1. THE METABOLIC SYNDROME THE NEW IDF DEFINTION and THE SOCIO-ECONOMIC BURDEN Prof. Morsi Arab University of Alexandria IDF Chairman EMME Region

2. THE SIMPLE CONCEPT OF THE METABOLIC SYNDROME ( MTS ) The Metabolic Syndrome is a cluster of the most dangerous risk factors for heart attack : - diabetes / raised fasting plasma glucose, + - abdominal obesity, - high blood pressure - defective Cholesterol Metab.

3. GLOBAL SIZE OF THE ( MTS ) PROBLEM 20-25 % of the world adult population have the metabolic syndrome ( MTS), and these are : - twice likely to die - 3 times likely to have a heart attack or stroke - 5 times at risk to develop diabetes type 2

4. THE CV RISK IN DIABETES AND IN THE METABOLIC SYNDROME ( MTS) Diabetes is the leading cause of CVD The existence of Metabolic Syndrome confers an additional risk for CVD The more components of MTS the higher the CVD risk and mortality The MTS, even before the diagnosis of diabetes, increases the risk and mortality of CVD

5. Causative Factors in the Metabolic Syndrome The Two significant factors : ( Insulin Resistance ) and ( Central Obesity ) Other possible Factors : - Genetics - physical inactivity - aging - a pro inflammatory state - a hormonal state (These may play variable roles in different ethnic groups)

6. “Obesity” is always involved, or associated with all elements of the Metabolic Syndrome : Obesity is associated with Insulin Resistance Obesity contributes to hypertension – high Cholesterol – low HDL Cholesterol - hyperglycemia and type 2 diabetes Obesity is associated with a high CVD risk But Which type of Obesity ?

8. “ Abdominal Obesity “ as measured by waist circumference is more indicative of the Metabolic Syndrome profile than increased BMI

10. Historical Context : -250 ys ago, Morgagni : associated visceral ob. - HT - atheroscl - uric ac. - obstruct. sleep apena. -1947 Vague ( France ) : Android obesity. -1960 : Plurimetabolic Syndrome ( ob+ diab + bld lipids + risk CHD. ) -1980 : Syndrome X : glucose & insulin metab + + obesity + HT + dyslipidemia Reavan : Insulin sensitivity - risk CHD - insulin resistance

11. Historical ( cont.) - 1998 : WHO definition - : EGIR Definition ( European Group Study of Insulin Resistance ) - 2001 : NCEP Definition ( National Cholesterol Education Program ) ATP III (Adult Treatment Panel ) - 2005/6 : The IDF Definition

12. The WHO Definition : 1998 I- Criteria : [ Type 2 diabetes or IGT ] * + 2 out of 4 :- 1- Hypertension 2- Blood fat 3- Obesity ( BMI) ** 4- micro albuminuria * In case of normal glucose tolerance, evidence of diminished insulin sensitivity (by Euglycemic clamp or HOMA) ** Obesity is assessed by BMI or waist/ hip ratio

13. Draw backs in the WHO Definition 1- BMI is not a reliable measure to obesity 2- Microalbuminuria is very rarely found in absence of diabetes. 3- Euglyc. clamp is not practically applicable (clinically or epidem.)

14. The ATP III ( Adult Treatment Panel ) Definition, 2001 …… by The US National Cholesterol Education Program Revised Criteria = at least 3 out of 5 :- M F 1- Visceral Obesity Waist circumference: 102 88 2- TG ………………………. above 150 mg 3- HDL Cholesterol …………. below 40 50 4- Hypertension …………………….. ( 130 / 85 ) 5- Fasting glucose : 100 mg/dl ( if diabetes or IGT is not already diagnosed)

15. The ATP III Definition 2001( cont. ) + Optional - C-reactive protein ( marker of inflammation ) - Fibrinogen ( marker of prothrombolic state ) Draw back - absence of ethnic consideration in the cut-off points.

16. Confusion results from different definitions Why ? differences in 1- the components of the MTS 2- the cut- off points This causes difficulties in : 1- identifying the MTS i.e. diagnosing 2- interpretation of its causation 3- comparing its burden in different populations

17. Therefore : A new IDF Definition is needed ….why ? 1- to define a set of criteria for use, both epidemiologically and in clinical practice, worldwide, so as to easily identify the MTS ( i.e. Diagnosis ) 2- can better define the nature of MTS ( Pathogenesis ) 3- to focus on …………… appropriate ( management ) 4- so as to contribute to long term reduction of risk to CVD and type 2 diabetes ( Prevention)

20. The new international Diabetes Federation (IDF) definition According to the new IDF definition, for a person to be defined as having the metabolic syndrome he/she must have : Central Obesity ( defined as waist circumference * with ethnicity specific values ) plus any two of the following four factors :  150 mg/dL (1.7 mmol/L ) or specifc treatment for this lipid abnormality. Raised triglycerides  40 mg/dl ( 1.03 mmol/L ) in males 50 mg/dL (1.29 mmol/L) in females  or specific treatment for this lipid abnormality Reduced HDL Cholesterol Systolic BP 130 or diastolic BP 85 mmHg Or treatment of previously diagnosed hypertension Raised blood pressure ( FPG) 100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes Raised fasting plasma glucose

21. Ethnic specific values for waist circumference Waist circumference Country / Ethnic group 94 cm 80 cm Male Female Europids* In the USA, the ATP III values ( 102 cm male; 88 cm female) are likely to continue to be used for clinical purposes 90 cm 80 cm Male Female South Asians Based on a Chinese, Malay and Asian-Indian population 90 cm 80 cm Male Female Chinese 90 cm 80 cm Male Female Japanese** Use South Asian recommendations until more specific data are available Ethnic South and Central Americans Use European data until more specific data are available Sub-Saharan Africans Use South Asian recommendations until more specific data are available EMME ( Arab) populations

22. Characteristic features of the IDF definition - Single, universally accepted - Simple to use clinically - Clear cut-off points, considering different ethnic groups - Central obesity is the core, and waist circumference is the proxy. - Open to additional criteria for research, and - Open to areas for further studies

23. The IDF Definition does not have the final word : 1- more research will possibly reveal more accurate predictive indices. 2- other major risk factors for CVD ( e.g. smoking & LDL cholesterol ) must be taken in consideration

24. The MTS in Young People Research studies so far denote : 1. Prevalence ? probably 30 % in overweight adolescents (US sample) 2. A high BMI in childhood is predictive of MTS in adult life. 3. CV risk factors in ( LDH & BMI ) are present in childhood, and are predictive of CHD in adulthood

25. MTS in the young ( cont.) There are no established criteria for diagnosis in the young There is urgent need to decide : 1.The cut -off values in children. 2. if the 100 mg/dl fasting glucose is correct. 3.The proper method to assess central obesity by accurate measuring waist circumference.

26. The IDF definition of the at risk group and metabolic syndrome in children and adolescents Glucose (mg/ dl) or known T2DM Blood pressure HDL-CTriglyceridesObesity * ( WC ) Age group (years) Metabolic syndrome cannot be diagnosed, but further measurements should be made if there is a family history of metabolic syndrome, T2 DM, dyslipidemia, cardiovascular disease, hypertension and/or obesity  90 6 - <10 (100 mg/dL) [ or known T2DM ] Syst.  130 diast  85 mmHg ( < 40mg/dL) (  150 mg/dL)  90 or adult cut-off if lower 10 - < 16 Use existing IDF criteria for adults16 +

27. The Socio economic Burden

28. World wide = 3.2 millions die from complications associated with diabetes In the ME : ( with high prev. of diab.) one in 4 deaths in adults 35-64 years is related to diabetes

29. ِ At The EMME Region Prevalence of Diabetes is 9.2 % (age 20 -79) Prevalence of IGT …….is 8.1 % 24.5 millions with Diabetes & 22.4 with IGT out of the top 10 highest diabetes prevalence rate countries 6 are EMME countries Estimated death due to DM as % of all deaths is 11.5% ( 11.1% in Europe and 11.8 % in NA )

30. Can we meet the Challenge ?

31. Mean Health Expenditure per person with diabetes ( 2007 ) in ID ( international Dollar) in different regions Africa 180 SEA 233 EMME (514) SACA 625 WP 684 NA 1188 EUR 1561 ---------------------------------- Global av. 712

33. > 1000600- 1000200-600> 200 Bahrain 1047 Lebanon 1050 Qatar 1198 Oman 614 Tunisia 637 Jordan 711 Iran 744 Kuwait 806 Saudi Arabia 891 Emirates 929 Alger 273 Morocco 285 Egypt 286 Libya 384 Afghanistan 56 Iraq 72 Pakistan 99 Sudan 103 Yemen 110 Syria 185 EMME Countries according to The Mean Health Expenditure per person with diabetes in ID (international Dollar) : Diabetes Atlas, 3rd Ed.

34. Cost of DM in relation to funds available (Egyptian Study) DIRECT COST OF TREATMENT OF DM L.E.235.2m AVAILABLE GOVERNMENT EXPENDITURE ON HEALTH L.E. 351.8m 2/3!!

35. Hospital Treatment 2001 Cost /Day (Egyptian Study )

36. 55% Medicine & Supp. 45% Basic ( Food : 5% H.C.Team 11% Others: 29%) Distribution of Hospital Cost

37. 8.85% EGYPT 1.9% QATAR 3.1% SAUDI ARABIA Year Cost / percapit. Burden for Human Insulin (40 u /d)

38. EGYPT 29.9% Cost Burden of Oral Treatment related to Per capitum QATAR 4.2% 8.4% SAUDI ARABIA

40. Alexandria – Montazah Palace Thank You