ESROC- KES Joint Symposium

SE-5-1

Metabolic Syndrome in Korea

CHuLwoo aHn

Department of Endocrinology and Metabolism, Internal Medicine Gangnam Severance Hospital, Seoul, Korea

Metabolic syndrome is a cluster of conditions including increased blood pressure, hyperglycemia, dyslipidemia, obesity which occur together under the common root of insulin resistance. Inadequate exercise, food, stress, and genetic susceptibility all contribute to insulin resistance, and it leads to the increased risk of diabetes and cardiovascular, cerebrovascular diseases. Insulin resistance and metabolic syndrome are inseparable, and the increase in insulin resistance results in cardiovascular, cerebrovascular events as well as the incidence of diabetes and hypertension. The cancer risk also has been shown to increase with the insulin resistance in Korea.

The prevalence of metabolic syndrome is quite high in the Western countries, and about 50% of peopled aged over 60 years have metabolic syndrome The prevalence has been a rapid increase in Korea as well, and the reasons for such a rapid rise seem to be due to the over nutrition, westernized lifestyles, and other socioeconomic transitions.

We are interested in treating metabolic syndrome because it is treatable. The treatment of metabolic syndrome can be divided into treating insulin resistance itself and treating each components of metabolic syndrome. To reduce insulin resistance, lifestyle modification is crucial with some additional help from pharmacotherapy. Also, many drugs are available for treating each component of metabolic syndrome. Several large scaled, prospective studies have demonstrated the effect of diet and exercise as well as some drugs reducing the risk of developing diabetes. However, many patients find it difficult to keep up with the behavioral modification, and new technologies may be helpful.

Internet diabetic patient management using a short messaging service was effective in lowering body weight, HbA1c, fasting and postprandial glucose, and similar services using internet phone and smart phone provided similar effects. IT-based U-health service seems an effective way to guide the behavioral modification.

SE-5-2

Graves’ Ophthalmopathy: Management from Point of View of Endocrinologist and Ophthalmologist

TIen-CHun CHang

Department of Internal Medicine, College of Medicine and National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan

Hyperthyroidism, Graves’ ophthalmopathy and pretibial myxedema are three major manifestations of Graves’ disease. TSH receptor antibody stimulates TSH receptors on the follicular cells of the thyroid to over-produce thyroid hormones, resulting hyperthyroidism. However, the etiology of Graves’ ophthalmopathy and pretibial myxedema is not so clear. It is quite clear that Graves’ ophthalmopathy is an autoimmune disease, and may be related to the action of T cells with TSH receptors on retrobulbar fibroblasts and adipocytes, and T cells produce cytokines to stimulate fibroblasts to secrete glycosaminoglycan which absorb water to make swelling of extraocular muscles and retrobulbar tissues. Orbital computed tomography is an important method to examine the morphologic change of Graves’ ophthalmopathy. In addition, the activity of Graves’ ophthalmopathy should be evaluated before medical treatment. Clinical Activity Score is an easy method to evaluate the clinical activity. The application of digital infrared thermal imaging in determining inflammatory state and follow-up effect of methylprednisolone pulse therapy through measurement of local heat in patients with Graves’ ophthalmopathy is also useful. The patient should be kept in euthyroid state at any stage. If it is in active stage, high dose of corticosteroid could be used. However, if the patients have B viral hepatitis, they should be treated with anti-viral agents first to avoid flare-up, although it is not necessary if the patients have C viral hepatitis. If it is inactive, but still has symptoms and/ or signs, surgery may be necessary. Retrobulbar fat removal, if possible, is a better way to relieve the orbital compression than orbital bone removal because postoperative diplopia less occurs. After decompression, muscle surgery and eyelid surgery could be considered if it is necessary. In addition, the management of Graves’ ophthalmopathy should be managed by team work to get the best result.

SE-5-3

Obesity and Thyroid Cancer

won bae KIM

University of Ulsan College of Medicine, Department of Internal Medicine, Asan Medical Center, Seoul, Korea

Obesity is associated consistently with the development and progression of various cancers such as breast cancer, endometrial cancer, colon cancer, esophageal adenocarcinoma, prostate cancer, liver cell carcinoma, leukemia, non-Hodgkin lymphoma, and melanom. Moreover, several recent epidemiological studies observed a positive association between obesity and the prevalence of thyroid cancers.

To see if obesity is associated with thyroid cancer we obtained data from 15,068 subjects that underwent a routine health checkup from 2007 to 2008 at the Health Screening and Promotion Center of Asan Medical Center. Thyroid ultrasonography was included in the checkup, and suspicious nodules were examined by ultrasonography-guided aspiration. Those with a prior history of thyroid disease or family history of thyroid cancer were excluded from this study. Of the 15,068 subjects screened by thyroid ultrasonography, 267 patients were diagnosed with thyroid cancer. The prevalence of thyroid cancer in women associated with a high body mass index (BMI, per 5kg/m2 increase) (odds ratios [OR]= 1.63, 95% CI 1.24–2.10, p<0.001), after adjustment of age, smoking status, and thyroid-stimulation hormone (TSH) levels. There was no positive correlation between the prevalence of thyroid cancer in men and a high BMI (OR=1.16, 95% CI 0.85–1.57, p=0.336). There was no association between age, fasting serum insulin, or basal TSH levels and thyroid cancer in both genders. Our study clearly showed that obesity was associated with an increase in prevalence of thyroid cancer, but serum TSH and insulin levels, known as risk factors for cancer, were not related to thyroid cancer.

We retrospectively reviewed records of 1,189 patients who underwent a total thyroidectomy for PTCs of 1 cm or larger in size. All clinical outcomes were evaluated and compared based on BMI quartiles. There were no significant associations between BMI quartiles and primary tumor size, extrathyroidal invasion, cervical lymph node metastasis, or distant metastasis. However, an increased BMI was associated with an increase in mean age (P for trend < 0.001), multifocality (P for trend = 0.02), and advanced tumor-node-metastasis (TNM) stage (stage III or IV; P for trend 0.001). However, the increases in multifocality and advanced TNM stage were no longer significant when further assessed using multivariate analyses adjusted for age and gender (P = 0.07 and P = 0.77, respectively). Furthermore, were no differences in recurrence-free survival rates according to BMI quartile (P = 0.26).

So, BMI was not associated with the aggressive clinicopathological features or recurrence-free survival rates of patients with PTC.

These findings suggest that obesity may be involved in earlier stage of carcinogenesis rather than affecting progression of thyroid cancer. Additional studies are required to understand the mechanism(s) behind the association of obesity with thyroid cancer risk.

SE-5-4

Metabolic Syndrome in Taiwan

dee PeI

Division of Endocrinology and Metabolism, Cardinal Tien Hospital

Companied with the increase prevalence of obesity, cardiovascular disease, stroke and diabetes have become the 3rd, 4th and 5th causes of death in Taiwan. Thus, early detection and prevention of these diseases become more important in recent two decades. Metabolic syndrome (MetS), first proposed by World Health Organization, serves the purpose of identifying subjects at risk. Ever since its publication, massive amount of studies were done. Based on the information derived from these researches, not only the prevalence of MetS is well known in different ethnic groups, but also its multirole is also elucidated.

In Taiwan, the same trend of increased incidence of MetS is also noted. Although there are many good-quality researches done to investigate different aspects of MetS. However, there is limited number of nation-wild survey. Among them, the one published by Huang et al. could provide a good glance at the picture of MetS in Taiwan. They found out that, in 5936 participants (2815 men, 3121 women; age between 20-79.9 years), the age-standardized prevalence was 15.7% by using the modified ATP III criteria. The percentage of each abnormal MetS components were 30.2% for waist circumference, 27.6% for TG, 23.8% HDL-C, 29.9% for BP and 10.6% for glucose. The prevalence of MetS increases gradually with age with a peak found in the 70s (36.5%).

Overweight had a profound impact on the occurrence of MetS. In subjects with BMI > 27 kg/m2 , around 50% had MetS compared to 6.5% with a normal BMI. In another longitudinal study done in in Kinmen, higher triglyceride and waist circumference were the best independent predictors for future MetS and diabetes. In the same time, the China Health and Nutrition Survey done in 2009 showed a higher prevalence of MetS (21.3%). Similar to our findings, women, subjects with higher BMI, older and living in the urban had a higher prevalence than their comparators. Since Taiwanese and Chinese are the same race, their data are could also be referred.

Since MetS has five different components. Each and every component has its unique effect on the cardiovascular diseases and diabetes. In the same time, it should also be noted that many nontraditional risk factors are also related to MetS. Being a complex and important syndrome, the MetS should further be emphasized.