Exercises to Lose Weight On Your Stomach

Flat Belly Fix

In Flat Belly Fix program, you learn the easy, tested and trusted method that saved the creator of this program (Todd Lamb) beautiful wife Tara from a life battling Type 2 Diabetes and experiencing possibly death. It was a very nasty experience with the couple during those times, but with the determination of Todd, he labored ceaselessly to finding a way out for his depressed and unhappy wife. Now they live together both happy and contented. Having used the same technique for people around (seeing the wonders it did to his wife) and also recording so much success, Todd Lamb wants to relate this secret to the world, to create this same atmosphere of joy produced in his immediate environment. Hence, he was motivated to put together this workable program. You also get to learn the secret to having a flat belly, and a healthy and fit body that has been hidden from you for so long now. The creator if this program is positive about the efficacy of this program and is so excited for you to personally experience what happens when you apply The 21 Day Flat Belly Fix in your life. More here...

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HsCRP Metabolic Syndrome and Type 2 Diabetes Mellitus

Hdl Metabolic

Another reason for clinical interest in adding hsCRP to current risk algorithms derives from the fact that inflammation may play a key role in processes associated with metabolic syndrome, a condition that confers increased cardiovascular risk (72). hsCRP levels are correlated positively with components of metabolic syndrome commonly measured in Fig. 8. Cardiovascular event-free survival according to baseline level of hsCRP among individuals with metabolic syndrome. (Adapted from ref. 75.) Fig. 8. Cardiovascular event-free survival according to baseline level of hsCRP among individuals with metabolic syndrome. (Adapted from ref. 75.) Data from the Women's Health Study also show that hsCRP levels 3 mg L successfully differentiated women with metabolic syndrome into low-, moderate-, and high-risk groups (Fig. 8) (75). In analyses comparing the predictive ability of hsCRP alone ( 3 vs

Whole body fat distribution subcutaneous and visceral fat

Even though the total fat mass determines the plasma pool of FFA and thereby the FFA flux from adipose to non-adipose tissue (Lewis et al. 2002), there are differences in the relationship of subcutaneous and visceral fat depots to features of peripheral and hepatic insulin sensitivity (Misra et al. 1997). Visceral fat cells are more sensitive than subcutaneous fat cells to the lipolytic effect of catecholemines and less sensitive to the antilipolytic and fatty acid re-esterification effects of insulin (Kahn & Flier 2000). Furthermore, the venous effluent of visceral fat depots leads directly into the portal vein, resulting in greater FFA flux to the liver. This makes the visceral fat depots more efficient than subcutaneous fat in influencing the carbohydrate metabolism in the human body (Kissebah 1996). Whole-body MRI and CT are the methods of choice for the quantitation of visceral fat accumulation and whole-body fat distribution. Their noninvasive nature and easy-to-follow clinical...

Prediabetes And Metabolic Syndrome

The assessment of metabolic syndrome is based on risk factors for the development of metabolic disorders, such as cardiovascular disease and type 2 diabetes20 (Table 10-8). Waist circumference is an estimate of abdominal obesity. Abdominal obesity (android distribution) is more closely associated with the development and progres-

Diabetes and Metabolic Syndrome

The relationship between diabetes and cancer is the focus of a lot of attention. This interest is often expanded to include the metabolic syndrome. Two parallel definitions of the latter exist. The Guidelines from the National Cholesterol Education Program (Adult Treatment Panel ATP III)7 require the presence of any three of the following Abdominal obesity, defined as a waist circumference in men 102 cm (40 in) and in women 88 cm (35 in)* * Some men can develop multiple metabolic risk factors when waist circumference is only marginally increased 94 to 102 cm (37 to 39 in) as such patients may have a genetic contribution to insulin resistance. Abdominal obesity, defined as a waist-to-hip ratio 0.90, a body mass index 30 kg m2, or a waist girth 94 cm (37 in) Since the metabolic syndrome was defined relatively recently, few studies are available on its impact on cancer. A study linked obesity in colon cancer patients with an increase in overall mortality and a borderline significant...

Molecular Mechanisms of Transdifferentiation

Transgenic mice lacking the RIIp subunit (one of the subunits regulating AMPc-dependent pro-teinphosphokinase A, abundant in adipose tissues) overexpress RIa subunit, which involves increased sensitivity of proteinphosphokinase A to AMPc in WAT, and consequent UCP1 gene activation 71 . This entails a brown phenotype of abdominal fat and resistance to obesity. Foxo2 is a gene for a transcription factor expressed exclusively in adipose tissue. Its overexpression in the adipose tissue of transgenic mice gives rise to an obesity-resistant and more insulinsensitive lean phenotype. These mice show a transformation of white into brown adipocytes 72 . Interestingly, individuals with greater insulin resistance exhibit a reduction of FOXO2 (human foxo2) in subcutaneous abdominal fat accompanied by down-regulation of other genes of the brown adipocytic phenotype.

Cytokines and Insulin Resistance

In addition to their well-known anorectic and hypermetabolic effects, cytokines appear to be involved in obesity-related disorders such as insulin resistance and vascular diseases 65 . Epidemiological findings support the hypothesis that the metabolic syndrome, type II diabetes and cardiovascular diseases have an inflammatory component mediated by cytokines 66, 67 . Thus, overweight and obese children as well as adults

And Paul M Ridker MD MPH

High-sensitivity C-reactive protein (hsCRP) is a marker of inflammation that predicts incident myocardial infarction, stroke, peripheral arterial disease, and sudden cardiac death among healthy persons without a history of cardiovascular disease, as well as recurrent events and death in patients with acute or stable coronary syndromes. hsCRP adds prognostic value at all levels of low-density lipoprotein cholesterol, Framingham coronary risk score, severity of the metabolic syndrome, and blood pressure, and in those with and without subclinical atherosclerosis. Among apparently healthy men and women, hsCRP levels of less than 1, 1 to 3, and greater than 3 mg L distinguish those at low, moderate, and high risk for future cardiovascular disease, respectively. In clinical settings, hsCRP should be used in conjunction with lipid evaluation as part of global risk assessment. Improved knowledge of cardiovascular risk should lead to better compliance with lifestyle and pharmacological...

Antihyperglycemic Agents

Given the interrelationship among inflammation, metabolic syndrome, and diabetes, it is not surprising that antihyperglycemic agents such as metformin and thiazolidinedione have been shown to lower hsCRP levels. In a 26-wk trial among patients with type 2 diabetes, rosiglitazone therapy reduced hsCRP levels and other inflammatory markers (118). Changes in hsCRP level were uncorrelated with changes in glycemic control, as measured by hemoglobin A1c (r 0.06) and fasting glucose level (r 0.06) and were only minimally correlated with changes in insulin resistance (r 0.13). Whether the ability of such agents to lower hsCRP has clinical relevance beyond improvements in glycemic control is a focus of current research.

Definition of Overweight Obesity and Health Implications

Waist circumference is increasingly recognized as a simple means of identifying abdominal obesity. A waist size greater than 102 cm for men and 88 cm for women, at least in Europid populations, markedly increases the risk of most weight-related illnesses. A moderately increased metabolic risk (including MetS) is already observed in individuals with waist circumference greater than 94 cm for men and 80 cm for women. Although the measurement of waist circumference gives little additional information in individuals with severe or extreme obesity, it is much more informative regarding the health risk in subjects with overweight (BMI 25-29.9kg m2) or mild obesity (BMI 30-34.9kg m2).1,2

Effects of Weight Loss on MetS Components

Although obesity is thought to be the main predisposing factor for MetS, how it relates to insulin resistance is not precisely established. Abdominal obesity was identified as being particularly associated with several of the components of MetS,2 3 and weight gain has been shown to be strongly correlated with MetS.12 Although the precise answer to the question whether it is nature (genetic) or nurture (environment) is not known, it seems that it is probably both, to some extent. Nevertheless, it is clear that the current epidemic of obesity, and as a correlate of MetS, is related to modern lifestyles that emphasize overconsump-tion of high-caloric food and lack of physical activity.1,2

From Recommendations to Practice

Despite the worldwide consensus on nutritional recommendations in cardiovascular prevention, their application in everyday life is far from optimal. Western countries are facing a significant increase in obesity, metabolic syndrome, and diabetes directly linked to unhealthy dietary and sedentary habits. However, studies are still needed to orientate strategies dealing with this multifac-

Fat Mass and Distribution Changes Total Adipose Tissue

Little is known about age-related changes in body fatness in elderly adults. Most studies have documented increases up to 50-60 years of age, after which body fatness appears to stabilise 13-16 . In a cross-sectional survey, Baumgartner et al. 6 suggest that body fatness (in terms of both absolute FM and percent body fat) may be relatively stable in elderly men, but may decrease with age in elderly women. In their study, the distribution of body fat, as assessed by DEXA, did not appear to change with age beyond 65 years, leading to the conclusion that the accumulation of abdominal and visceral fat with age (in both men and women) occurs primarily in middle age, while FM remains constant or increases slightly in subsequent decades. In a longitudinal observation of body composition in older adults, as determined using hydrodensitometry, Hughes et al. 17 found an overall increase in adipose tissue in an older cohort, but this increase was attenuated with advancing age in women, whereas...

Magnetic Resonance Imaging MRI and spectroscopy

Computed Tomography Fatty Liver

Figure 13.3 Assessment of Abdominal Fat Storage by Computed Tomography (CT) Representative cross-sectional abdominal CT scans of a lean (A) and an obese (B) research volunteer, demonstrating the fat muscle CT contrast shown with demarcations of visceral (large arrowheads), deep subcutaneous (open arrows) and superficial subcutaneous (closed arrows) adipose tissue (AT) depots. The fascia (small arrowhead) within subcutaneous abdominal AT was used to distinguish superficial from deep depot. In the two CT scans shown, the area of superficial subcutaneous AT was similar (144 vs 141 cm2), whereas areas of deep subcutaneous (126 vs 273 cm2) and visceral (84 vs 153 cm2) AT were quite different. Insulin-stimulated glucose metabolism was 6.1 and 4.0 mg min-1 kg FFM-1 in lean and obese volunteers, respectively (FFM fat-free mass). Reproduced from Kelley D E et al. (2000) Am J Physiol Endocrinol Metab 278 (5) E941-E948. Courtesy of the American Physiological Society. Figure 13.3 Assessment of...

Congenital Partial Lipodystrophy Type 1 Dunningam Syndrome

Atrophy of the subcutaneous fat layer usually manifests at puberty, involving the arms, legs, and buttocks. The subcutaneous adipose tissue of the face, neck, and intra-abdominal area may be preserved, giving patients a silhouette of visceral obesity. An increase in intramuscular fat has been reported. Insulin resistance, reduced glucose tolerance, overt diabetes, hypertriglyceridaemia, and low levels of HDL cholesterol are associated with Dunningam syndrome and lead to early onset of atherosclerotic vascular diseases. Acute pancreatitis and liver steatosis may complicate the clinical picture. The identification of missense mutations on chromosome 1q 21-22, involving genes encoding lamins A and C, in affected members of a family suggests the molecular basis of the disease 33 . Lamins provide structural integrity to the nuclear membrane, such that mutations in the

Changing Patterns of Cachexia in the HAART

With the introduction of potent antiretroviral combination treatments, including nucleoside and non-nucleoside reverse transcriptase inhibitors (NRTI, NNRTI) and protease inhibitors (PIs), which have prolonged patient survival, the incidence of the previously described changes has been dramatically reduced. Since 1996, when HAART was introduced, the number of patients who died of AIDS and opportunistic infections has decreased by two-thirds, although wasting remains a clinical problem for patients 114,115 . In addition, new disorders involving lipids, glucose metabolism, and body fat have acquired greater clinical importance 116-120 . The changes are characterised by hyperlipidaemia, generalised, central, or peripheral fat redistribution, and hormonal disturbances 116,120-124 , and have been named lipodystrophy syndrome, HIV-associated adipose redistribution syndrome (HARS) 125 , or metabolic syndrome-X (Tables 5,6,7).

Ultrasound Contrast Agents

Ultrasound Acoustic Windows

Drawbacks of Traditional Ultrasound Imaging The drawbacks in traditional UI and Doppler include blocking of the US beam by anatomical structures, for instance bones US beam attenuation or reflection by air and other substances, such as free air, intestinal loops, cirrhotic liver dense fat pads in the region of organ or site interrogated such as the abdominal fat pad, obese patients, liver enlargement, or hypertrophic muscle bundles artifacts created by organ movements such as vessels or intestinal loops and deteriorated patients lacking cooperation or poor patient compliance 24, 25 .

Maintenance Phase A Long Term Approach

The maintenance phase follows the in-hospital and transition phases of CR. In this phase patients should be autonomous, being in charge of their own personal healthcare program as recommended by a cardiologist. This must include a clear definition of the usual medication, exercise program and the goals to be reached in terms of tobacco cessation, blood pressure, glycemia, lipids, body weight, waist circumference, and stress control.

Dual Energy Xray Absorptiometry DXA

Several studies have shown some correlation between DXA and CT measurements of body compositions and abdominal obesity (Kelley et al. 2000 Park et al. 2002 Snijder et al. 2002). But methodological limitations linked to the effect of hydration on X-ray attenuation (Pietrobelli et al. 1996, 1998 Lohman et al. 2000) and distortions of planar projections when scanning the thicker tissue of obese or overweight patients (Roubenoff et al. 1993 Brownbill & Ilich 2005) (Figure 13.2) make DXA model dependent and less accurate than CT or MRI.

Definition of MetS and Health Implications

MetS (also called deadly quartet, syndrome X, insulin resistance syndrome, plurimetabolic syndrome, dysmetabolic syndrome, cardiometabolic syndrome) comprises a cluster of abnormalities that occur as a result of perturbations in multiple metabolic pathways, leading to insulin resistance and hyperinsulinemia, hyperglycemia, athero-genic dyslipidemia, hypertension, fibrinolytic abnormalities, etc.3 Numerous other disturbances have been progressively added to the syndrome, including a prothrombotic state, endothelial dysfunction and inflammation, all conditions associated with cardiovascular diseases (CVD). In 1998, the World Health Organization (WHO) recommended a unifying definition and chose the term metabolic syndrome (MetS). However, an alternative definition has been proposed in 2001 by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III).14 This definition is easier to use in clinical practice and now widely accepted.3 According to this definition,...

Effects of Lifestyle Change on MetS Components

Finally, the influence of intensive lifestyle intervention on the emergence of MetS was studied in the DPP. At baseline, about one-half of the participants showed at least three constituents of MetS. Lifestyle modification was superior to other treatments in reducing abdominal obesity and offered the best protection against the development of MetS. This highly successful lifestyle intervention applied in the DPP was based on empirical literature in nutrition, exercise, and behavioral weight control. The program has been described exten-sively12 and was designed to achieve and maintain at least a 7 weight loss and 700 calories week of physical activity (a minimum of 150 minutes of exercise equivalent to brisk walking) in all lifestyle participants.

Heterogeneity Of Atherogenic Lipoproteins

It is well established that the cholesterol content of LDL (LDL-cholesterol LDL-C ) is a risk factor for atherosclerotic cardiovascular disease (ASCVD), and therapy that lowers LDL-C limits ASCVD events. This paradigm has spawned clinical guidelines that set convenient targets for LDL lowering (1-8). Yet many patients continue to have events despite reaching LDL-C targets, and many who have low LDL-C at baseline present with ASCVD events. Several studies suggest that even patients with optimal LDL-C levels benefit from lipid-lowering therapy. These observations have led to a search for other biomarkers that might predict risk of ASCVD events and, in particular, markers that refine the ability to forecast risk from atherogenic lipoproteins. Responding to these concerns, the Adult Treatment Panel III (ATP-III) proposed two important clinical tools to identify patients whose risk may be underestimated by traditional markers (1). First, it adopted a treatment goal based on non-HDL-C in...

Clinical Applications of apoB see also Incorporating Lipoprotein Number Into Treatment of Lipoprotein Disorders

ApoB has gained support as a risk marker from several recent analyses that have directly compared apoB to LDL-C (34,35). Grundy outlined the advantages and disadvantages of non-HDL-C and apoB and concluded that apoB is a reasonable alternative to non-HDL-C and proposed practical cutoffs (Table 2) (28). Updated prevention guidelines from the Canadian Cardiovascular Society (CCS) (4) and Canadian Diabetes Association (41) have also introduced apoB as an alternative to LDL-C. The CCS notes that apoB is especially useful for patients with metabolic syndrome and for following patients on lipid-lowering therapy (Table 2).

Congenital Generalised Lipodystrophy Berardinelli Seip Syndrome or Lipoatrophic Diabetes

Lawrence Syndrome Lipodystrophy

Congenital generalised lipodystrophy (CGLD) is an autosomal recessive, transmitted disease characterised by a pronounced loss of subcutaneous and visceral fat tissue manifested since birth. The condition is associated with acromegalic traits (Fig. 2), accelerated growth with normal hGH

Computerbased decision aids

Care resources 156-158 , partly because the patho-physiology of ischemia in women is incompletely understood and gender-specific diagnostic and treatment strategies are underdeveloped 159 . Gender differences with regard to ischemic heart disease appear to exist in several areas, including established and novel risk factors the metabolic syndrome the physiology of endogenous reproductive hormones the role of endothelial dysfunction in producing obstructive macrovascular CAD, myocardial ischemia, chronic chest pain syndromes, and ACS genetic factors proteomics the menstrual cycle and reproductive status pain threshold perception neurohumoral control and behavioral psychosocial factors.

Pathophysiology of Lipodystrophy Mechanisms of Lipodystrophy The Effects of Protease Inhibitors

Lipoatrophy Extreme

Different hypotheses have been put forward to explain the putative mechanism of HAART drugs in the development of lipodystrophy syndrome 116-120,122-124,126,134,141,147-152 . The first postulates that PIs primarily block cytochrome P450, which is involved in fat metabolism. The second postulates an interaction between PIs and human proteins. HIV protease has a sequence homology of 12 amino acids with two human proteins playing an important role in fat metabolism, namely, LDL-receptor-related protein (LRP) and cytoplasmic retinoic-acid-binding protein type-1 (CRABP-1). PIs inhibit both HIV protease and these two proteins. Inhibition of LRP leads to a reduction in the absorption of fatty acids by capillary endothelium and liver cells. This causes elevated serum triglycerides, visceral fat accumulation, buffalo humps, bull neck, insulin resistance, type II diabetes, breast hypertrophy, etc. Inhibition of CRABP-1 and cytochrome P450 3A isoform results in decreased cell differentiation and...

Reduction in Testosterone Growth Hormoneand IGF1

It is clear that a reduction in the testosterone concentration in healthy young individuals will result in a loss of fat-free mass and muscle strength 15 . It is also well-known that there is a reduction in testosterone of at least 1 per year after the age of 50 in normal healthy men 4 . Furthermore, it has been reported that reduced testosterone concentrations are related to reduced fat-free mass, appendicular skeletal muscle mass, and muscle strength in elderly individuals 16-19 . Additionally, growth hormone decreases with age. This results in a reduction in fat-free mass and an increase in visceral fat mass in the abdominal region 20-22 . An additional manifestation of the reduction in growth hormone is a reduction in circulating insulin-like growth factor (IGF)-1. Statistically significant inverse correlations have been observed between increasing age and IGF-1 concentrations 23 . It is believed that the effects of growth hormone on fat-free mass and fat mass are mediated through...

The Cardiovascular Prevention CVP Program Primary Care

The initial assessment of the family by the nurse is the starting point for the intervention. The nurse explains the concept of cardiovascular risk, carries out a full assessment of risk, and discusses a family plan for reducing risk. This assessment of patients and their partners includes smoking habit, diet and physical activity measurement of BMI, waist circumference, blood pressure, cholesterol, and glucose. Medications are recorded and compliance is assessed. Health beliefs, anxiety and depression, illness perception and mood are also assessed.

Approach To Diabetes Mellitus Definitions

Type 2 diabetes has a stronger familial predisposition than type I. Type 2 diabetics often have a family history of the disease. The genetic factors are multifactorial and have not been identified. It is strongly associated with obesity and its complications metabolic syndrome, hyperinsulinemia. hypertension, dyslipidemia. hyperglycemia, and central obesity.

The Finnish Heart Association

The changes in the patient's risk factors are monitored for a year. The monitored risk factors are blood pressure, lipids, body mass index, waist circumference, a 6-minute walking test, and smoking. Exercise and food diaries are also used. An evaluation study was done of the program in 2002 (57 groups, N 547). The average age of the patients was 64, and 54 were still working. Eighty-eight percent of the patients in the program had coronary artery disease, and the rest had metabolic syndrome. Over half of them had had cardiac infarction. Blood pressure, choles terol, and waist circumference all decreased and the walked distance increased during the year by a statistically significant amount. For those patients whose initial blood pressure was over 140 85mmHg, the systolic pressure decreased on average by 14.2 mmHg (P 0.001), and for those patients who chose blood pressure as their key risk factor, the drop was 17 mmHg. For patients whose initial cholesterol level exceeded 5 mmol L,...

Pharmacotherapy for Weight Management and Prevention of Diabetes

Weight reduction for the prevention of cardiovascular disease is an imperative in the current environment of epidemic obesity and metabolic syndrome. However, the failure rate is 70-95 within 1-2 years of weight loss. Weight loss is followed by a number of adaptations including decreased thyroid and immune function and changes in signaling in the central nervous system that result in weight regain. Thus, the treatment of obesity, which is the common denominator underlying the variable symptoms of the metabolic syndrome, remains a challenge in cardiovascular rehabilitation and prevention. Programs should emphasize a moderate weight loss of 5-10 that is achievable by lifestyle change, rather than dieting, and that is maintainable over time. Drugs may assist with this goal,but no studies that demonstrate a reduction in cardiovascular morbidity or mortality as a result of drug-assisted weight reduction have been done. Promisingly, treatment with a number of drugs may reduce the incidence...

The Dilemma of Traditional Identification of High Risk Patients

Two large cohort studies revealed that 80 to 90 of the patients with CHD had at least one of four traditional risk factors (cigarette smoking, hyper-lipidemia, arterial hypertension, or diabetes).54,55 In the clinical practice of prevention, however, we have the opposite problem of course we treat arterial hypertension and diabetes anyway, but which asymptomatic patient without demonstrable myocardial ischemia with which risk factors is at high risk for developing a cardiovascular event The identification of high-risk individuals based on a single laboratory parameter may be misleading for example, only about 50 of patients having an MI demonstrated hypercholesterolemia.56 Thus, predicting a heart attack based on hypercholesterolemia alone may be like flipping a coin. The diagnosis of a metabolic syndrome has not been shown to be of additional value in predicting events as compared to the Framingham score.57 Adding abdominal obesity, triglycerides, and fasting glucose to these...

Ghb With Synthetic Glycogen For Cancerous Cells

Hexokinase method in, 106-107, 107t medical decision limits in, 72-73, 73t in metabolic syndrome, 353-356, 355t methodology for, 152 point-of-care, 164, 173-176 in prediabetes, 353-356, 355t quality assessment in, 173-176 self-monitoring meters for, 161 specimen handling for, 49t spectrophotometric reactions in, 110t metabolism of, 12-14, 13f in osmolality, 227 reference ranges for, 151t, 454t storage of, 9 structure of, 10f Glucose challenge test, 150-152, 151t Glucose dehydrogenase method, for glucose, 152

Functional Anatomy of White Adipose Tissue

Over time, other molecules were reported to be WAT secretion products (adipokines), and the relationship between their excessive secretion and the severe complications of obesity became increasingly apparent. Especially interesting was the correlation between secretion of tumour necrosis factor (TNF)-a, resistin and adiponectin and diabetes between angiotensinogen and min-eralocorticoid-releasing factors and arterial hypertension 21 and between plasminogen activator inhibitor (PAI 1) and coagulation problems 22 . These data contributed to clarify the molecular mechanism underpinning the early clinical observation that androgenic obesity (i.e. central adiposity with a greater accumulation of visceral fat) carries more dangerous complications than gynoid obesity (peripheral adiposity with a greater accumulation of subcutaneous fat), because of the inhomogeneous secretion of adipokines across depots. An especially close relationship was described for adiponectin and diabetes.

Answers To Case 33 Obesity

Summary A 20-year-old obese female presents for a routine examination. Along with her abdominal obesity, she has irregular menstrual cycles, acanthosis nigricans, and hirsutism. Next steps in evaluation Calculate a body mass index (BMI), measure waist circumference, repeat blood pressure. Order laboratory tests to measure fasting glucose, lipids, thyroid-stimulating hormone (TSH), and liver enzymes. 3. Learn the diagnostic criteria for obesity and the metabolic syndrome. Increased body weight is a major risk factor for the development of disease and for premature death. In National Health and Nutritional Examination Surveys (NHANES) III. the metabolic syndrome was present in 5 of those at normal weight. 22 of those who were overweight, and 60 of those who were obese. The metabolic syndrome is an important risk factor for subsequent development of type 2 diabetes and cardiovascular disease. In this case, this patient's BMI is 33.5. Further measurements included a waist circumference of...

Clinical Approach

Therefore, in addition to BMI, additional measurements, like waist circumference, hip circumference, and waist-to-hip ratio, need to be used to accurately identify the population at risk. Direct measurement of percentage of body fat may also provide additional information. Table 33-1 lists the classification of overweight obesity based on BMI. Along with the measurements mentioned above, a physical examination and focused laboratory work-up should be performed to look for complications and comorbid conditions. A fasting glucose level should be measured to evaluate for diabetes mellitus and impaired glucose tolerance. The presence of acanthosis nigricans a velvety, hyperpigmented, thickening of the skin commonly found on the neck and axillary regions may also be a sign of insulin resistance. Fasting lipids should also be measured, both to evaluate for the presence of metabolic syndrome and for the assessment of the patient's risk for cardiovascular disease. TSH should be measured to...

The Cardiovascular Prevention and Rehabilitation CVPR Program Hospital

The initial assessment of the family is by the whole multidisciplinary team and forms the starting point for the intervention. The nurse explains the nature of the diagnosis and the causes of atherosclerosis, and the three disciplines carry out a full family assessment of cardiovascular risk, and discuss a plan to work together to reduce that risk. This assessment of patients, partners, and relatives includes smoking habit, diet and physical activity measurement of body mass index (BMI), waist circumference, blood pressure, cholesterol, and glucose. Medications are recorded and compliance is assessed. Health beliefs, anxiety and depression, illness perception and mood are also assessed with self-administered questionnaires. The dietitian assesses knowledge and attitudes to diet, and measures weight and height and waist circumference in patients and their families. Body mass index (BMI) is calculated from the weight

Computed Tomography CT

Gynoid Fat Android Fat

Signal intensity in the CT images corresponds to the linear attenuation coefficient, which depends on physical properties (including density) of tissue within the volume of interest. Signal intensity is expressed in so-called computed tomography numbers or Hounsfield units (HU), which range from -1,000 to +3,095 (4,096 values). Based on their density and the resulting differences in X-ray attenuation, muscle and fat tissue display different ranges of intensity (-190 to -30 HU for fat and 0 to 100 HU for muscle), resulting in muscle fat contrast on the CT image (Figure 13.3). Recorded fat accumulation (for subcutaneous and visceral fat depots) is thus based on volumetric measurements (Dixon 1983 Tokunaga et al. 1983 Busetto et al. 1992). For ectopic (intrahepatic, intramyocellular) lipid accumulation, measurements are based on comparison of X-ray attenuation in liver tissue and spleen (Figure 13.4) or in muscle and fat tissue (bone marrow or external phantom (Goodpaster et al. 2000a))....

The Team Approach

The Registered Dietitian (RD) can assist an individual with metabolic syndrome with a weight loss program. The RD is trained to provide medical nutrition therapy to reduce blood pressure and address prediabetic glucose intolerance. Through the assessment of biochemical markers of nutrition, the RD can provide a diet for weight loss that also regulates lipids and glucose. The assessment and management of metabolic syndrome is a classic example of the team approach to health care. Prediabetes and metabolic syndrome are also associated with high triglycerides, low HDL, hypertension, and the development of cardiovascular disease. The association of these states with cardiovascular risk is discussed in the Chapter 4, Diabetes and Other Carbohydrate Disorders. The assessment of prediabetes and metabolic syndrome are examples of protocols that are designed to be used to prevent disease rather than to diagnose disease. Health providers may identify individuals who are at risk for future...

Plasminogen Activator Inhibitor1Tissue Type Plasminogen Activator

Prospective studies evaluating the predictive risk associated with increased plasma PAI-1 levels have been performed. In patients with acute ST-elevation MI, PAI-1 levels correlate with mortality (76). In young patients who survive MI, high PAI-1 levels have been reported in association with hypertriglyceridemia (77). Finally, in patients without a previous MI, increased PAI-1 levels in men were found to correlate with future MI (78). Future studies must consider carefully the independent prognostic value of PAI-1 levels above current clinical risk factors. A special emphasis should continue on patient populations with insulin resistance and metabolic syndrome.

Toward a Biological Definition of Aging

Reduced production of sexual hormones by the gonads is the most obvious manifestation of endocrine senescence and may affect development and growth of hormone-dependent tumors, such as prostatic, mammary, and endometrial cancer. It is important to remember that the activity of sexual hormones is also influenced by body size and shape. With aging, abdominal deposition of fat becomes more common and is associated with increased aromatization of androgens and circulating levels of estrogens (17). In addition, abdominal obesity is associated with decreased concentrations of sexual hormone-binding proteins in the circulation (17). For this reason, obesity may favor the development of breast cancer in postmenopausal women and favor its recurrence after surgery. Obesity may also be associated with increased insulin resistance, increased circulating levels of insulin and, consequently, of growth hormone and of insulin-like growth factor 1 (IGF-1), that is, a powerful growth stimulator of...

Initial Evaluation

On examination, RC appears healthy, with a BP of 128 80 mmHg and a heart rate of 102 beats min. He stands 5 ft, 10 in. weighs 190 lb and has a waist circumference is 38 in. The remainder ofhis examination is unremarkable. Fasting lab work reveals normal electrolytes and a glucose of106 mg dL. His total cholesterol is 147 mg dL, LDL-C is 92 mg dL, HDL-C is 26 mg dL, and TGs are 145 mg dL.

Treatment Strategies to Prevent Resistance to Estrogen Deprivation

A number of pathways stimulate the activity of the aromatase enzyme including prostaglan-dins IL6 and TNFa. Potentially this could cause resistance to aromatase inhibitors by increasing the substrate. Thus, there remains interest in attempting to reduce aromatase activity by inhibitors of prostaglandin synthesis via COX-2. Potentially TNFa and IL6 production by macrophages and adipocytes could be reversed by calorie restriction (as could several other pathways including NFKB and leptin). In this regard, it is of interest that a recent study examining gene expression profiles in subcutaneous abdominal fat in obese premenopausal women showed upregu-lation of multiple anti-inflammatory genes and downregulation of pro-inflammatory genes after a 1-month 800-calorie diet (Clement et al. 2004). We have recently reported that loss of 5 or more of body weight (and maintaining the loss) reduces premenopausal breast cancer by 40 and postmenopausal disease by 25 (Harvie et al. 2005). The...

Clinical Trial Data

Included improvement in endothelial function, decrease in the biomarkers of inflammation, favorable effects on multiple coronary risk factors including all components of the metabolic syndrome, potential anti-ischemic effects, ischemic preconditioning, and favorable hemostatic effects.

Creactive protein

Many clinical conditions are associated with an inflammatory state and or profiles. Obesity 74 , especially that of the abdominal type 75 , is commonly associated with elevated CRP concentrations. The expanded abdominal fat deposits of overweight obese patients represent a source of inflammatory cytokines (interleukin IL -6 and tumour necrosis factor TNF -a) 76 . The production of CRP by the hepatocytes is stimulated by IL-6 77 , and adipose tissue is a key source of circulating IL-6 in patients with abdominal obesity 78, 79 . Intervention studies have shown that weight loss is associated with a reduction in circulating CRP concentrations, and this reduction is proportional to the extent of weight loss 80,81 . It has been shown repeatedly that endurance training can reduce CRP concentrations 85, 86 . Part of this effect seems to be mediated by the exercise-associated weight loss. The specific impact of selective loss of visceral adipose tissue 87 associated with endurance exercise...

Ultrasonography US

Differences in the ultrasonic reflection and transmission coefficient between water and fat tissue enables us to visualise fat layer accumulation in the subcutaneous regions. Even though the imaging ability of the method can be limited by human anatomy and the depth of observed regions, US measurement has made its way to broad clinical applicability. Measurement schemes for the assessment of visceral fat volumes have been introduced (Armellini et al. 1990 Abe et al. 1995) and validated against measurements by computed tomography (Ribeiro-Filho et al. 2003 Hirooka et al. 2005). Using US, the distances between anatomical landmarks in the subcutaneous area and abdominal cavity (Hirooka et al. 2005) or the lower back region (Ribeiro-Filho et al. 2003) are measured, and the volume of intra-abdominal fat is calculated by empirical model equations (Figure 13.1).

Case Scenario 103

Prediabetes and Metabolic Syndrome Apples and Pears The chemist pointed to one result, a fasting glucose level of 111 mg dL. Follow up on this patient. Evaluate the laboratory results for assessment of prediabetes and metabolic syndrome. If the glucose is abnormal, what other laboratory results may be abnormal he asked. Case Scenario 10-3 Prediabetes and Metabolic Syndrome Apples and Pears (continued) Waist circumference (in.) 45 BMI (kg m2) 34 A week later, the student noticed that a fresh blood specimen was drawn on Mr. Layne. Mr. Layne's fasting glucose was 114 mg dL, and a 2-hour glucose challenge test result was 170. These tests confirmed the assessment of prediabetes and ruled out a diagnosis of diabetes. Mr. Layne was also screened for assessment of metabolic syndrome. Mr. Layne's low high-density lipoprotein (HDL) level, high triglyceride level, waist circumference, hypertension, and glucose intolerance confirmed the assessment of metabolic syndrome.

Adipose Tissue AGT

This demonstration that AGT produced by the adipose tissue may be released in the bloodstream suggests that the high circulating levels of AGT associated with obesity may be a result of the increased fat mass. We have recently tested the hypothesis that obesity may be associated with an adipose tissue-specific increase in the AGT gene transcription (summarized in Fig. 1) (55). We found that mice with obesity induced by high-fat diet exhibited a greater AGT gene expression in visceral fat (omental fat, perirenal fat, repro-

Epidemiology

The prevalence of CAN increases with age, duration of diabetes and poor glycaemic control, and in the presence of distal symmetric polyneuropathy, microangiopathy and macroangiopathy (Ziegler 1999). Recent data suggest a correlation between the components of the metabolic syndrome and reduced HRV. In the MONICA KORA cohort we showed at the population level that age, diabetes, obesity and smoking should be regarded as primary risk factors of reduced HRV (Ziegler et al. 2004).

Ldl Particle Number

No doubt, the ATP-III strategy emphasizing metabolic syndrome and following non-HDL-C will detect many individuals who warrant aggressive preventive efforts. However, the objective to better identify at-risk patients has prompted new discussion on how to measure lipoproteins (28,34,42,43). The ideal measure of dyslipidemia might be to estimate the number of lipoprotein particles, because LDL-C does not distinguish small, dense LDL, and particle number may actually correlate more closely with outcomes than level of LDL-C does (10). Direct measurement of LDL particle number has been elusive because of technical limitations. However, a technique to measure LDL particle number is now clinically available. apoB levels also correspond to the number of atherogenic lipoprotein particles. Hence, the differences between particle number and cholesterol content apply to apoB as well.

Diagnostic Workup

The diagnosis of amyloidosis depends on the pathologic demonstration of typical congophilic deposits. The most common strategy is to take the biopsy from the most easily available tissue. Small amyloid deposits often occur in subcutaneous tissue of most people with AL or AA amyloidosis. For this reason, an abdominal fat aspirate is often used as an initial screen. However, a negative result does not exclude a diagnosis of AL, and other sites, such as rectal mucosa, marrow, and particularly the involved organ may need to be sampled.

Discussion

At baseline, RC had optimal cholesterol levels, few major risk factors, and a reassuring Framingham score. Yet he had an ominous family history, impaired fasting glucose, and a low HDL-C. The low HDL-C was the only lipid abnormality that suggested he had atherogenic dyslipidemia, but prediabetes is also an important clue. Although the standard labs hinted at subtle abnormalities, the apoB and NMR findings revealed substantial lipoprotein abnormalities that were not reflected in his LDL-C levels. In fact, the optimal LDL-C might be falsely reassuring. The ATP-III approach helps to overcome this problem by adding criteria for managing hypertriglyceridemia (and, in turn, non-HDL-C) and metabolic syndrome. Many patients with atherogenic dyslipidemia, however, do not meet criteria

Mechanisms of Action

Although exercise training has multiple beneficial effects, current knowledge does not permit accurate estimation of the relative contribution of each mechanism. Exercise training has additional benefits that go beyond improvements in functional capacity and claudication symptoms. Exercise-induced enhancement of endothelial function may also improve systemic cardiovascular health. Additional potential benefits of exercise include reduced blood pressure, an improved lipid profile, better glycemic control in patients with diabetes, and reduced central obesity, although the magnitude and durability of these effects have yet to be studied prospectively in patients with claudication.

NSAIDS and Statins

Interestingly, the two groups of syndromes mentioned above share common treatments within each category. Inflammatory diseases are often treated with NSAIDS, and diabetics and patients with the metabolic syndrome often take statins. These two categories of medications have been analyzed for their role in cancer prevention.

Future directions

It is likely that the scope of exercise testing in clinical practice will extend beyond diseases such as COPD, ILD, PPH and CHF in the future to include diseases whose prevalence is increasing and which often express exercise intolerance, such as the metabolic syndrome 55 . It is also likely that exercise testing will assume greater

Fat Tissue

Only 2 of mature adipocytes undergo mitosis, under appropriate stimulation. Therefore, adipocyte hypertrophy, rather than an increase in their number, seems responsible for the diffuse or localised increases in fatty masses 99 . There is, however, a pool of quiescent or immature adipocytes that can differentiate into mature adipocytes under hormonal and vitamin stimulation 98, 100 . During differentiation, markers such as LPL mRNA, glyc-erol triphosphate dehydrogenase (GPDH), hormone-susceptible lipase (HSL), perilipin, a glucose carrier (GLUT4), and p-3 receptors are acquired. Triglycerides comprise 90 of the mature adipocyte and provide a source of easily available energy through their hydrolysis to fatty acids and glycerol. Mature adipocyte expresses a-2 -adrenergic receptors (a2AR) and adipsin 98 . Adipose tissue secretes LPL, adipsin, complement C3 and B fractions, P450 aromatase, leptin, and growth factors 94, 101 . Its main metabolic functions are...

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