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___________________________________ Interabdominaal vet het grootste endocriene orgaan

17 januari 2013, Utrecht Dr. Janneke Wittekoek, Cardioloog Stichting Actief Preventie Plan

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Sterfte hart-vaatziekten

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Conclusies • Er is een overall daling sterftecijfers tgv HVZ

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• De sterft tgv HVZ bij met name jonge vrouwen

neemt langzaam weer toe sinds 1997.

• Toename van het metabool syndroom is een

bedreiging voor de sterftewinst die we tot nu toe in de strijd tegen hart –en vaatziekten hebben bereikt.

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De opmars van het metabool syndroom

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Metabool Syndroom

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Er is sprake van het metabool syndroom als er ten minste 3 criteria aanwezig zijn (ongeachte combinatie).

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 Overgewicht

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 Verhoogde Bloeddruk  Afwijkend lipidenspectrum  Diabetes

___________________________________ Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Circulation 2002; 106:3143

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___________________________________ “Food was fast”

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“Fast food”

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Evolution of men ……………

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CASUS  heer O, 47 jaar

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 keuring

levensverzekering  geen klachten

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 nooit ziek geweest

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Anamnese  directeur bedrijf in sportkleding

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 reist veel, eet meestal buitenshuis  rookt 30 sigaretten per dag

 gebruikt 5 glazen alcohol per dag  beweegt weinig

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Lichamelijk onderzoek

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 adipeuze man  RR 170/105 mmHg

 pols 80/min, regulair  lengte 178 cm, gewicht 100 kg, BMI 32

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 buikomvang 110 cm

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Laboratorium

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6.5 mmol/l

 totaal cholesterol 5.3 mmol/l  LDL-c

 HDL-c  triglyceriden

3.9 mmol/l 0.7 mmol/l 1.5 mmol/l

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___________________________________ Conclusie • 47 jarige man met hoog risico HVZ • atherosclerose risicofactoren roken hypertensie abdominale obesitas gestoorde glucose tolerantie (metabool syndroom)

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Risico factoren voor atherosclerose  niet beinvloedbaar  leeftijd

 geslacht  familie anamnese  HVZ

 beinvloedbaar  dyslipidemia

     

primair secundair diabetes hypertensie roken abdominale obesitas inactiviteit diet

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Overgewicht

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USA ___________________________________ ___________________________________ ___________________________________ 20

25

30

40

45

55

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Obesity Trends* Among U.S. Adults

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1985 (*BMI  30 overweight for woman)

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2001 (*BMI  30, overweight for woman)

___________________________________ ___________________________________ ___________________________________ Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

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NL

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___________________________________ ___________________________________ ___________________________________ ___________________________________ Miami 2009

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___________________________________ ___________________________________ ___________________________________ ___________________________________ the Netherlands tomorrow !!!!

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Gevolgen obesitas Comorbiditeit bij overgewicht  DM2 en obesitas  Hart- en vaatziekten  Obstructief Slaap Apneu Syndroom        

(OSAS) Polycysteus Ovarium Syndroom Artrose Hypertensie Ademhalingsproblemen Maligniteiten  Kortere levensverwachting: 5-20 jaar Dislipidemie  Overgewicht en DM2 hand in hand: 8085% is te zwaar Nefropathie Depressie

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1. Olshansky et al N Engl J Med 2005. 2. Bray et al. Endocrine 2006 . 3. Bean et al. J Clin Psychol Med Settings. 2008 4. Roberts et al. Int J Obes Relat Metab Disord 2003. 5. Lemieux et al, Circulatino 102 (2000) . 6. Renehan et al. Lancet 2008 7.Cowie et al. National Institutes of Health, 1997

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Prevalentie Diabetes

Prevalentie diabetes Nederland 2007: 4%, per norm huisartsenpraktijk 94 patiënten 2025: 8%, per norm huisartsenpraktijk 186 patiënten

Grote boosdoeners  Toename overgewicht  Afname fysieke activiteit Andere oorzaken  Vergrijzing  Overleving  Vroegtijdige opsporing

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Baan C. et al. Ned Tijdschr Geneeskd 2009

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BMI

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 BMI  Duidelijke risicofactor DM2, maar houdt geen

rekening met:  Lichaamssamenstelling (vet vs spier)  Locatie vet  Geslacht  Leeftijd  Etniciteit  Lichaamsvorm - Met name visceraal vet relatie met DM2 1. 2. 3.

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Pischon T et al. New England Journal of Medicine 2008; 359: 2105-20. Deurenberg et al., Obesity Reviews 2002 Westphal et al. Clin Cornerstone 2008

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Vet  Perifeer vet  Abdominaal vet

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 Subcutaan vet

 Intra-abdominaal vet

 Retroperitoneaal vet  Intraperitoneaal vet (visceraal vet)  Mesenteriaal vet  Vet in omentum

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Stelling 1: juist of onjuist?

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kg/m2 verhoogt de kans

Een BMI van 25 op DM2 bij vrouwen met factor 2 t.o.v BMI < 23 kg/m2

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Metabole gevolgen centrale obesitas  Insuline resistentie

 Hypertensie

 Hyperinsulinemie

 Endotheeldysfunctie

 Glucose intolerantie

 Atherosclerose

 Type-2 diabetes

 Hart en Vaatziekten

 Hypertriglyceridemie

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 Small Dense LDL  Postprandiale

hyperlipidemie

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___________________________________ ___________________________________ Afvallen

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Afvallen is fundamenteel  ↑ insuline gevoeligheid  ↓ RR

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 ↓ totaal cholesterol; ↓ triglyceriden; HDL ↑  ↓ ontstekingseiwitten; ↓ endotheel disfunctie  10 % gewichtsverlies geeft 20 % ↓ mortaliteit  ↑ kwaliteit van leven

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1. 2.

Webber J. et al. Int J Obes.1994; 18:725–730 Williamson D.F. et al. Am J Epidemiol 1995; 141:1128–1141

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Quality of Life (QoL)  Effect obesitas op QoL bij mensen met diabetes

    

Comorbiditeit Vaker verzuim op werk Depressie Angst Laag gevoel van eigenwaarde

 Gewichtsverlies verbetert QoL in alle opzichten

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Williamson et al. Arch Intern Med. 2009 ; 169(2):163-171

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Interventies afvallen  Dieet  Meer bewegen

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 Psychologische methoden  Medicatie  Bariatrische chirurgie

Doel: 5-15% gewichtsverlies en 10 % afname van de buikomvang

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NDF Voedingsrichtlijn bij Diabetes

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Stelling 3:NIET juist of WAAR OF WAAR? onjuist? Diabetes patiënten die na de diagnose naar de diëtist worden verwezen gaan gezonder eten

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Uitleg stelling  Mensen met diabetes eten bij diagnose ongezonder dan

gemiddelde bevolking (meer calorieën en ongezonde vetten);

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 Ze pakken dat voedingspatroon wel aan na verwijzing

naar diëtist;  Na 4 jaar eten ze nog steeds betere vetten en

waarschijnlijk ook wat minder calorieën;  Patiënten vallen na diagnose aanvankelijk af, maar zijn na 4 jaar meestal weer op oude gewicht;  Ongeveer 50 % was 3 – 4 kg zwaarder dan voor de interventie.

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1. Van de Laar, F.A. et al. British Journal of General Practice. 2004. 5: 177-182 2. Van Strien T. et al. Health Psychology. 2007; 26: 105-112 3. Herman C.P. et. al.American Psychologist. 2008; 63: 202-203 4. Mann,T, et al. American Psychologist. 2007; 62: 220-233.

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Multifactoriële aanpak 1

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Look AHEAD studie, 5145 DM2, 12 maanden  Dieet + menuplan

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< 113 kg 1200 – 1500 Kcal > 113 kg 1500 – 1800 Kcal  Bewegen

175 min wandelen (10.000 stappen)  Psychologische interventie

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Self monitoring, goalsetting, stimuluscontrole 7,9 % gewichtsverlies t.o.v controlegroep 6 mmol/mol HbA1c daling t.o.v controlegroep

1. 2.

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The Look AHEAD Research Group. Diabetes Care.2007; 30:1374-1383 Moore H. et al. Cochrane review) In: The Cochrane Library

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___________________________________ Multifactoriële aanpak 2  Cochrane review 22 RCT’s  Dieet- bewegings- en gedragsadviezen

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 Na 1 – 2 jaar interventiegroep 1,7 kg meer gewichtsverlies  Grootste gewichtsverlies met VLCD in combinatie met bewegen en

gedragstherapie (-11 %)  Lichaamsbeweging of gedragstherapie zonder dieet had geen effect

op het HbA1c

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1. 2.

Thomas DE et al.Exercise for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2006, Issue 3. Nield L et al. Dietary advice for treatment of type 2 diabetes mellitus in adults.Cochrane Database Syst Rev. 2007;issue 3:

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Medicatie  Orlistat

Remt vetafbraak in het maagdarm kanaal  ↓ opname vet  Gewichtsreductie van 2 – 4 kg in 1 – 2 jaar  HbA1c daling 0,4 % in 1 jaar  Geen veiligheidsgegevens > 4 jaar  Bijw.: olie-achtige ontlasting en flatulentie Orlistat wordt niet aanbevolen door de CFH op basis van beperkt effect op gewicht en gebrek aan langetermijnsgegevens (Farmacotherapeutisch Kompas 2011, www.fk.cvz.nl)

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 Sibutramine  Rimonabant

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Padwal R,. et al. Cochrane Database. Syst Rev 2004(3):CD004094 Anderson J.W. et al. Ann Pharmacother. 2006; 40:1717-23 Kelley D.E. et al. Diabetes Care. 2003;26:971

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Bariatrische Chirurgie  Procedure:  Restrictief, bv maagband

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 Malabsorptief, bv Gastric bypass

 Voorwaarden  BMI > 35 kg/m2 met co-morbiditeit (DM2)  BMI > 40 kg/m2 zonder co-morbiditeit

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 Gangbare behandelingen geprobeerd, maar geen gewichtsverlies

of -behoud.  BMI > 50 kg/m2 bariatrische chirurgie als eerste behandeling

overwegen.  Leeftijd 18-60 jaar

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Van Binsbergen JJ et al. NHG-Standaard Obesitas. Huisarts Wet 2010;53:609-25.

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Tot slot Beheersing van het gewicht in de behandeling van type 2 diabetes blijft een permanent behandeldoel Goede gewichtsbeheersing bij patiënten met type 2 diabetes draagt gunstig bij aan de diabetesregulatie en betekent een vermindering van het cardiovasculaire risico door verbetering van de daarvoor relevante parameters.

1. 2.

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Look AHEAD Research Group. Diabetes Care. 2007 Jun;30(6):1374-1383 Cohen O., et al. Diabetes Res Clin Pract 2007 Aug 24

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___________________________________ Back up slides

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