Obesity And Abdominal Adiposity

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The problem of obesity has reached epidemic proportions in the majority of developed nations worldwide. The World Health Organization (WHO) has reported that over 1 billion adults worldwide meet the definition for overweight (body mass index (BMI) of greater than 25 kg/m2) and at least 300 million adults meet criteria for clinical obesity (BMI of greater than 30 kg/m2)17. Obesity is associated with a myriad of medical conditions including coronary artery disease, peripheral arterial disease, cerebrovascular disease, congestive heart failure, the metabolic syndrome, hypertension, insulin resistance, type 2 diabetes mellitus, dyslipidemia, obstructive sleep apnea, liver disease, and degenerative joint disease. A subset of obese patients demonstrate abdominal obesity or adiposity which is defined by increasing waist circumference, sagittal abdominal diameter, and waist-to-hip ratio. Waist circumference and sagittal abdominal diameter have been shown to correlate best with intra-abdominal adiposity which is a risk factor for cardiovascular disease as well as for dyslipidemia and diabetes18. The definition for abdominal adiposity varies between different ethnic populations as well as within the current literature. A recent study revealed that 36.9% of men and 55.1% of women in the US met the definition of abdominal adiposity based on high-risk waist circumference (waist circumference of greater than 102 cm in men and greater than 88 cm in women)19.

Overall obesity has been identified as a major risk factor for cardiovascular events and mortality. A

Figure 7.3 Stroke mortality rate in each decade of age versus usual systolic (a) and diastolic (b) blood pressure at the start of that decade. From reference 9, with permission

prospective study of over 1 million adults in the US evaluated the relationship between BMI and cardiovascular mortality as well as all-cause mortality20. The risk of death from cardiovascular disease as well as all causes was noted to increase progressively over the range of overweight to clinically obese patients regardless of age or sex (Figure 7.7)20. One study demonstrated that risk factors for coronary artery disease such as low HDL cholesterol levels, systolic blood pressure, triglycerides, glucose, and serum total cholesterol often cluster with obesity21. The study also demonstrated that a 2.25 kg weight reduction was associated with a 48% reduction in the sum of risk factors for coronary artery disease in man and a similar 40% reduction in women21. A recent study investigated the relationship between being overweight or obese at 40 years of age and life expectancy22. Overweight and obesity were both strongly associated with large decreases in life expectancy, even among patients who were non-smokers (Figure 7.8)22. Another recent study investigated the impact of BMI and measures of abdominal adiposity including waist circumference and waist-to-hip ratio on the prognosis of patients with stable cardiovascular disease who had been enrolled in the Heart Outcomes Prevention Evaluation (HOPE) study23. When compared with the first tertile, the third tertile of BMI was associated with a 20% increase in the relative risk of myocardial infarction23. The third tertile of waist circumference was associated with a 23% increase in the relative risk of myocardial infarction, a 38% increase in the relative risk of heart failure, and a 17% relative increase in total mortality when compared with the first tertile23. Patients within the third tertile of waist-to-hip ratio demonstrated a 24% increased relative risk of cardiovascular death, a 20% increased relative risk of

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