“Overweight” and CardioVascular diseases

22nd December 2015Peringatan Hari Ibu (ke-87),

Dharma Wanita Persatuan KJRIOsaka, Jepang

Hokusetsu General HospitalEdhi Sudjono Gunawan. M.D.,

Ph.D.( 医学博士　黄俊　貴文）

Obesity, a growing problem in the nation

• Elly Burhaini Faizal, The Jakarta Post, Jakarta | National | Thu, April 05 2012, 10:17 AM

• Undernutrition in early life – Increases the risk of overnutrition in later life

• Children with undernutrition in their early lives are more susceptible to infectious diseases, which may lead to death

Obesity trends and determinants in Indonesia

• Department of Agricultural Economics and Rural Development, Georg-August-University of Goettingen, Platz der Goettinger Sieben 5, 37073 Goettingen, Germany 

• Over the past 20 years, obesity has increased remarkably in Indonesia across all population groups, including rural and low income strata

• The problem is particularly severe among women • Nutrition awareness and education campaigns, combined

with programs to support leisure time exercise especially for women, seem to be most promising to contain the obesity pandemic

IRIN humanitarian news and analysis

• JAKARTA, 5 June 2013 (IRIN) – • The Indonesian Ministry of Health reports

– Non-communicable diseases • Strokes, hypertension and diabetes • Replaced communicable diseases • As the leading cause of death in the country

• Deaths from non-communicable diseases – 41% (1995)– 60% (2007)

• Communicable disease – An infectious disease transmissible – Direct contact – Indirect contact (vector)

• Noncommunicable diseases (NCDs) – Chronic diseases, are not passed from person to person. – Long duration and slow progression – The 4 main types of noncommunicable diseases

• Cardiovascular diseases (like heart attacks and stroke) • Cancers• Chronic respiratory diseases (chronic obstructed pulmonary disease and

asthma)• Diabetes

• Dr. Elvina Karyadi, the director for the Micronutrient Initiative in Indonesia– People in Jakarta don't have time to exercise and people

go by car – People also like junk food and snacking– They say they don't have time to prepare healthy food – Starting from childhood, parents give children money

• They can buy their own food instead of preparing them a meal

– This is a change of lifestyle

Effects of obesity on women's health• Overweight and obesity are associated with elevated

mortality from all causes in both men and women– The risk of death rises with increasing weight

• Obesity, especially abdominal obesity, is central to the metabolic syndrome and is strongly related to polycystic ovary syndrome (PCOS) in women

• Obese women are particularly susceptible to diabetes, and diabetes, in turn, puts women at dramatically increased risk of cardiovascular disease (CVD).

• Obesity increases the risk of several major cancers in women – Postmenopausal breast cancer and endometrial cancer

Obesity and cardiovascular disease

• Overweight may develop – Hypertension, diabetes and atherosclerosis.  – These conditions

• High risk of cardiovascular disease 

– Central obesity/Abdominal obesity

CardioVascular ? Disease

Cardiovascular disease• A diseases that involve the heart or blood vessels • Includes coronary artery diseases (CAD)

– Angina (penyempitan pembuluh darah jantung)

– Myocardial infarction (heart attack)

• Other CVDs – Stroke, hypertensive heart disease, rheumatic heart

disease, cardiomyopathy, atrial fibrillation, congenital heart disease, endocarditis, aortic aneurysms, peripheral artery disease and venous thrombosis

CardioVascular ? Disease

The underlying mechanisms

• Depending on the disease• Coronary artery disease, stroke, and peripheral

artery disease, aneurysm involve atherosclerosis. – Caused by high blood pressure, smoking, diabetes, lack

of exercise, obesity, high blood cholesterol, poor diet, and excessive alcohol consumption

• Rheumatic heart disease may follow untreated streptococcus throat infection

Cardiovascular disease

1. Coronary disease

2. Aortic Aneurysm

3. Cerebrovascular disease

4. Perpheral artery disease

5. Thrombosis/Embolism

and Sudden death

Sudden death Causes

• Coronary artery disease is the leading cause of sudden cardiac arrest

• Many other – Cardiac– Non-cardiac conditions

• Cardiac– Coronary artery disease– Myocardial infarction– Non-ischemic heart disease

• Cardiomyopathy, cardiac rhythm disturbances (arrythmia)• Hypertensive heart disease (Tekanan darah tinggi)• Congestive heart failure (Gagal Jantung)

• Non Cardiac– Bleeding

• Gastrointestinal bleeding, aortic rupture, or intracranial hemorrhage

– Overdose, drowning and pulmonary embolism– Cardiac arrest can also be caused by poisoning

Sudden death

Cardiovascular disease

1. Coronary disease

2. Aortic Aneurysm

3. Cerebrovascular disease

4. Peripheral artery disease (PAD)

5. Thrombosis/Embolism

and Sudden death

1. Coronary artery disease　　　　　　　　　　　　　　 ⇒ MI

Therapy of Coronary artery disease

Stent(PCI = percutaneous coronary intervention)

PCI = percutaneous coronary intervention

Unstable Angina Clinical Presentation • Ischemic pain• heaviness, tightness, aching, fullness, or burning of the

chest, epigastrium, or arm or forearm (usually the left)• Involve the lower jaw, neck, or shoulder • Associated symptoms :

– dyspnea, generalized fatigue, diaphoresis, nausea and vomiting– flulike symptoms, lightheadedness or abdominal pain

• The intensity of pain does not correlate with diagnosis or prognosis

• Elderly and female patients are more likely to present with atypical signs and symptoms

2. Aortic aneurysm

Aneurysm• An aneurysm or aneurism 

– from Greek:"dilation", "to dilate“– localized – Blood-filled balloon-like bulge in the wall of

a blood vessel• Risk factors

– Diabetes, obesity, hypertension, tobacco use,alcoholism, high cholesterol, copper deficiency, increasing age, and tertiary syphilis and TBC infection

Therapy

Abdominal aneurysm

Case Study• Oct 12th 2015, 21p.m.

• Chest discomfort

• chest pain

• Emergency unit– Lab:Normal limit

– BP 185/102

• Chest Rontgent

• Inpatient recommended– Rejected

Aortic aneurysm rupture• Oct 13th, 07 a.m.

• Brushing teeth

• She felt down suddenly (Collaps)

• Emergency services called and Cardiopulmonary resuscitation start

• 08:14 a.m. confirmed death

• R-1, R-2, R-3

Aortic aneurysm Symptoms• Many aneurysms do not have symptoms• Detected during a routine physical exam or

– X-ray evaluation for another disorder• Symptoms occur

– When the aneurysm grows/disrupts the wall of the aorta• Symptoms depend on the size and location

– Pain in the abdomen or in the lower back– Constant pain occurring over hours or days– Sudden onset of severe stabbing pain– Unusual sensation of pulsing in the abdomen– Cough, shortness of breath (thoracic aortic aneurysm)– Fainting, Chest pain

Subarachnoid haemorahge

• 66 years old man• 2 days ago

– Headeche

– Vomit

– General malaise

• Walking to Hospital• BP 207/85• Concious

• SAH.wmv

3. Cerebrovascular disease

SAH (Subarachnoid haemorrhage)

• acute nontraumatic headache – maximum intensity within 1 hour– “Worst headache of my life"

• 30-40% of patients are at rest at the time of SAH

• The remaining 60-70% of cases – Physical or emotional strain– Defecation, coitus, and head trauma

SAH Prodromal events• Signs and symptoms

– Ruptured cerebral aneurysm (10-50% of cases.)– 10-20 days prior to rupture

• The most common symptoms– Headache (48%)– Dizziness (10%)– Orbital pain (7%)– Diplopia (4%), Visual loss (4%)– Sensory or motor disturbance (6%)– Seizures (4%), Dysphasia (2%), Ptosis (3%)

• Prodromal signs and symptoms– Sentinel leaks

• Headaches, nausea, vomiting, photophobia, malaise, neck pain.

• These symptoms may be ignored by the physician

– Mass effect (aneurysm expansion)

– Emboli

Cerebrovascular disease

• 92 years old woman

• Fall down, Head injury

• Headeache, nausea, vomiting

• Right Intracranial haemorrhage

• (Epidural hematoma)

(head injury)

• Sarcopenia

Cerebrovascular disease,

• 47 years old woman• Past history : Iron Defficiency Anemia• 28th Oct 2015

– Suddenly fall down and feel dysarthria• 29th Oct 2015 night

– Numbness left hand and leg • 30th Oct 2015 Emergency department

– No sign of paralysis, walking to hospital– BP 182/104– Head MRI exam– 脳梗塞（ DWI).wmv 　脳梗塞（ MRA 1 ） .wmv– 脳梗塞（ MRA-2).wmv 　脳梗塞（頚動脈－１） .wmv

Cerebrovascular infarct (Stroke)

Internal carotid artery oclusion

4. Peripheral artery disease (PAD)

• Narrowing of the arteries – Other than the heart or brain

• classic symptom – Leg pain when walking, resolves with rest– Intermittent claudication

• Other symptoms – Skin ulcers, bluish skin, cold skin, or poor nail and hair growth in

the affected leg – Complications

• Infection or tissue death • May require amputation

• 50% are without symptoms

Symptom Screening

Therapy of Peripheral artery disease

Peripheral artery disease• 72 Years old Man (Inpatient caused by Osteomyelitis)

– Diabetes Mellitus

– Hypercholesterol, Hyperlipidemia

– Hypertension

• Bilateral Leg PAD

5. Pulmonary embolism

• Inhospital caused by lower extremities infection

• Oct 6th 22 p.m. – Suddenly

– Chest pain, dyspnea

– Cold sweat

• ECG: look like Angina or MI

• PE- 造影０１ .wmv• PE ー造影２ .wmv• PE ー造影３ D.wmv

A former minister for health in Indonesia,

• The rates of infectious diseases have gone down, while non-communicable diseases have gone up tremendously

• The non-communicable diseases are not included in our health insurance schemes

90% of CVD : preventable

• Prevention of atherosclerosis by decreasing risk factors– Healthy eating, exercise

– Avoid tobacco smoke

– Limiting alcohol intake

– Treating high blood pressure and diabetes 

– Treating people who have strep throat with antibiotics can decrease the risk of rheumatic heart disease

– Avoid or reduce exposure to air pollution

Cardiovascular disease = Obesity only?

1. Visceral fat (abdominal fat) – Body fat that exists in the abdomen 

– Surrounds the internal organs 

2. Cholesterol Ratio– L/H Ratio

3. Air Pollution

Cardiovascular disease = Obesity only?

Air Pollution ＝ PM2.5

Air pollution• Currently, PM2.5  is the major focus• short- and long-term exposure 

– Increased rate of atherosclerosis and inflammation– Effects on cardiovascular disease– Estimated 8–18% CVD mortality risk – Women had a higher relative risk coronary artery disease than

men did – 5 days of exposure, a rise in Blood pressure– Irregular heart rhythm, reduced heart rate variability, and heart

failure – Artery thickening– Increased risk of acute myocardial infarction

Respiratory system

Others effects PM2.5

• Irritation of the eyes, nose and throat• Coughing, chest tightness and shortness of breath• Reduced lung function• Irregular heartbeat• Asthma attacks• Lung Cancer• Premature death in people with heart or lung

disease

Reduce exposure to PM2.5

• When outdoor levels of PM2.5 are elevated,

– Going indoors

• Limit indoor and outdoor activities that produce fine particles – Burning candles indoors/open burning outdoors

– Avoid strenuous activity in areas where fine particle levels are high

– Tobacco (Passive smoking)

• Air purifier

PM 2.5 Concentration expected

1. Visceral fat, or abdominal fatHas significant impact on metabolism

• Affects blood pressure; blood lipid levels, cardiac rhythm • Interferes with ability to use insulin effectively, disturb

neurohormonal function ect 

LiverIntestine

FatTG

TG

2. Cholesterol

1. “Scour" the walls of blood vessels

2. Cleaning out excess cholesterol (plaques that cause CAD)

3. Carried to the liver

• Processed into bile

• Secreted into the intestines and out of the body

HDL

3. Cholesterol ratio

• Cholesterol ratio• Total cholesterol/HDL

• Total cholesterol• High-density lipoprotein, HDL (good cholesterol), • + Low-density lipoprotein, LDL (bad cholesterol), • + 20 percent of triglycerides• a type of fat carried in blood

Total Cholesterol/HDL Ratio (U.S.A) LDL/HDL Ratio (Japan)

Cholesterol ratio : Total cholesterol/HDL• An optimal ratio 3.5 ～ 1• A higher ratio : a higher risk of heart disease• Non-HDL cholesterol

– Total cholesterol ー HDL cholesterol – All the "bad" types of cholesterol– Higher numbers mean a higher risk of heart disease

• Ratio of 5 ： average risk of heart disease for men– Ratio 9.6 : double the risk

• Women, a 4.4 ratio ： average risk for heart disease– A ratio 3.3 : roughly half the average risk– Ratio  7 : double the risk for heart disease– Because their HDL levels are often higher

Cholesterol ratio : Total cholesterol/HDL• HDL ＜ 40 mg/dL

– Increased risk of CAD – Normal total cholesterol and LDL cholesterol levels 

• HDL 40 ― 60 mg/dL ： considered "normal" – Do not very much affect the risk of CAD

• HDL ＞ 60 mg/dL – Reduced risk of heart disease

L/H ratio– <1.5 Good condition– >2.0 accumulation of cholesterol, Probability of atherosclerosis– >2.5 Risk for Plaque and CardioVascular disease

Target HDL cholesterol level

At risk Desirable

Men ＜ 40 mg/dL

(1.0 mmol/L)

≧60 mg/dL

(1.6 mmol/L)

Women ＜ 50 mg/dL

(1.3 mmol/L)

≧60 mg/dL

(1.6 mmol/L)

How can We Increase Our HDL Levels?

• Aerobic exercise• Lose weight• Stop smoking • Cut out the trans fatty acids• Alcohol : one or two drinks /day • Increase the Monounsaturated Fats In Your Diet • Add soluble fiber to your diet • Other dietary means to increasing HDL • What About A Low-Fat Diet? • What About Drugs?

Trans fatty acid

• Made through the chemical process of hydrogenation of oils

• Margarine, crackers, cookies, and snack foods

• Abundance in many deep-fried foods • Raise the 'bad' (LDL) cholesterol • Lower the 'good' (HDL) cholesterol levels• Increase the risk of heart disease 

Increase in HDL levels

• Removing trans fatty acids • Monounsaturated fats : canola oil, avocado oil, olive oil

– Without increasing the total cholesterol• Soluble fibers : fruits, vegetables

– Reduction in LDL cholesterol– Increase HDL cholesterol

• Cranberry juice • Fish and other foods containing omega-3 fatty acids

– Increase HDL levels. In postmenopausal women – (but not, apparently, in men or pre-menopausal women) 

Regular aerobic exercise increase your HDL level

• Walking, jogging or bike riding• duration ＞ intensity

– At least 20 minutes (though 40 would be better)

– At least 3 ~ 4 times/week

• Raises your heart rate for 20 to 30 minutes at a time– THR (Target heart zone)

Low-fat diet

• Reduces HDL - rather than increases - HDL levels – Not specifically caused by “not enough fat”

– But, is caused by consuming too many carbohydrates

• The American Heart Association and the American College of Cardiology – Stopped recommending low-fat diets for heart disease

prevention

• Low-carb diets - and not low-fat diets – – Can increase HDL levels

• Drug therapy for raising HDL cholesterol levels • Disappointment • Statins

– Has proven highly successful in reducing LDL – Not very effective at increasing HDL levels

• Niacin : drug therapy for raising HDL levels. – One of the B vitamins – The amount of niacin needed are so high – Raising HDL levels with niacin

• No improvement in cardiovascular outcomes– Treatment with niacin

• Increased risk of stroke, diabetic complications

Healty eating and exercise = Lose weight

• BMI : (kg/m2)– weight (kilograms) : the square of height in meters

• BMI score– Underweight ：＜ 18.5 – Healthy weight ： 18.5 ー 24.9– Overweight ： 25 ー 29.9  – Obese ： 30 ー 39.9– Severely obese ＞ 40

Waist circumference Another indicator of your risk of developing health problems

• USA– Men > 94cm

– Women > 80cm 

• Japan– Men > 85cm

– Women > 90cm

Lose weight too fast ⇒ Rebound

• Lose weight at a safe rate of 0.5kg to 1kg / week • A daily calorie : 1,900kcal for men

– 1,400kcal for women

• Losing weight faster – Increase the risk of health problems

– Malnutrition, gallstones, feel tired and unwell • 1 Kg = ? Calories = ?cm waist circumference

• Caloric needs (simple guide)– Body weight (Kg)× ２５〜３０ Kcal– Adult women ± １５００ Kcal/day

Caloric needs (simple guide)

• Calorie need/kg– Desk work (Low active) 25~30 kcal– Standing work or work outside

• (Moderate active) 30~35 kcal

– Hard work (Active) 35~40 kcal

Conclusion = Live well

Live well• Eat well

– Good fats• Monounsaturated fats :avocados, nuts and seeds • Polyunsaturated fats, including Omega-3s, : fatty fish• Good vegetarian sources of polyunsaturated fats : walnuts

– Bad fats• Trans fats, margarines, candies, cookies, snack foods, fried foods

• Exercise• Avoid / reduce polution

– PM2.5 of 880 ug/m3 (city with high pollution)– Smoking area 700 ~ 800 ug/mg3

Fat composition recommndedSaturated fat Unsaturated fat

Trans fat Monounsaturated

Polyunsaturated

Omega-3 Omega-6

Source Animal fatMeat, milk

Chemical process Olive oilavocados

Fish, salmonBeans,sardine

Vegetable oil, nuts

intake Limit consumtion

Avoid, do not eat“hydorogenated oil”

RecommnededBad Chol↓Good chol ↑

Good fatBrain healthHelp metabolism

Good fatOver consumed caused health problem

Food composition

Case 1

2014/8/6 2014/11/12 2015/6/10 2015/10/20

T-Chol 209 228 254 123

T-G 550 261 351 186

HDL 37 40 41 27

LDL 120 149 166 57

Tchol/HDL 5.6 5.7 6.2 4.5

L/H ratio 3.2 3.7 4.0 2.1

Case 22012/4/19 2014/10/17 2015/10/13

T-Chol 305 272 272

T-G 223 162 79

HDL 48 68 74

LDL 221 181 186

Tchol/HDL 6.4 4 3.6

L/H ratio 4.6 2.6 2.5

Case 1 & 2

2014/8/6 2014/11/12 2015/6/10 2015/10/20

T-Chol 209

305

228

272

254 123

272

T-G 550

223

261

162

351 186

79

HDL 37

48

40

68

41 27

74

LDL 120

221

149

181

166 57

186

Case 1

2014/8/6 2014/11/12 2015/6/10 2015/10/20

HDL 37 40 41 27

Tchol/HDL 5.6 5.7 6.2 4.5

L/H ratio 3.2 3.7 4.0 2.1

take madication Statin

Case 2

2012/4/19 2014/10/17 2015/10/13

HDL 48 68 74

Tchol/HDL 6.4 4 3.6

L/H ratio 4.6 2.6 2.5

didn’t take madication

3 ~ 4 times/week exercise + Low carb diet

Metabolic syndrome• Waist circumference

– Man > 85cm Women > 90cm

• Trigliceride ・ HDL Cholesterol – TG >150mg/dl– HDL<40mg/dl– One or both

• Blood pressure – Systolic blood pressure >130m ｍ Hg– Diastolic blood pressure > 85m ｍ Hg– One or both

• Blood Sugar – Fasting blood sugar >110mg/dl

Conclusion

BMR is the number of calories you would burn with NO activity

Effect on BMR

BMR (Simple guide) (Kcal)

Years/gender Man woman

50~69 old 21.5 x weight 20.7 x weight

30~49 old 22.3 x weight 21.7 x weight

18~29 old 24.0 x weight 23.6 x weight

15~17 old 27.0 x weight 25.3 x weight

Conclusion

Meal TEF

(% of calories consumed)

Protein 20~30 %

Carbohydrates 5 ~10 %

Fat 0 ~ 3 %

Exercise THR (Target heart zone)• First step ：  resting heart rate (RHR)  • Before get out of bed in the morning,

– Take pulse for 1 full minute – Beats per minute (bpm)

• For a more accurate measurement – Take pulse for 3 mornings and take an average – A normal RHR for adults is between 60-100

• Use this number to find target heart rate zones – Karvonen formula

• Calculate a THR zone between 50% and 85% – Heart rate reserve

Exercise

• Low Intensity - 50-60%

• Moderate Intensity - 60-70%

• Vigorous or High Intensity - 75-85%

• The Talk Test and Perceived Exertion– Can speak comfortably

• Around the low-middle range of  THR zone

To calculate the low end THR zone• 50% of heart rate reserve

•  Max Heart Rate (MaxHR) = 206.9 - (0.67 x age)

• Heart Rate Reserve (HRR) = MaxHR - (resting heart rate)

• HRR x 50% = training range %

• Training range % + resting heart rate = low end of THR zone

• 35-year-old RHR of 60/m • 206.9 - (0.67 x 35) = 183.45

183.45 - 60 = 123.45123.45 x 50%= 62%62 + 60 = 122 bpm

• For this person,

– The low end THR starts at 122 bpm,

– A light, warm up pace

calculating the high end (85%) of THR zone

• 85% of heart rate reserve

• Max Heart Rate (MaxHR) = 206.9 - (0.67 x age)

• Heart Rate Reserve (HRR) = MaxHR - (resting heart rate)

• HRR x 85% = training range %

• Training range % + RHR = high end of your THR zone

• 35 year old RHR 60 bpm

• 206.9 - (0.67 x 35) = 183.45 (MaxHR)

• 183.45 - 60 = 123.45 (HRR)

• 123.45 x 85%= 105 (training range % )

• 105 + 60 = 165 bpm (high end of THR zone )

• Training heart rate zone : 120-180 beats per minute

Terima Kasih

Cardiac rhythm