Metabolic Obesity PreDM EMA IDF97

Premature detection and integral handling of the Metabolic Obesity (MO) and the Pre-diabetes (Insulin resistance: Hyperinsulinemia -Impaired Tolerance to the Glucose) in an Unit of Metabolism Carri贸n J, Aliaga E, Navarrete M, Palomino J. UNIT METABOLISM AND SERVICE OF ENDOCRINOLOGY HOSPITAL NATIONAL ALMENARA. ESSALUD. LIMAPERU.

Premature detection and integral handling of the Metabolic Obesity (MO) and the Pre-diabetes (Insulin Resistance: Hyperinsulinemiaimpaired glucose tolerance) in a Metabolism Unit Carrión J, Aliaga E, Navarrete M, Palomino J. UNIT METABOLISM AND SERVICE OF ENDOCRINOLOGY HOSPITAL NATIONAL ALMENARA. ESSALUD. LIMA-PERU. OBJECTIVE: The Unit of Metabolism develops a general strategy, to identify a High Risk Group (HRG) for Metabolic Atherogenic Disease (MAD) with its causal Metabolic Obesity (MO) and its syndromes: Diabetes Mellitus 2 (DM), Dyslipidemia (DL), Arterial Hypertension (AHT); the Metabolic Obesity (MO), specially, pathophysiologically to detect prematurely and to manage the MO and the PreDiabetes integrally (Insulin resistance: Hyperinsulinemia-Impaired tolerance Glucose-ITG to glucose intolerance), to conform the cohort, in which tests diagnostics and intervention measures plows applied with to smaller cost.

METHODOLOGY: From 315 patients with diagnosis of Metabolic Obesity(MO) and Insulin resistance(IR): 105 of them are presented preliminarily taken at random with characteristic: workers supposedly healthy, patients and their relative of the unit of Metabolism.

Gender: F = 84(80%) M = 21(20%); Age=57±12(10-82) and 55±14(18-77) respectively.

Methods of clinical evaluation Waist Circumference(WC) >80 cm in women and WC>90 male cm MO diagnoses; and, laboratorial (enzimoinmunotest-IMX): glycaemia’s >140 mg/dl in Overload Glucose Oral (OGO) IGT; insulinemia >30 uUI/ml in Sensibility Insulin Oral to Glucose - 120´ (SIGO-120´) it diagnoses of HIIR, fail lipid profile:Dyslipidemia. The interviews determines Risk Factors (RF) like: Fetal Macrosomia (FM), Personal Antecedent (PA) and Family (FA); it is detected the other components of the MAD. Measured intervention: Dietary (1000,1200,1500 Kcal), Pharmacological: Metformin (850,1700 mg/day) RESULTS: Women 17(37.78%) with FM, MO 45 with WC x97,4 DS 8,7 (82 at 117) and 7 males with WC x102.2 DS 9,6(91 at 121);y, Pre-diabetes: IR Hyperinsulinemia (HI) in 32(30.77)/104, Insulin Resistance: Impaired tolerance Glucosa (IR-ITG) in 20(19.23%) /104, with OGIS-120´ insulinemia x108 DS 109.2(15.6-559) in 40 women; and x121.6 SD 93.7(26.5-277.5) in 6 males.

MO+PreDM2+Dyslipidemia: mixed DL in 27(51.9%), Hypercholesterolemia in 12(23.1%) and Hypertriglyceridemia in 5(9.6%) fellows. Non pharmacological intervention measures (diet) WC reduces in 4 of 10; Pharmacological: Metformin WC reduces in 12 of 14; mixed: Diet+Metformin WC reduces in 12 of 28, in the lapse of 12 months of pursuit; however, p is not significant statistically and the OR = 1.71 (0.80 < OR < 3.76).

CONCLUSION: with the WC it is determined: 1º) clinically the cohort in RA with MAD (OM+PreDiabetes) in which intervention measures are applied yes and not pharmacological, 2º) the impact of the intervention in the reduction of the MO and the consequent decrease of the conversion rate of PreDiabetes to Diabetes.

Presently case is verified the action of the Metformin in reducing the MO and the recovery from the sensibility to the action of the Insulin; and the null significance of our measure of intervention dietetic.

Summary In our Unit of Metabolism develops a general strategy, to identify a High Risk Group (HRG) for Metabolic Atherogenic Disease (MAD) with its causal Metabolic Obesity (MO) and its syndromes: Diabetes Mellitus 2 (DM), Dyslipidemia (DL), Arterial Hypertension (AHT); and in the integral handling of the MAD, it is defined to cohort of 315 patients with Metabolic Obesity(MO) and in High Risk for MAD :Diabetes, measuring Waist Circumference (WC), precociously detecting the Pre-Diabetes (Insulin resistance: Hyperinsulinaemia - Impaired Tolerance Glucose).

They are subjected to the Sensibility of Insulin to the Oral Glucose 120´ (OGIS-120´) it is diagnosed with Insulinaemia >30 uUI/ml. Insulin Resistance (RI). We proceeds to the application of intervention measures in the style of alimentary life (inhabit alimentary) pharmacological and/to with Metformin(MTF). 105 patients preliminarily presented 1 in those that it is possible to diminish the MO (WC) based on the pharmacological intervention, but not with the intervention dietetic that indicates us to reformulate strategies.

En Castellano :

Resumen En el manejo integral de la Enfermedad Metabólica Aterogenica (EMA) en nuestra Unidad de Metabolismo se define una cohorte de 315 pacientes con Obesidad Metabólica(OM) y en Riesgo Muy Alto para EMA y sus síndromes, la que es causada por la Obesidad Metabólica : Diabetes Mellitus (Dislipidemia, Hipertension Arterial); midiendo Circunferencia de Cintura(CIN) detectando precozmente la PreDiabetes(Resistencia a la Insulina: Hiperinsulismo--Tolerancia Disminuida a la Glucosa). Se les somete a la Sensibilidad de Insulina a la Glucosa Oral 120´ (SIGO-120´); se diagnostica con Insulinemia 120´>30uUI/ml Resistencia a la Insulina (RI): Hiperinsulinismo (HI). Se procede a la aplicación de medidas de intervención en el estilo de vida(habito alimentario) y/o farmacológica con Metformina(MTF). Se presentan preliminarmente 105 pacientes en los que se logra disminuir la OM(CIN) en base a la intervención farmacológica, mas no con la intervención dietaría que nos indica reformular estrategias.

INTRODUCTION The Metabolic Atherogenic Diseases (MAD) in the beginning of their natural history presents as common denominator the binomial given by the Insulin Resistance (IR) and the Dysfunction Endothelial (DE), caused by Metabolic Obesity (MO) and its primary phenomena of their syndromes: Diabetes Mellitus (DM2), Dyslipidemia (DL) and Arterial Hypertension (AHT); that cause cardiovascular damage causing a problem for Public Health because of their discharges morbid mortality rates.

The Metabolic Obesity (MO) it is at the same time a factor of causality and exposition for MAD their genesis and their complications, for the great metabolic activity of the visceral fat when exposing to the liver to an excessive liberation of free fatty acids that which alters the insulin action.

In the Diabetes pathophysiologically three states happen in which those the I and II are denominated Pre-diabetes (Insulin resistance: Hyperinsulinaemia -Impaired tolerance Glucose): hyperinsulinaemia postprandial causing insulinotoxicidity; for the hyperglycemia postprandial glucotoxicidity, the lipotoxicidity post prandial with hypertriglyceridemia (with low HDL) which are the expression of their pathophysiology and consequently Endothelial Metabolic disease: Atherosclerosis.

OBJECTIVE: The Unit of Metabolism develops a strategy, in general, to identify Group in Risk (GR) for Metabolic Atherogenic Diseases(MAD) with its causal Metabolic Obesity(MO) and their syndromes: Diabetes Mellitus (DM2), Dyslipidemia (DL), and Hypertension Arterial (AHT); especially, pathophysiologically to detect precociously and to manage the MO and the Pre-diabetes integrally (Insulin resistance: Hyperinsulinaemia Impaired tolerance Glucose), to conform the cohort, in which tests diagnostics and intervention measures are applied with a smaller cost.

MATERIAL AND METHODS I design: study of nested type Cohort: 315 patients with diagnose of Metabolic Obesity (MO) and Insulin Resistance It shows: n = 105 taken at random Characteristic: supposedly healthy in their majority, patient and their relative of the unit of Metabolism.

Género : feminine (F) = 84(80%), masculine (M) = 21(20%) Instruments: Medical history that consigns filiations data, factors of risk (FR) as fetal macrosomia (FM) antecedents: personal and family.

Methods of clinical evaluation: measure of waist Circumference (WC) with ranges normal women WC < 80 cm; male WC < 90 cm; weight, hieght, and blood pressure. See Chart # 1.

It overloads to the Oral glucose (OGO) with glycaemia 30´ 60´ 90´ and 120 ´ >140 mg/dl diagnose of ITG. Sensibility Insulin Glucose Oral-120´ (OGIS–120´); with Insulinaemia 120´ >30 uUI/m diagnostics of plasmatic Hyperinsulinaemia-RI. Glycaemia and lipids for enzimoinmuno test, Insulinaemia for IMX. Waist Circumference (WC) >80 cm in women and WC>90 male cm MO diagnoses; Stratification of the Risk for Pre Diabetes according to WC: Very High risk Women WC > 86 cm. Males WC>100 cm.

High risk Women WC 80 at 86 Males WC 90 at 100 Group in Pre-diabetes the one that presents fetal macrosomia (FM), and personal antecedents (PA) y/o family (AF), MO with WC>86cm in women, WC>100 cm in males, glycaemia >140 mg/dl among the 30 ` and 120`(OGO); with postload of Glucose 2 hours (OGIS - 120´) Insulinaemia > 30 uU/ml or smaller 3 approaches (WC in High Risk, OGO < 0´, I/G > 0.3), hyperlypemia e/o HTA. Measured intervention: Dietaria (1000,1200,1500 Kcal), Pharmacological: Metformina (850,1700 mg/day) Calculation of the statistical significance with p < 0.005 and OR. Software EpiInfo version 6.04

Clinical characteristics of the group in study by gender Chart #1 Feminine n = 45 Variable n Aver. ±DS Age 45 54 13 Circunfer 45 97.4 8.7 Waist Height 45 1.56 0.07 Weight 22 82.47 18.36 PAS 9 131 17.6 PAD 9 77.2 9.1 Macros.F 45 17

Range 10 a 78 82 a 117

Masculine n = 7 n Aver. ±DS Range 7 57 21 18 a 77 7 102.2 9.6 91 a 121

1.4 at 1.72 50 at 128 100 a 160 60 a 90

7 1.6 5 83.12 1 1

0.1 8.5

1.5 a1.7 75 at 92.6

R E S U L T S (1) Insulinaemia and glycaemia in the Sensibility of the Insulin to the Oral Glucose and it Overloads Oral Glucose

SIGO and OGO Glicemia 0 ' Glicemia 30 ' Glicemia 60 ' Glicemia 90 ' Glicemia 120 ' Insulinemia120

Females N Aver.

44 86 36 135 37 133 36 133 44 125 40 108

Males ÂąDS Range n Aver.

16 58-122 6 86 26 94-199 5 142 40 65-231 6 141 35 72-221 6 144 36 50-194 7 128 109.2 15.6-559 6 121.6

ÂąDS 13 23 29 26 34 93.7

Pre-diabetes according to state I - II and gender Females category RI:HI (I) RI:TDG (II)

n=45 28 17

Males n=7 4 3

Total (%) 52(100) 32(61.5) 20(38.5)

Range 65 -102 112-173 104-185 106-176 86 -176 26.5-277.5

R E S U L T S (2) Variation of the Waist Circumference according to intervention measurement and gender Female

Diet D+MTF MTF

n=45 9 23 13

WCiWCf -3 -8 -11

Male n=7 1 5 1

WCi- Total WCf -28 -1 -4 -4 -12 -1 -12

p: NS(0.18377166)

OR = 1.71 (0.80<OR<3.76)

Percentage with Diet Diet plus MTF MTF

WC diminishes

4/10 (40.0%) 12/28 (42.9%) 12/14 (85.7%)

R E S U L T S (3) Pre-diabetes and Dyslipidemia Category HTGC+HCOL HCOL HTGC

Female n=37 22 11 4

Male Total (%) n=7 44(100) 5 27(61.4) 1 12(27.3) 1 5(11.4)

DISCUSSION Having the MAD in their primary genesis the Metabolic Obesity (MO) and Insulin resistance to becomes necessary its measurement through methods indexes them: technique of the euglycemic hyperinsulinemic clamp (gold standard) and the â&#x20AC;&#x153;minimal modelâ&#x20AC;? of Bergman; or the simplified biological methods: HOMA, CIGMA, Test of insulin suppression and the insulin test tolerance; and, anthropometric measurements. The first 2 groups you impracticable turning in our means; fortunately, it has been possible to correlate the Sensibility of the Insulin in the Overload Oral Glucose (OGIS) with them.

The anthropometrics measurements of the Metabolic Obesity (MO) or Visceral Obesity determines the tendency to the insulin resistance to the of patient in those that we need to measure their insulin resistance.

These are it bases two on the high correlation, which has been established, among the abdominal fat (visceral) and the insulin resistance. More recent data and imperfections in the use of the Index Waist Hip make prefer as minimum measurement the waist circumference the one which goes better with the abdominal fat and Insulin resistance.

CONCLUSION Metabolic Obesity (OM) with waist circumference it is determined: 1ยบ) The stratification of the Risk in degrees 2ยบ) Clinically the cohort in High Risk with MAD (MO+Pre Diabetes) in which intervention measures are applied yes and not pharmacological, 3ยบ) the impact of the intervention in the reduction of the MO and the consequent decrease of the conversion rate of Pre Diabetes to Diabetes.

The present work verifies the effect of the Metformin in reducing the Metabolic Obesity(MO) or Visceral Obesity and the recovery from the sensibility to the action of the Insulin; however, it is not achieved a measure of intervention in lifestyle with diet have an impact on reducing the OBA as regards literature, they call our attention to reformulate strategies.

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