross-sectional baseline study. SAMPLE: 273 men, aged 40, living in Helsinki, Finland. METHODS: Postal questionnaires and health examinations by public health nurses were used in data collection. Statistical differences between groups of self-rated health and risk factors were analyzed by chi-square tests. RESULTS: Of all the respondents, 55% rated their health as good and 45% as average. Two thirds were overweight or obese, and 35% had waist-hip ratio more than 100 cm. Approximately 43% had diastolic blood pressure greater than 90 mmHg. Over half of the men smoked daily, and 28% used alcohol excessively. CONCLUSIONS: The men in this sample were found to be at high risk of developing MBO. The results underscore the importance of understanding the contradiction that exists between subjective and objective health ratings. Public health nurses are in a key position to educate men on how to use simple measurements to objectively assess their risk factors and, thus, potentially reduce their risk of developing diabetes, heart attack, or stroke.     

Abdominal obesity is essential for the risk of venous thromboembolism in the metabolic syndrome: the Tromsø study

Summary.  Background:  The metabolic syndrome is a cluster of cardiovascular risk factors, including abdominal obesity, hypertension, dyslipidemia and insulin resistance, associated with increased risk of cardiovascular diseases and all cause mortality. Objectives:  The purpose of the study was to assess the impact of the metabolic syndrome, and its individual components, on the risk of venous thromboembolism (VTE) in a prospective population-based study. Methods:  Individual components of the metabolic syndrome were registered in 6170 subjects aged 25–84 years in the Tromsø Study in 1994–1995, and first ever VTE events were registered until 1 September 2007. Results:  The metabolic syndrome was present in 21.9% (1350 subjects) of the population. There were 194 validated first VTE events (2.92 per 1000 person-years) during a mean of 10.8 years of follow-up. Presence of metabolic syndrome was associated with increased risk of VTE (HR, 1.65; 95% CI, 1.22–2.23) in age- and gender-adjusted analysis. The risk of VTE increased with the number of components in the metabolic syndrome ( P  < 0.001). Abdominal obesity was the only component significantly associated with VTE in multivariable analysis including age, gender, and the individual components of the syndrome (HR, 2.03; 95% CI, 1.49–2.75). When abdominal obesity was omitted as a diagnostic criterion, none of the other components, alone or in cluster, was associated with increased risk of VTE. Conclusions:  Our study provides evidence for the metabolic syndrome as a risk factor for TE. Abdominal obesity appeared to be the pivotal risk factor among the individual components of the syndrome.     

妊娠期代谢综合征诊断标准的评价及危险因素分析

目的 探讨妊娠期代谢综合征（GMS ）的诊断标准,并分析引起GM S的危险因素。方法 选取该院定期进行产科检查并住院分娩的154例单胎妊娠且子痫前期者为子痫前期组,310例妊娠期糖尿病孕妇为妊娠期糖尿病组,同时选取500例健康孕妇作为健康对照组。记录各组孕妇年龄、怀孕周数、血压、孕前体质量、孕前体质量指数,检测各组孕妇空腹血糖、胰岛素以及总胆固醇、三酰甘油、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇和游离脂肪酸的含量,并对检测结果 进行比较分析。结果 （1）子痫前期组及妊娠糖尿病组孕妇的年龄、怀孕周数、血压、孕前体质量指数分别与健康对照组比较,差异均有统计学意义（P＜0．05）。（2）子痫前期组和妊娠期糖尿病组孕妇各项检测指标分别与健康对照组比较,差异均有统计学意义（P＜0．05）。（3）子痫前期组和妊娠期糖尿病组孕妇发生GMS的风险显著升高（P＜0．05）。结论 孕前体质量指数和总胆固醇是子痫前期和妊1娠期糖尿病发生的危险因素,而两组均显示高密度脂蛋与代谢综合征的发生无显著相关。     

Apolipoprotein A-II: Evaluating its significance in dyslipidaemia,insulin resistance,and atherosclerosis

Abstract

Reduced HDL cholesterol, commonly found in subjects with obesity and type 2 diabetes, is associated with increased risk of cardiovascular disease (CVD). ApoA-II, a constituent apolipoprotein of certain HDL particles, plays an important role in the regulation of cholesterol efflux, HDL remodelling, and cholesteryl ester uptake via its interactions with lipid transfer proteins, lipases, and cellular HDL receptors. Recent studies have linked apoA-II directly with triglyceride and glucose metabolism. Most of the data are, however, derived from cellular systems and transgenic animal models. Direct evidence from human studies is scarce. Clinical studies demonstrate that apoA-II is a strong predictor of risk for CVD. There is no evidence, however, that selective therapeutic modification of apoA-II impacts on atherosclerosis and clinical outcomes. More research is required to investigate further the significance of apoA-II in clinical medicine.