Page 904 - Cardiac Nursing

9
/
/
2
9
9
0
/
/
2
0
6
6
6-8
6-8
88.
p87
p87
6-8
88.
d
d
2
88.
qx
qx
e 8
e 8
80
Pa
g
g
80
ar
a
a
Apt
Apt
ar
009
1
1
2
009
009
0:0
M
M
Pa
0:0
1 P
1 P
K34
K34
LWB
LWBK340-c39_p876-888.qxd 29/06/2009 10:01 PM Page 880 Aptara
LWB
39_
39_
0-c
K34
0-c
880 PA R T V / Health Promotion and Disease Prevention
circumference to measure central obesity and introduce ethnicity comparisons between nations. According to the IDF, up to 25%
as a risk factor. of the world’s adults have metabolic syndrome. 1
Although debate exists about which definition of the metabolic
Metabolic Syndrome Definitions. The WHO definition syndrome is the best, in clinical practice it is important to assess for
of metabolic syndrome requires the presence of insulin resistance insulin resistance, risk factors for heart disease, and diabetes in all
as identified by either type 2 diabetes, impaired fasting glucose, or patients. The position of ACE highlights a main feature of insulin
impaired glucose tolerance plus at least two of the following: resistance; it is not only associated with heart disease and diabetes,
but with a multitude of other conditions that interlink with in-
2
■ BMI 30 kg/m and/or waist to hip ratio 0.90 in men or
creased risk of hyperglycemia and vascular disease. According to
0.85 in women.
ACE, risk factors that increase the likelihood of the insulin resist-
■ Serum triglycerides 50 mg/dL (1.7 mmol/L) or HDL choles-
ance syndrome include the following:
terol 35 mg/dL (0.9 mmol/L) in men and 39 mg/dL (1.0
mmol/L) in women. ■ Diagnosis of CVD, hypertension, polycystic ovary syndrome,
■ Raised arterial blood pressure 140/90 mm Hg. nonalcoholic fatty liver disease, or acanthosis nigricans
■ Urinary albumin excretion rate 20 g/min or albumin to cre- ■ Family history of type 2 diabetes or glucose intolerance
atine ratio 30 mg/g. ■ Non-Caucasian ethnicity
■ Sedentary lifestyle
According to the NCEP III, hyperglycemia is not the critical ■ BMI 25.0 kg/m (or waist circumference 40 in (102 cm) in
2
factor to enter the risk stratification for metabolic syndrome; in- men and 35 in (88 cm) in women)
stead, adults who are diagnosed with metabolic syndrome must
have three or more of the following: Some authors have argued that since there is no unifying cause
of the syndrome and that the CVD or diabetes risk prediction is no
■ Waist circumference 40 in (102 cm) in men and 35 in (88
greater than the sum of its parts and treatment of the syndrome is
cm) in women.
no different from treatment of its components, that we put aside
■ Serum triglycerides 150 mg/dL (1.7 mmol/L).
the metabolic syndrome as a unique disease. Instead, until the rela-
■ Blood pressure 130/ 85 mm Hg.
tionship and etiology of the clustering of these risk factors is better
■ HDL cholesterol 40 mg/dL (103 mmol/L) in men and 50
understood, the focus should be on assessing for the well-known di-
mg/dL (1.29 mmol/L) in women.
abetes and heart disease risk factors and treating according to guide-
■ Fasting glucose 110 mg/dL (6.1 mmol/L).
lines with a special emphasis on regular exercise and weight man-
Here, there is a shift from waist to hip ratio to waist circum- agement. 27 This alternative perspective being promoted by the
ference and elevated glucose levels may be included but are not ADA is called the cardiometabolic risk initiative. The risk factor
critical for diagnosis of diabetes. In this stratification, the risk fac- map (Fig. 39-1) describes a pathway from obesity to insulin resist-
tors carry a similar weight. ance to type 2 diabetes and/or CVD. It is designed to highlight the
The IDF organized a consensus panel to create a worldwide individual risk factors and their interrelationships. The ADA is also
definition of metabolic syndrome. The results of the consensus promoting the use of a well-validated global risk assessment tool
32
group were presented in 2005 in Berlin at the First International called Diabetes Personal Health Decisions (Diabetes PHD) that is
Conference on prediabetes and the metabolic syndrome. This new a user friendly online algorithm that can provide a personalized risk
definition of metabolic syndrome is more user friendly for those assessment based on user health data (including height, weight,
in clinical practice. While the underlying cause of the metabolic lipid level, family history, blood pressure, etc.). In addition to pro-
syndrome is still the subject of intense debate, the IDF consensus viding a risk assessment, it also provides strategies to decrease risk
statement identifies both abnormal abdominal fat distribution through lifestyle and pharmacologic interventions. Improvements
and insulin resistance as critical, interrelated causes. To be defined and patient outcomes should certainly improve as the understand-
as having metabolic syndrome, the IDF definition requires the ing of the complex interrelationships between insulin resistance,
following: central obesity (defined as waist circumference 37 in obesity, heart disease, and hyperglycemia expand.
(94 cm) in European men and 31.5 in (88 cm) for European
women with ethnicity specific values for other groups, plus two of Prevention of Type 2 Diabetes
the following four additional factors: Since even mildly elevated blood glucose levels indicate greater
risk for heart disease and the development of diabetes, it is critical
■ Raised triglycerides: 150 mg/dL (1.7 mmol/L) or specific
to identify people at risk for developing type 2 diabetes and pro-
treatment for this lipid abnormality.
vide risk reduction interventions. People at risk for type 2 diabetes
■ Reduced HDL cholesterol: 40 mg/dL (1.03 mmol/L) in men
are easily identified through standardized risk assessments, blood
and 50 mg/dL (1.29 mmol/L) in women or specific treat-
glucose measurements, or by ascertainment of family history,
ment for this lipid abnormality. 5
lifestyle, and BMI or waistline measurements. The risk of devel-
■ Raised blood pressure: systolic BP 130 mm Hg or diastolic
oping diabetes is a complex interaction of genetics and lifestyle. A
BP 85 or treatment of previously diagnosed hypertension.
person at risk of diabetes who is not overweight and exercises reg-
■ Raised fasting plasma glucose level FPG 100 mg/dL (5.6
ularly has less chance of developing diabetes during their lifetime
mmol/L) or previously diagnosed diabetes. If above 100 mg/dL
than their counterpart who leads a sedentary lifestyle and is over-
or 5.6 mmol/L, oral glucose tolerance test is strongly recom-
weight. Certainly, if a particular family has several members with
mended but not necessary to define the presence of the syn-
type 2 diabetes, this may be due to not only genetic susceptibility
drome.
but also shared environment and similar lifestyles, demonstrating
With the creation of an international definition, it is now pos- that a combination of genetics and behavioral influences work to
sible to estimate the prevalence of metabolic syndrome and make increase or decrease risk of disease expression. 13