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Wednesday, June 26, 2013

U.S. Sees Hike in Obesity, Hyperglycemia (CME/CE)

By Charles Bankhead, Staff Writer, MedPage Today Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse PlannerFewer Americans meet diagnostic criteria for metabolic syndrome compared with 10 years ago.Note that three of the five components of metabolic syndrome declined in prevalence (hypertension, hypertriglyceridemia, and low HDL), and two increased (abdominal obesity and fasting hyperglycemia).

Fewer Americans met diagnostic criteria for metabolic syndrome, but rates for some syndrome components continued to increase, data through the first decade of the millennium showed.

The prevalence of metabolic syndrome in adults decreased from 25.5% in 1999-2000 to 22.9% in 2009-2010. Rates of hypertension and high triglycerides also declined.

However, waistlines -- particularly women's -- continued to expand, such that more than half of adults met the diagnostic criterion for obesity by 2009 to 2010. And the prevalence of hyperglycemia increased by 65%, so that by the last 2 years of the study period, a fifth of all U.S. adults had elevated fasting glucose, as reported in the Journal of the American College of Cardiology.

"Evidence of underlying divergent trends in cardiometabolic risk in the adult U.S. population has also revealed an alarming increase in abdominal obesity since 1999, despite apparently stable prevalence of metabolic syndrome during the same time period," Hiram Beltran-Sanchez, PhD, of the Harvard School of Public Health, and co-authors concluded.

"Our results demonstrate potential targets for interventions to reduce the future burden of cardiovascular disease (CVD) and type 2 diabetes and confirm the urgent need for multifaceted and coordinated treatment programs to address the increasing prevalence of obesity in the U.S."

The concept of metabolic syndrome arose from the observation that several metabolic risk factors often occur together in patients at high risk for CVD. Diagnostically, metabolic syndrome comprises five risk factors: abdominal obesity (as assessed by waist circumference), hypertriglyceridemia, low HDL, elevated blood pressure, and fasting hyperglycemia. A positive diagnosis of metabolic syndrome requires co-occurrence of at least three of the factors.

The components of metabolic syndrome have independent associations with CVD and type 2 diabetes and have become therapeutic targets. Despite the syndrome's and individual components' established recognition, few studies have examined trends in metabolic syndrome prevalence. To address the lack of information, Beltran-Sanchez and colleagues analyzed data from six 2-year cycles of the National Health and Nutrition Examination Survey (NHANES): 1999 to 2000 through 2009 to 2010.

Investigators excluded NHANES participants who did not have complete data on the parameters that make up metabolic syndrome. The analysis had two principal objectives: to evaluate prevalence trends for the syndrome and its individual components and to compare time trends in risk factors across racial/ethnic groups and by sex.

The cumulative study sample included 10,814 participants from the six NHANES cycles, ranging from 1,613 participants from the 1999 to 2000 cycle to 2,034 from the 2009 to 2010 cycle.

The decline in age-adjusted prevalence of metabolic syndrome across the six cycles achieved statistical significance (P=0.024 for trend). Mexican-American women had higher rates throughout the study period.

Three of the five components of metabolic syndrome declined in prevalence and two increased: Elevated blood pressure - 32.3% versus 24.0%, P<0.001Abdominal obesity - 45.4% versus 56.1%, P<0.001Hypertriglyceridemia - 33.5% versus 24.3%, P<0.001Low HDL - 38.5% versus 30.1%, P<0.001Fasting hyperglycemia - 12.9% versus 19.9%, P<0.001

Subgroup analysis showed variation by racial/ethnic group. Metabolic syndrome prevalence was driven by a decline among non-Mexican-American whites (25.59% versus 21.77%, P=0.009), whereas rates remained stable in non-Mexican-American blacks and Mexican Americans.

Waist circumference increased significantly in whites and blacks but did not change significantly in Mexican Americans, although their rate of abdominal obesity increased from 49.9% to 58.73% over the study period (P=0.119). Rates of elevated blood pressure decreased in all three major racial/ethnic groups but achieved statistical significance among whites and Mexican Americans only.

Hypertriglyceridemia prevalence declined significantly in whites, nonsignificantly in Mexican Americans, and increased slightly in blacks (not significant). Low-HDL occurred significantly less often over time in all three groups, but the largest decrease occurred in whites (39.52% versus 29.63%, P=0.001).

The decline in dyslipidemia was accompanied by increased use of lipid-modifying agents (8% to 15.6%), which was similar across population subgroups.

Prevalence of fasting hyperglycemia increased significantly in all three groups, lead by and 11-point rise among Mexican Americans (18.75% versus 29.81%, P<0.001).

Similar variability was observed by sex.

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute on Aging.

The authors reported no relevant disclosures.

Primary source: Journal of the American College of Cardiology
Source reference:
Beltran-Sanchez, H et al "Prevalence and trends of metabolic syndrome in the adult US population, 1999-2010" J Am Coll Cardiol. 2013; Epub.

Charles Bankhead

Staff Writer

Working from Houston, home to one of the world's largest medical complexes, Charles Bankhead has more than 20 years of experience as a medical writer and editor. His career began as a science and medical writer at an academic medical center. He later spent almost a decade as a writer and editor for Medical World News, one of the leading medical trade magazines of its era. His byline has appeared in medical publications that have included Cardio, Cosmetic Surgery Times, Dermatology Times, Diagnostic Imaging, Family Practice, Journal of the National Cancer Institute, Medscape, Oncology News International, Oncology Times, Ophthalmology Times, Patient Care, Renal and Urology News, The Medical Post, Urology Times, and the International Medical News Group newspapers. He has a BA in journalism and MA in mass communications, both from Texas Tech University.

Tuesday, June 25, 2013

AHA Lauds AMA Call on Obesity

By Chris Kaiser, Cardiology Editor, MedPage Today

The American Medical Association's decision to identify obesity as a disease will help bring "additional focus on this important risk factor for heart disease and stroke," said the American Heart Association (AHA).

The AHA statement is a response to a new AMA policy approved this week by its House of Delegates stating that obesity should be called a disease and not simply a condition.

The vote by the AMA's delegates contradicted an opinion from the group's Council on Science and Public Health, which warned that calling obesity a disease would be problematic.

"The AHA is very concerned about obesity and we are delighted that more attention will be brought to this public health issue," AHA President Donna Arnett, PhD, told MedPage Today.

One hope, said Arnett, is that the AMA's declaration will help align government policies regarding reimbursement, as well as private insurers, to cover more treatment and preventive methods aimed at reducing the obesity epidemic.

Millions of Medicare beneficiaries are obese and receive reimbursement for bariatric surgery and behavioral therapy, but coverage for obesity treatment by private insurance is spotty.

"We work with individuals, industry, healthcare professionals, and national, state and local governments to recognize the severity of the issue and the need for more coordinated and comprehensive solutions," Arnett said.

Perhaps the "disease" nomenclature will help remove the stigma attached to obesity, some have suggested.

Johns Hopkins researchers found that doctors were 35% less likely to have an emotional rapport with their overweight patients compared with normal weight patients.

"Having strong emotional rapport with your patients can affect care, especially when it comes to building a partnership to improve care and prognosis," the lead researcher of that study had told MedPage Today.

But many clinicians who commented on MedPage Today's coverage of the AMA's decision did not concur with the AMA, pointing to the possibility that identifying obesity as a disease will add to the nation's annual healthcare tab.

No matter, Arnett said, the AMA's decision supports the AHA's emphasis on Life's Simple 7 -- risk factors and behaviors that when kept in line promote a longer and healthier life.

The seven ideal cardiovascular health targets include four core behaviors -- no smoking, a normal body mass index (BMI), engaging in physical activity, and eating healthfully -- and meeting at least three of the following criteria: cholesterol lower than 200 mg/dL, blood pressure lower than 120/80 mm Hg, not having diabetes, or being free of heart disease.

Arnett and the AHA are also hoping increased attention will focus on environmental aspects that help reduce obesity such as safer walking paths, biking lanes, and greener inner city parks.

In Birmingham, Ala., where Arnett is a professor in the department of epidemiology at the University of Alabama in Birmingham, the city has been very involved in creating pedestrian and bike pathways that help commuters be more active.

"There is also a greenway that links the closest suburb to the downtown area," she said.

The AMA's declaration also might have a positive impact on workplace wellness programs, Arnett suggested.

Obesity is defined as a body mass index of 30 or higher. Over one-third of U.S. adults are obese (nearly 75 million adults) and about 12 million (16.9%) U.S. children ages 2 to 19 are obese.

"Obesity is mainly caused by taking in more calories than are used up in physical activity and daily life, but other factors may also contribute to obesity including genetics, limited access to healthy foods, or unsafe environment for physical activity," Arnett said.

From the American Heart Association:

Chris Kaiser

Cardiology Editor

Chris has written and edited for medical publications for more than 15 years. As the news editor for a United Business Media journal, he was awarded Best News Section. He has a B.A. from La Salle University and an M.A. from Villanova University. Chris is based outside of Philadelphia and is also involved with the theater as a writer, director, and occasional actor.

Tuesday, June 18, 2013

Obesity Not a Disease, AMA Council Says

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By David Pittman, Washington Correspondent, MedPage Today

CHICAGO -- Obesity is hard to define and diagnose, and partly because of that is not a disease, an American Medical Association (AMA) council said in a report issued here Monday.

The report from the AMA's Council on Science and Public Health, released at the organization's annual meeting, angered many medical specialties who do consider obesity a disease.

The report panned body mass index as a proxy for obesity, saying it's limited as a stand-alone. Furthermore, calling obesity a disease may undermine prevention efforts and will do little to impact its treatment, the report said.

"Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state," the council told the AMA's policy-making House of Delegates. "Similarly, a sensitive and clinically practical diagnostic indicator of obesity remains elusive."

Delegates here are considering that report along with a conflicting resolution from the New York delegation that would change AMA policy to call obesity a disease. They will try to resolve the AMA's stance later in the meeting, which ends Wednesday. Current AMA policy calls obesity a major public health problem, but stops short of calling it a disease.

The topic drew about 45 minutes of back-and-forth discussion during Sunday's public health reference committee session.

Supporters of defining obesity as a disease disagreed with the report and said if the AMA were to agree with them, it would help highlight the epidemic in this country and spur health insurers to take greater responsibility for obesity.

"A condition leads to one set of solutions. A disease might lead to another," said John Armstrong, MD, a delegate of the American College of Surgeons, which co-sponsored the resolution that would call obesity a disease.

"I would like to move away from the tyranny of 'Is it a condition or is it a disease?' and simply define obesity as a chronic disease, combine public health and clinical approaches, and work to bend the weight curve in the U.S."

The obesity-is-a-disease contingent also included the American Academy of Family Physicians and the American Association of Clinical Endocrinologists, who said evidence shows obesity is a multimetabolic and hormonal disease.

Those in support of the council report not calling obesity a disease noted obesity rates have risen along with sugar intake in diets and reduced activity -- which are not indicative of a disease. If obesity is called a disease, they said employers would have to give obese workers special considerations.

"We cannot say just because you are obese you will experience harm and morbidity from this, and that is part of a definition of a disease," said AMA public health council member Ilse Levin, DO, of the American Society of Addiction Medicine.

Defining obesity as a disease will do little to actually change treatment management, she continued. "In this case, I don't really see how it will at this point."

Changing the definition to a disease could have negative public health consequences and worsen the epidemic, others argued.

"I believe telling people they have a disease allows people to throw up their arms and surrender and do nothing," Texas delegate Russ Kridel, MD, said.

Payers already recognize obesity as a serious medical condition and Medicare covers bariatric surgery, he said, noting that people with a BMI greater than 40 can be considered disabled if it's called a disease.

David Pittman

David Pittman is MedPage Today’s Washington Correspondent, following the intersection of policy and healthcare. He covers Congress, FDA, and other health agencies in Washington, as well as major healthcare events. David holds bachelors’ degrees in journalism and chemistry from the University of Georgia and previously worked at the Amarillo Globe-News in Texas, Chemical & Engineering News and most recently FDAnews.