Elevated Cardiometabolic Risk Research Articles

Discordant Risk: Overweight and Cardiometabolic Risk in Chinese Adults

Recent US work identifies “metabolically healthy overweight” and “metabolically at risk normal weight” individuals. Less is known for modernizing countries with recent increased obesity. Fasting blood samples, anthropometry and blood pressure from 8,233 adults aged 18–98 in the 2009 nationwide China Health and Nutrition Survey, were used to determine prevalence of overweight (Asian cut point, BMI≥23 kg/m2) and five risk factors [pre-diabetes/diabetes (HbA1c≥5.7%) inflammation (hsCRP ≥3 mg/L), pre-hypertension/hypertension (SBP/DBP≥130/85 mmHg), high triglycerides (≥150 mg/dL), low high-density lipoprotein cholesterol (<40 (men)/<50 mg/dL (women)]. Sex-stratified, logistic and multinomial logistic regression models estimated concurrent obesity and cardiometabolic risk, with and without abdominal obesity, adjusting for age, smoking, alcohol consumption, physical activity, urbanicity, and income. Irrespective of urbanicity, 78.3% of the sample had ≥1 elevated cardiometabolic risk factor (normal weight: 33.2% had ≥1 elevated risk factor; overweight: 5.7% had none). At age 18–30, 47.4% had no elevated risk factors, which dropped to 6% by age 70, largely due to age-related increase in hypertension risk (18–30 years: 11%, >70 years: 73%). Abdominal obesity was highly predictive of metabolic risk, irrespective of overweight (e.g., “metabolically at risk overweight” relative to “metabolically healthy normal weight” [men: Relative Risk Ratio (RRR) =39.06; 95% Confidence Interval (CI): 23.47, 65.00; women: RRR=22.26; 95% CI: 17.49, 28.33]). To conclude, a large proportion of Chinese adults have metabolic abnormalities. High hypertension risk with age, irrespective of obesity underlies the low prevalence of metabolically healthy overweight. Screening for cardiometabolic-related outcomes dependent upon overweight will likely miss a large portion of the Chinese at-risk population.

Anthropometric Correlates of Total Body Fat, Abdominal Adiposity, and Cardiovascular Disease Risk Factors in a Biracial Sample of Men and Women

ObjectiveTo investigate associations between anthropometric measurements and total body fat, abdominal adipose tissue, and cardiovascular disease risk factors in a large biracial sample. Patients and MethodsThis study is limited to cross-sectional analyses of data from participants attending a baseline visit between January 26, 1996, and February 1, 2011. The sample included 2037 individuals aged 18 to 69 years: 488 African American women (24%), 686 white women (34%), 196 African American men (9%), and 667 white men (33%). Anthropometry included weight; hip circumference; waist circumference; waist-hip, waist-height, and weight-height ratios; body adiposity index; and body mass index. Body fat and percentage of fat were measured by dual-energy x-ray absorptiometry, and abdominal visceral and subcutaneous adipose tissue were measured by computed tomography. Bivariate correlations, logistic regression models, and receiver operator characteristic curves were used, and analyses were stratified by sex and race. ResultsIn each sex-by-race group, all anthropometric measures were highly correlated with percentage of fat, fat mass, and subcutaneous adipose tissue and moderately correlated with visceral adipose tissue, with the exception of the waist-hip ratio. The odds of having an elevated cardiometabolic risk were increased more than 2-fold per SD increase for most anthropometric variables, and the areas under the curve for each anthropometric measure were significantly greater than 0.5. ConclusionSeveral common anthropometric measures were moderately to highly correlated with total body fat, abdominal fat, and cardiovascular disease risk factors in a biracial sample of women and men. This comprehensive analysis provides evidence of the linkage between simple anthropometric measurements and the purported pathways between adiposity and health.

Age, Abdominal Obesity, and Baseline High-Sensitivity C-Reactive Protein Are Associated with Low-Density Lipoprotein Cholesterol, non–High-Density Lipoprotein Cholesterol, and ApoB Responses to Lipid-Lowering Therapy in Patients with Metabolic Syndrome and Moderately High/High Coronary Heart Disease Risk†

Metabolic syndrome (MetS) affects more than 30% of the U.S. population and is associated with coronary heart disease (CHD) and increased cardiometabolic risk (CMR), attributable in part to dyslipidemia (elevated triglycerides (TGs), low high-density lipoprotein cholesterol [HDL-C], increased small-dense low-density lipoprotein cholesterol [LDL-C] particles). The American Diabetes Association/American College of Cardiology Foundation 2008 consensus statement suggests LDL-C, non-HDL-C, and apolipoprotein B (Apo B) treatment targets for the management of dyslipidemia in patients with CMR. Baseline demographic characteristics and metabolic factors such as dyslipidemia, diabetes mellitus, abdominal obesity, and insulin resistance may influence response to lipid-altering therapy; however, systematic evaluation of these effects in patients with elevated CMR is limited.

Anthropometric indices of fat distribution and cardiometabolic risk in Parkinson’s disease

Background & aimsTo investigate the association between anthropometric indices of body fat distribution and cardiometabolic risk factors in a population of Parkinson’s disease (PD) patients. Methods & resultsOne hundred and fifty-seven PD patients (57.3% males) were studied measuring: waist circumference (WC), waist-hip ratio (WHR), waist-to-height ratio (WtHR), body fat percentage (BF%) by impedance, fasting glucose, serum lipids. Information was collected also on diabetes, hypertension and metabolic syndrome (MetS). Increased cardiometabolic risk was defined by ≥2 MetS component traits other than abdominal adiposity. In the whole population, prevalence of overweight and obesity were 35.0% and 19.2%, respectively. However, prevalence of MetS and elevated cardiometabolic risk were 14.6% and 18.5%, respectively. Prevalence was similar between genders, with one exception: adverse fat distribution according to WC and WHR was more common in females (P < 0.001). Using a multivariable model (adjustments: age, smoking status and disease duration), indices were highly correlated with BF% in both genders. WC and WtHR were associated with the number of MetS criteria and elevated risk. The only cardiometabolic parameters associated with anthropometric indices were HDL in men and triglycerides in women. After adjusting also for BMI all the associations found with anthropometric indices disappeared. ConclusionsDespite their correlation with BF%, anthropometric indices of body fat distribution appear to poorly account for the reduced cardiometabolic risk of the PD patient. This finding suggests a low metabolic activity within the adipose tissue. The implications of fat distribution on the cardiometabolic risk of PD patients clearly deserves further investigation.

Severe Obesity and Selected Risk Factors in a Sixth Grade Multiracial Cohort: The HEALTHY Study

The purpose of this study was to document the prevalence of severe obesity and associated risk in the HEALTHY cohort. A total of 6,365 students were assessed at school-based screenings. Results showed that 6.9% of students were severely obese. Severe obesity was associated with elevated cardiometabolic risk and race/ethnicity. Severe obesity is common and requires preventive intervention.

Effects of Weight Loss Among Metabolically Healthy Obese Men and Women

OBJECTIVEWeight loss among metabolically healthy obese (MHO) individuals may be unnecessary or result in elevated cardio-metabolic risk. We studied the effects of exercise- or diet-induced weight loss on cardio-metabolic risk among MHO and metabolically abnormal obese (MAO) adults.RESEARCH DESIGN AND METHODSParticipants were 63 MHO and 43 MAO adults who took part in 3 to 6 months of exercise- or diet-induced weight loss intervention. Changes in anthropometry, adipose tissue distribution, and cardio-metabolic risk factors were assessed.RESULTSBody weight, waist circumference, and total abdominal and visceral adipose tissue were reduced in all subjects (P < 0.05). Improvements in insulin sensitivity were observed in MHO and MAO men and women (P < 0.05), but were greater in the MAO individuals (P < 0.05). Fasting insulin was the only other cardio-metabolic improvement among MHO individuals (P < 0.05).CONCLUSIONSLifestyle-induced weight loss among MHO subjects is associated with a reduction in total and abdominal obesity and improvement in selected cardio-metabolic risk factors.

PS2-05: The Readiness of U.S. Health Plans to Manage Cardiometabolic Risk

Background: A large proportion of health status is determined by personal behavior. One manifestation of unhealthy personal behavior is the development of elevated cardiometabolic risk. Because health plans already manage care for a large proportion of the United States population, they are in a position to make a significant contribution to the control of cardiometabolic risk if they are prepared to offer health assessment, feedback, and behavior change support. Our goal in conducting this research was to assess health plan awareness of cardiometabolic risk and their current activities aimed at preventing and managing cardiometabolic risk. Methods: In January 2008, Americas Health Insurance Plans, in collaboration with the HealthPartners Research Foundation, surveyed 74 member health insurance plans that offer commercial Health Maintenance Organization, Point of Service and Preferred Provider Organization insurance. The response rate was 47%, representing 47 million lives. Results: The 35 responding health plans reported that they identify members with cardiometabolic risk through referral from case or care management (89%), health risk assessment data (86%), claims data (82%), and pharmaceutical utilization data (79%). Nearly all (97%) plans currently offer interventions for tobacco use, obesity/overweight, and nutrition. Ninety-four percent of the plans reported that they offer interventions to increase physical activity. All plans reported that they offer health risk appraisal or assessment with feedback and education, 91% reported that they use web-based tools, and 85% reported that they use health coaching to help plan members lower their risk. Perceived barriers to broader implementation of cardiometabolic risk control programs included lack of resources (79%), limited availability of enrollee level data (74%), and lack the reporting systems that would be necessary to manage individual plan members (79%). While one quarter of the responding health plans viewed lack of purchaser interest in cardiometabolic risk management programs as an important barrier to program implementation, only 6% named lack of purchaser interest as one of the three most important barriers to implementation. Conclusion: While the responses probably represent the best case scenario because of potential response bias, U.S. health plans appear to be well positioned to provide cardiometabolic risk control services.

Sagittal Abdominal Diameter as a Screening Tool in Clinical Research: Cutoffs for Cardiometabolic Risk

Background. Waist girth and BMI are commonly used as markers of cardiometabolic risk. Accumulating data however suggest that sagittal abdominal diameter (SAD) or “abdominal height” may be a better marker of intra-abdominal adiposity and cardiometabolic risk. We aimed to identify cutoffs for SAD using a cardiometabolic risk score. Design. A population-based cross-sectional study. Methods. In 4032 subjects (1936 men and 2096 women) at age 60, different anthropometric variables (SAD, BMI, waist girth, and waist-to-hip ratio) were measured and cardiometabolic risk score calculated. ROC curves were used to assess cutoffs. Results. Among men SAD showed the strongest correlations to the majority of the individual risk factors; whereas in women SAD was equal to that of waist girth. In the whole sample, the area under the ROC curve was highest for SAD. The optimal SAD cutoff for an elevated cardiometabolic risk score in men was ∼22 cm (95%CI; 21.6 to 22.8) and in women ∼20 cm (95%CI; 19.4 to 20.8). These cutoffs were similar if the Framingham risk score was used. Conclusions. These cutoffs may be used in research and screening to identify “metabolically obese” men who would benefit from lifestyle and pharmacological interventions. These results need to be verified in younger age groups.

Managing Mixed Dyslipidemia in Special Populations

Controlling low-density lipoprotein cholesterol is one of the major focuses of cardiovascular care. However, the twin global pandemics of obesity and diabetes are promoting an increased prevalence of associated cardiometabolic risk factors. These factors include mixed dyslipidemia, which is prevalent among several important subgroups of the overall population. Cardiovascular risk increases as women reach and extend beyond menopause, partly reflective of dyslipidemia. In addition, women with polycystic ovary syndrome display a cluster of risk factors reminiscent of the metabolic syndrome. Certain ethnic groups are also at increased risk for type 2 diabetes or the metabolic syndrome. Dyslipidemia contributes significantly to overall cardiovascular risk in the elderly, and the frequency of children and adolescents presenting with type 2 diabetes or metabolic syndrome is increasing worldwide. Physicians should be aware of the possibility of mixed dyslipidemia in patients at elevated cardiometabolic risk. However, while combination therapy may successfully correct the associated dyslipidemia, it remains to be established whether the addition of a second agent improves coronary risk beyond statin monotherapy.

Evaluation of lifestyle interventions to treat elevated cardiometabolic risk in primary care (E-LITE): a randomized controlled trial

BackgroundEfficacy research has shown that intensive individual lifestyle intervention lowers the risk for developing type 2 diabetes mellitus and the metabolic syndrome. Translational research is needed to test real-world models of lifestyle interventions in primary care settings.DesignE-LITE is a three-arm randomized controlled clinical trial aimed at testing the feasibility and potential effectiveness of two lifestyle interventions: information technology-assisted self-management, either alone or in combination with care management by a dietitian and exercise counselor, in comparison to usual care. Overweight or obese adults with pre-diabetes and/or metabolic syndrome (n = 240) recruited from a community-based primary care clinic are randomly assigned to one of three treatment conditions. Treatment will last 15 months and involves a three-month intensive treatment phase followed by a 12-month maintenance phase. Follow-up assessment occurs at three, six, and 15 months. The primary outcome is change in body mass index. The target sample size will provide 80% power for detecting a net difference of half a standard deviation in body mass index at 15 months between either of the self-management or care management interventions and usual care at a two-sided α level of 0.05, assuming up to a 20% rate of loss to 15-month follow-up.Secondary outcomes include glycemic control, additional cardiovascular risk factors, and health-related quality of life. Potential mediators (e.g., treatment adherence, caloric intake, physical activity level) and moderators (e.g., age, gender, race/ethnicity, baseline mental status) of the intervention's effect on weight change also will be examined.DiscussionThis study will provide objective evidence on the extent of reductions in body mass index and related cardiometabolic risk factors from two lifestyle intervention programs of varying intensity that could be implemented as part of routine health care.Trial registrationNCT00842426

Pleiotropic Effects of Rimonabant: Clinical Implications

Abdominal obesity (high waist circumference) is more strongly associated with cardiovascular disease and type 2 diabetes than generalized adiposity (high body mass index). Recent research has highlighted the role of chronic overactivation of the endogenous endocannabinoid system, acting through its CB(1) receptor, as a key factor involved in the development of abdominal obesity and related cardiometabolic risk abnormalities such as insulin resistance, low HDL-cholesterol, hypertriglyceridemia, inflammation and low adiponectin. Evidence suggests that these cardiometabolic risk factors/markers are not optimally managed by current treatments. Improving the nutrition and physical activity/exercise habits of patients remains the cornerstone of management of elevated global cardiometabolic risk. Antagonism of the endocannabinoid system provides a novel strategy to target several unaddressed cardiometabolic risk markers/factors. Randomized trials of rimonabant in patients with overweight or obesity and/or type 2 diabetes have demonstrated marked and significant improvements in body weight, waist circumference, glycemic control (in patients with type 2 diabetes), features of atherogenic dyslipidemia, insulin resistance, adipose tissue-derived cytokines (leptin and adiponectin) and C-reactive protein (a marker of systemic inflammation). Further analyses suggested that about half of the improvements of several cardiometabolic risk markers were independent from concomitant weight loss. Blood pressure also improved with rimonabant treatment, this effect being consistent with the blood pressure lowering effect of weight loss. The tolerability and safety of rimonabant have been extensively studied and most transient side effects include some gastrointestinal side effects, anxiety, mood changes and incidence of depressive disorders, particularly in patients with previous history of depression. Rimonabant is a useful option for patients with abdominal obesity and with related cardiometabolic risk abnormalities such as an atherogenic dyslipidemia and/or type 2 diabetes.

Overweight and obesity: The pathogenesis of cardiometabolic risk

Obesity, particularly abdominal adiposity, is increasingly recognized as a cause of elevated cardiometabolic risk--the risk of developing type 2 diabetes mellitus (DM) and cardiovascular disease (CVD). The predominate mechanisms appear to involve the promotion of insulin resistance, driven largely by excess free fatty acids secreted by an expanded adipose tissue mass, and the development of an inflammatory milieu due to increased secretion of inflammatory cytokines and adipokines from adipose tissue. Key proinflammatory cytokines secreted by adipocytes include tumor necrosis factor-alpha, interleukin-6, leptin, resistin, and plasminogen activator inhibitor-1. All have been variously associated with hyperinsulemia, hyperglycemia, insulin resistance, diabetes, and endothelial dysfunction, as well as plaque development, progression, and rupture. Adiponectin, another important adipocyte, has protective cardiometabolic actions; however, adiponectin levels decline with increasing obesity. Understanding the role of obesity in the pathogenesis of cardiometabolic risk is crucial for the development of treatment strategies that will provide maximum benefit for patients with, or at risk for, type 2 DM and CVD.

Influence of age on the relation between waist circumference and cardiometabolic risk markers

Background and aims To determine whether the relation between waist circumference (WC) and cardiometabolic risk markers is attenuated with advancing age. Methods and results The study population consisted of 5222 adults from the 1999 to 2004 U.S. National Health and Nutrition Examination Survey, a nationally representative cross-sectional study. Study variables were assessed in a clinical exam. Subjects were grouped into low, moderate, and high sex-specific WC tertiles. The cardiometabolic risk markers examined consisted of insulin resistance (HOMA method), high C-reactive protein, hypertension, and high LDL-cholesterol. Logistic regression was used to determine and compare the association between WC categories with high-risk cardiometabolic risk marker values within young (20–39 years), middle-aged (40–59 years), and older (60+ year) adults. With few exceptions, within each of the three age categories, individuals with a moderate and high WC were significantly more likely to have elevated cardiometabolic risk markers than individuals with a low WC. There was a significant interaction between age and WC indicating that the relation between WC with insulin resistance, high CRP, and hypertension was attenuated in older adults. For example, the odds ratio for hypertension in those with a high relative to low WC was 11.07 (95% CI: 6.13–20.00) in young adults, 3.67 (2.47–5.46) in middle-aged adults, and 2.68 (2.00–3.59) in older adults. Similar observations were made for BMI to those reported for WC. Conclusions A high WC was associated with elevated cardiometabolic risk markers irrespective of age. However, the association between WC and cardiometabolic risk markers was greatly attenuated with advancing age.

Influence of Elevated Cardiometabolic Risk Factor Levels on Treatment Changes in Type 2 Diabetes

Undertreatment of risk factors in patients with type 2 diabetes is common. We assessed the influence of elevated levels of blood pressure, total cholesterol, and A1C on decisions of Dutch general practitioners to change drug treatment in a cohort of 3,029 patients during a 1-year period. Respectively, 58, 71, and 21% of patients remained untreated despite poor blood pressure, lipid levels, and glycemic control. Of poorly controlled but already drug-treated patients, 52% did not receive intensification for antihypertensive medication, 81% not for lipid-lowering medication, and 43% not for glucose-lowering medication. We observed a significantly lower treatment intervention rate in moderately than in poorly controlled patients for blood pressure. This was not seen for decisions on cholesterol or A1C results. The low overall action rates observed for blood pressure and especially lipid management cannot sufficiently be explained by the use of treatment thresholds higher than those indicated by guidelines.

Effects of Exercise Training Intensity on Cardiometabolic Risk in Women with the Metabolic Syndrome with or without Hypertension

The metabolic syndrome (MS) and hypertension (HTN) are both associated with elevated cardiometabolic risk including insulin resistance. PURPOSE: We examined the effects of intensity of aerobic exercise training on resting blood pressure and insulin sensitivity in normotensive (NT) and hypertensive (HT) abdominally obese women with the MS. METHODS: Twenty-six abdominaly obsese women [mean (SD); age 51.0 (8.7) y, ht 165.8 (5.6) cm, wt 94.0 (18.1) kg, % fat 44.1 (4.3)] who met the IDF criteria for the MS were randomly assigned to one-of-three 16-week conditions: (i) No Exercise Training (NOET): (7) maintained existing levels of physical activity, (ii) Low-Intensity Exercise Training (LIET): (10) exercised 5x/week at an intensity < lactate threshold (LT) (iii) High-Intensity Exercise Training (HIET): (9) exercised 3x/week at an intensity > LT and 2x/week < LT. Exercise time was adjusted to maintain caloric expenditure (400 kcal/session). Each subject completed a VO2 Peak treadmill test, seated blood pressure, and fasting laboratories. Group differences were examined using Mixed-Effects ANO VA. RESULTS: At baseline, there were no significant differences between conditions for VO2 Peak, SBP, DBP, insulin, or QUICKI (all p-values > 0.05) [SBP: 129+16 mm Hg, DBP: 78 + 10 mm Hg, VO2 Peak: 38.5 + 6 ml/kg-FFM/min, insulin: 13 + 7 uU/ml, SBP: 0.323 + .022 (mean + SD, pooled)]. Exercise training reduced SBP, with LIET resulting in an 11.2 mmHg reduction in SBP (−3.9 mmHg for NT and - 16.4 mmHg for HT) (p = 0.002), which was superior to NOET (+ 4.8 mmHg for NT, - 1.0 mmHg for HT, p = 0.023) and HIET (−0.75 mmHg for NT, −3.3 mmHg for HT, p = 0.056). QUICKI was significantly elevated in the LIET subjects with HT (p < 0.05). There were no significant changes in DBP, or fasting insulin. The reduction in SBP was related to increased QUICKI (r=−0.57). CONCLUSION: We conclude that exercise training reduces SBP in an intensity dependent manner, with LIET resulting in the greatest reduction in SBP, particularly in those women with HT. The reduction in SBP appears to be related to improved insulin sensitivity. These data suggest that lower intensity exercise (individualized to the lactate threshold) may have utiltiy for designing exercise intervention programs for lowering blood pressure, particularly in abdominally obese women with elevated blood pressure.