Präsentation zum Thema: "XXL – Gibt es ein Adipositas Paradox? Therapeutische Bedeutung ?"— Präsentation transkript:
1XXL – Gibt es ein Adipositas Paradox? Therapeutische Bedeutung ? C. A. SchneiderKlinik III für Innere MedizinUniversität zu Köln
2Was lehrt Bacchus uns? Bacchus Gott des Weins (150 Kb); Oil on canvas, transferred from panel, 191 x cm (75 x 63 1/2 in); Hermitage, St. Petersburg Rubens, Peter PaulThe Flemish baroque painter Peter Paul Rubens, b. June 28, 1577, d. May 30, 1640 was the most renowned northern European artist of his day, and is now widely recognized as one of the foremost painters in Western art history.Created in the last years of Rubens' life, this painting amazes the viewer with its virtuosity of style and unusual interpretation of the image of the god of wine and merriment. Bacchus is depicted as a grossly obese man, surrounded by a satyr, a maenad and putti. The rich palette, in which all the colours blend into one golden stream, and the natural, sketchy technique, enabled the artist to create a genuine sense of debauchery, or bacchanalia. This is a paean to human flesh. According to Rubens' nephew, Philip, this was not a commissioned work, and the artist kept it in his studio till the end of his life p
3Leitlinie der Deutschen Adipositas-Gesellschaft aktuelle Version 2007
4Overweight, Obesity, and Mortality in a Large Prospective Cohort of Persons 50 to 71 Years Old Gesamtsterblichkeit89 kg /1,60 m51 kg/1,60 mBackgroundObesity, defined by a body-mass index (BMI) (the weight in kilograms divided by thesquare of the height in meters) of 30.0 or more, is associated with an increased riskof death, but the relation between overweight (a BMI of 25.0 to 29.9) and the risk ofdeath has been questioned.MethodsWe prospectively examined BMI in relation to the risk of death from any cause in527,265 U.S. men and women in the National Institutes of Health–AARP cohort whowere 50 to 71 years old at enrollment in 1995–1996. BMI was calculated from selfreportedweight and height. Relative risks and 95 percent confidence intervals wereadjusted for age, race or ethnic group, level of education, smoking status, physicalactivity, and alcohol intake. We also conducted alternative analyses to address potentialbiases related to preexisting chronic disease and smoking status.ResultsDuring a maximum follow-up of 10 years through 2005, 61,317 participants (42,173men and 19,144 women) died. Initial analyses showed an increased risk of death forthe highest and lowest categories of BMI among both men and women, in all racialor ethnic groups, and at all ages. When the analysis was restricted to healthy peoplewho had never smoked, the risk of death was associated with both overweight andobesity among men and women. In analyses of BMI during midlife (age of 50 years)among those who had never smoked, the associations became stronger, with the riskof death increasing by 20 to 40 percent among overweight persons and by two to atleast three times among obese persons; the risk of death among underweight personswas attenuated.ConclusionsExcess body weight during midlife, including overweight, is associated with an increasedrisk of death.NormalgewichtNormalgewichtFollow up 10 JahreNIH-AARP KohorteKenneth F. Adams et al. N Engl J Med 2006;355:
5Body-mass index and cause-specific mortality in adults: collaborative analyses of 57 prospective studiesSummaryBackground The main associations of body-mass index (BMI) with overall and cause-specifi c mortality can best beassessed by long-term prospective follow-up of large numbers of people. The Prospective Studies Collaboration aimedto investigate these associations by sharing data from many studies.Methods Collaborative analyses were undertaken of baseline BMI versus mortality in 57 prospective studies withparticipants, mostly in western Europe and North America (61% [n= ] male, mean recruitment age46 [SD 11] years, median recruitment year 1979 [IQR 1975–85], mean BMI 25 [SD 4] kg/m²). The analyses wereadjusted for age, sex, smoking status, and study. To limit reverse causality, the fi rst 5 years of follow-up were excluded,leaving deaths of known cause during a mean of 8 (SD 6) further years of follow-up (mean age at death67 [SD 10] years): vascular; 2070 diabetic, renal or hepatic; neoplastic; 3770 respiratory; 7704 other.Findings In both sexes, mortality was lowest at about 22·5–25 kg/m². Above this range, positive associations wererecorded for several specifi c causes and inverse associations for none, the absolute excess risks for higher BMI andsmoking were roughly additive, and each 5 kg/m² higher BMI was on average associated with about 30% higheroverall mortality (hazard ratio per 5 kg/m² [HR] 1·29 [95% CI 1·27–1·32]): 40% for vascular mortality (HR1·41 [1·37–1·45]); 60–120% for diabetic, renal, and hepatic mortality (HRs 2·16 [1·89–2·46], 1·59 [1·27–1·99], and1·82 [1·59–2·09], respectively); 10% for neoplastic mortality (HR 1·10 [1·06–1·15]); and 20% for respiratory and for allother mortality (HRs 1·20 [1·07–1·34] and 1·20 [1·16–1·25], respectively). Below the range 22·5–25 kg/m², BMI wasassociated inversely with overall mortality, mainly because of strong inverse associations with respiratory disease andlung cancer. These inverse associations were much stronger for smokers than for non-smokers, despite cigaretteconsumption per smoker varying little with BMI.Interpretation Although other anthropometric measures (eg, waist circumference, waist-to-hip ratio) could well addextra information to BMI, and BMI to them, BMI is in itself a strong predictor of overall mortality both above andbelow the apparent optimum of about 22·5–25 kg/m². The progressive excess mortality above this range is duemainly to vascular disease and is probably largely causal. At 30–35 kg/m², median survival is reduced by 2–4 years; at40–45 kg/m², it is reduced by 8–10 years (which is comparable with the eff ects of smoking). The defi nite excessmortality below 22·5 kg/m² is due mainly to smoking-related diseases, and is not fully explained.-0,5 Jahre-3 Jahre-9 Jahre LebenserwartungFU 8 JahreProspective Studies Collaboration 2009; Lancet 2009; 373: 1083–96
7Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studiesSummaryBackground Studies of the association between obesity, and total mortality and cardiovascular events in patients withcoronary artery disease (CAD) have shown contradictory results. We undertook a systematic review to determine theextent and nature of this association.Methods We selected cohort studies that provided risk estimates for total mortality, with or without cardiovascularevents, on the basis of bodyweight or obesity measures in patients with CAD, and with at least 6 months’ follow-up.CAD was defi ned as history of percutaneous coronary intervention, coronary artery bypass graft, or myocardialinfarction. We obtained risk estimates for fi ve predetermined bodyweight groups: low, normal weight (reference),overweight, obese, and severely obese.Findings We found 40 studies with 250,152 patients that had a mean follow-up of 3·8 years. Patients with a low bodymassindex (BMI) (ie, <20) had an increased relative risk (RR) for total mortality (RR=1·37 [95% CI 1·32–1·43), andcardiovascular mortality (1·45 [1·16–1·81]), overweight (BMI 25–29.9) had the lowest risk for total mortality (0·87[0·81–0·94]) and cardiovascular mortality (0·88 [0·75–1·02]) compared with those for people with a normal BMI.Obese patients (BMI 30–35) had no increased risk for total mortality (0·93 [0·85–1·03]) or cardiovascular mortality(0·97 [0·82–1·15]). Patients with severe obesity (≥35) did not have increased total mortality (1·10 [0·87–1·41]) but theyhad the highest risk for cardiovascular mortality (1·88 [1·05–3·34]).Interpretation The better outcomes for cardiovascular and total mortality seen in the overweight and mildly obesegroups could not be explained by adjustment for confounding factors. These fi ndings could be explained by the lackof discriminatory power of BMI to diff erentiate between body fat and lean mass.40 StudienN=FU = 3,8 JahreBek. KHKGomero-Corall A. et al. Lancet 2006; 368: 666–78
8The relationship between body mass index, treatment, and mortality in patients with established coronary artery disease: a report from APPROACHAlberta Provincial Project for Outcome Assessment in Coronary Heart DiseaseAims Our objective was to examine the association between body mass index (BMI) and survival according to the type oftreatment in individuals with established coronary artery disease (CAD).Methodsand resultsPatients with CADwere identified in the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease(APPROACH) registry between January 2001 and March Analyses were conducted separately by treatmentstrategy [medical management only, percutaneous coronary intervention (PCI), or coronary artery bypass grafting(CABG)]. Patients were grouped according to six BMI categories. Multivariable-adjusted hazard ratios (HRs) for mortalitywere calculated using the Cox regression with the referent group for all analyses being normal BMI (18.5–24.9 kg/m2).The cohort included patients with a median follow-up time of 46 months. In the medically managed onlygroup, BMIs of 25.0–29.9 and 30.0–34.9 kg/m2 were associated with significantly lower mortality compared withnormal BMI patients (adjusted HR 0.72; 95% CI 0.63–0.83 and adjusted HR 0.82; 95% CI –0.98, respectively). Inthe CABG group, BMI of 30.0–34.9 kg/m2 had the lowest risk of mortality (adjusted HR 0.75; 95% CI 0.61–0.94),whereas in the PCI group, BMI of 35.0–39.9 kg/m2 had the lowest risk of mortality (adjusted HR 0.65; 95% CI0.47–0.90). Patients who were overweight or have mild or moderate obesity were also more likely to undergo revascularizationprocedures compared with those with normal BMI, despite having lower risk coronary anatomy.Conclusion A paradoxical association between BMI and survival exists in patients with established CAD irrespective of treatmentstrategy. Patients with obesity may be presenting earlier and receiving more aggressive treatment compared withthose with normal BMI.N= 31021FU 84 MonateOreopoulos A et al. European Heart Journal (2009) 30, 2584–2592
10OBESITY AND THE RISK OF HEART FAILURE BSTRACTBackgroundExtreme obesity is recognized to be arisk factor for heart failure. It is unclear whether overweightand lesser degrees of obesity also pose a risk.MethodsWe investigated the relation between thebody-mass index (the weight in kilograms divided bythe square of the height in meters) and the incidenceof heart failure among 5881 participants in the FraminghamHeart Study (mean age, 55 years; 54 percentwomen). With the use of Cox proportional-hazardsmodels, the body-mass index was evaluated bothas a continuous variable and as a categorical variable(normal, 18.5 to 24.9; overweight, 25.0 to 29.9; andobese, 30.0 or more).ResultsDuring follow-up (mean, 14 years), heartfailure developed in 496 subjects (258 women and238 men). After adjustment for established risk factors,there was an increase in the risk of heart failureof 5 percent for men and 7 percent for women for eachincrement of 1 in body-mass index. As compared withsubjects with a normal body-mass index, obese subjectshad a doubling of the risk of heart failure. Forwomen, the hazard ratio was 2.12 (95 percent confidenceinterval, 1.51 to 2.97); for men, the hazard ratiowas 1.90 (95 percent confidence interval, 1.30 to 2.79).A graded increase in the risk of heart failure was observedacross categories of body-mass index. The hazardratios per increase in category were 1.46 in women(95 percent confidence interval, 1.23 to 1.72) and 1.37in men (95 percent confidence interval, 1.13 to 1.67).ConclusionsIn our large, community-based sample,increased body-mass index was associated withan increased risk of heart failure. Given the high prevalenceof obesity in the United States, strategies topromote optimal body weight may reduce the populationburden of heart failure. (N Engl J Med 2002;347: )Framingham Heart StudySATISH KENCHAIAHN et al. Engl J Med 2002; 347:305-13
11Body Mass Index and Prognosis in Patients With Chronic Heart Failure Insights From the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) ProgramBackground—In individuals without known cardiovascular disease, elevated body mass index (BMI) (weight/height2) isassociated with an increased risk of death. However, in patients with certain specific chronic diseases, including heartfailure, low BMI has been associated with increased mortality.Methods and Results—We examined the influence of BMI on prognosis using Cox proportional hazards models in 7599patients (mean age, 65 years; 35% women) with symptomatic heart failure (New York Heart Association class II to IV)and a broad spectrum of left ventricular ejection fractions (mean, 39%) in the Candesartan in Heart failure: Assessmentof Reduction in Mortality and morbidity (CHARM) program. During a median follow-up of 37.7 months, 1831 patientsdied. After adjustment for potential confounders, compared with patients with BMI between 30 and 34.9, patients inlower BMI categories had a graded increase in the risk of death. The hazard ratios (95% confidence intervals) were 1.22(1.06 to 1.41), 1.46 (1.24 to 1.71), and 1.69 (1.43 to 2.01) among those with BMI of 25 to 29.9, 22.5 to 24.9, and 22.5,respectively. The increase in risk of death among patients with BMI 35 was not statistically significant (hazard ratio,1.17; 95% confidence interval, 0.95 to 1.43). The association between BMI and mortality was not altered by age,smoking status, or left ventricular ejection fraction (P for interaction 0.20). However, lower BMI was associated witha greater risk of all-cause death in patients without edema but not in patients with edema (P for interaction 0.001).Lower BMI was associated with a greater risk of cardiovascular death and noncardiovascular death. Baseline BMI didnot influence the risk of hospitalization for worsening heart failure or due to all causes.Conclusions—In patients with symptomatic heart failure and either reduced or preserved left ventricular systolic function,underweight or low BMI was associated with increased mortality, primarily in patients without evidence of fluidoverload (edema). (Circulation. 2007;116:&NA;-.Satish Kenchaiah et al. Circulation. 2007;116:
13Weight-change as a prognostic marker in patients following acute myocardial infarction or with stable coronary artery diseaseGesamt-Sterblichkeit>3%3%Aims To examine the prognostic importance of weight-change in patients with coronary artery disease(CAD), especially following acute myocardial infarction (AMI).Methods and results In 4360 AMI patients (OPTIMAAL trial) without baseline oedema, we assessed3-month weight-change, baseline body mass index (BMI), demographics, patient history, medication,physical examination, and biochemical analyses. Weight-change was defined as change kg/baselineBMI-unit. Patients were accordingly categorized into three groups; weight-loss, weight-stability,and weight-gain. Our findings were validated in 4012 AMI patients (CONSENSUS II trial) and 4178stable CAD patients (79% with prior AMI, 4S trial). Median follow-up was 2.7 years, 3 months, and 4.4years, respectively. In OPTIMAAL, 3-month weight-loss (vs. weight-stability) independently predictedincreased all-cause death [n ¼ 471; hazard ratio (HR) 1.26; 95% CI 1.01–1.56; P ¼ 0.039] and cardiacdeath (n ¼ 299, HR 1.33, 95% CI 1.02–1.73, P ¼ 0.034). Weight-gain yielded risk similar toweight-stability (HR 1.07, P ¼ and 0.97, P ¼ 0.866, respectively). In CONSENSUS II, 3-monthweight-loss independently predicted increased mortality (HR 3.87, P ¼ 0.008). Weight-gain yieldedrisk similar to weight-stability (HR 1.11, P ¼ 0.860). In 4S, 1-year weight-loss independently predictedincreased mortality (HR 1.44, P ¼ 0.004). Weight-gain conferred risk similar to weight-stability (HR1.05, P ¼ 0.735).Conclusion In patients following AMI or with stable CAD, weight-loss but not weight-gain was independentlyassociated with increased mortality risk.N= 4360OPTIMAAL trialKennedey L et al. Eur Heart J 2006; 27:
14Weight-change as a prognostic marker in patients following acute myocardial infarction or with stable coronary artery diseaseAims To examine the prognostic importance of weight-change in patients with coronary artery disease(CAD), especially following acute myocardial infarction (AMI).Methods and results In 4360 AMI patients (OPTIMAAL trial) without baseline oedema, we assessed3-month weight-change, baseline body mass index (BMI), demographics, patient history, medication,physical examination, and biochemical analyses. Weight-change was defined as change kg/baselineBMI-unit. Patients were accordingly categorized into three groups; weight-loss, weight-stability,and weight-gain. Our findings were validated in 4012 AMI patients (CONSENSUS II trial) and 4178stable CAD patients (79% with prior AMI, 4S trial). Median follow-up was 2.7 years, 3 months, and 4.4years, respectively. In OPTIMAAL, 3-month weight-loss (vs. weight-stability) independently predictedincreased all-cause death [n ¼ 471; hazard ratio (HR) 1.26; 95% CI 1.01–1.56; P ¼ 0.039] and cardiacdeath (n ¼ 299, HR 1.33, 95% CI 1.02–1.73, P ¼ 0.034). Weight-gain yielded risk similar toweight-stability (HR 1.07, P ¼ and 0.97, P ¼ 0.866, respectively). In CONSENSUS II, 3-monthweight-loss independently predicted increased mortality (HR 3.87, P ¼ 0.008). Weight-gain yieldedrisk similar to weight-stability (HR 1.11, P ¼ 0.860). In 4S, 1-year weight-loss independently predictedincreased mortality (HR 1.44, P ¼ 0.004). Weight-gain conferred risk similar to weight-stability (HR1.05, P ¼ 0.735).Conclusion In patients following AMI or with stable CAD, weight-loss but not weight-gain was independentlyassociated with increased mortality risk.Kennedey L et al. Eur Heart J 2006; 27:
15Weight loss and mortality risk in patients with chronic heart failure in the candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) programmeS. Pocock et al. European Heart Journal (2008) 29, 2641–2650
18Effect of Weight Reduction on Outcome in Diabetic Patients TI - Intentional weight loss and mortality among overweight individuals with diabetes [In Process Citation] AU - Williamson DF; Thompson TJ; Thun M; Flanders D; Pamuk E; Byers T SO - Diabetes Care 2000 Oct;23(10): OBJECTIVE: To estimate the effect of intentional weight loss on mortality in overweight individuals with diabetes. RESEARCH DESIGN AND METHODS: We performed a prospective analysis with a 12-year mortality follow-up ( ) of 4,970 overweight individuals with diabetes, years of age, who were enrolled in the American Cancer Society's Cancer Prevention Study I. Rate ratios (RRs) were calculated, comparing overall death rates, and death from cardiovascular disease (CVD) or diabetes in individuals with and without reported intentional weight loss. RESULTS: Intentional weight loss was reported by 34% of the cohort. After adjustment for initial BMI, sociodemographic factors, health status, and physical activity, intentional weight loss was associated with a 25% reduction in total mortality (RR = 0.75; 95% CI ), and a 28% reduction in CVD and diabetes mortality (RR = 0.72; ). Intentional weight loss of lb was associated with the largest reductions in mortality (approximately 33%). Weight loss >70 lb was associated with small increases in mortality CONCLUSIONS: Intentional weight loss was associated with substantial reductions in mortality in this observational study of overweight individuals with diabetes.12 JahreN= 497040-64 JahreWilliamson DF et al. Intentional weight loss and mortality among overweight individuals with diabetes Diabetes Care 2000 Oct;23(10):
19Adipositas Paradox – epidemiologisches Artefakt ? Analyse des Bauchumfangs besser?
20Präford Studie – Korrelation BMI Bauchumfang Männer kg/m²r=0.87N=3867Mittleres Alter 45
21Obesity and the risk of myocardial infarction in participants from 52 countries: a case-control studyVeränderung der Odds ratio für Herzinfarkt pro Zunahme des Parameters um 1 SDWaist = BauchumfangHip = HüftumfangW-H Ratio:= Verhältnis Bauch HüfteYusuf S et al. The Lancet 2005; 366:
22Measures of Obesity and Cardiovascular Risk Among Men and Women Tödliche und nicht-tödliche kardiovaskuläre EreignisseMänner(body mass index)(waist to height ratio)(waist circumference)(waist to hip ratio)Objectives This study examined associations between anthropometric measures (body mass index, waist circumference,waist-to-hip ratio, waist-to-height ratio [WHtR]) and risk of incident cardiovascular disease (CVD) (including nonfatalmyocardial infarction, nonfatal ischemic stroke, and cardiovascular death).Background Controversy exists regarding the optimal approach to measure adiposity, and the utility of body mass index hasbeen questioned.Methods Participants included 16,332 men in the Physicians’ Health Study (mean age 61 years in 1991) and 32,700women in the Women’s Health Study (mean age 61 years in 1999). We used Cox proportional hazards modelsto determine relative risks and 95% confidence intervals (CIs) for developing CVD according to self-reported anthropometricindexes.Results A total of 1,505 CVD cases occurred in men and 414 occurred in women (median follow-up 14.2 and 5.5 years,respectively). Although WHtR demonstrated statistically the strongest associations with CVD and best model fit,CVD risk increased linearly and significantly with higher levels of all indexes. Adjusting for confounders, the relativerisk for CVD was 0.58 (95% CI: 0.32 to 1.05) for men with the lowest WHtR (0.45) and 2.36 (95% CI: 1.61to 3.47) for the highest WHtR (0.69; vs. WHtR 0.49 to 0.53). Among women, the relative risk was 0.65 (95%CI: 0.33 to 1.31) for those with the lowest WHtR (0.42) and 2.33 (95% CI: 1.66 to 3.28) for the highest WHtR(0.68; vs. WHtR 0.47 to 0.52).Conclusions The WHtR demonstrated statistically the best model fit and strongest associations with CVD. However, comparedwith body mass index, differences in cardiovascular risk assessment using other indexes were small andlikely not clinically consequential. Our findings emphasize that higher levels of adiposity, however measured,confer increased risk of CVD. (J Am Coll Cardiol 2008;52:605–15)Physiscians‘ Health StudyWomens Health StudyN= 16332, N=32700Mittleres Alter JahreFU 14, 2 Jahrekg/m²< 2022.5to24.9> 35Gelber R et al J Am Coll Cardiol 2008;52:605–15
23Adipositas Paradox – epidemiologisches Artefakt ? Bauchumfang besser als BMI?Dicke früher diagnostiziert?BNP niedrig –Luftnot?Dicke besser therapiert?Dicke besser gegen Nebenwirkungen von Medikamenten geschützt?Niedrigeres Blutungsrisiko bei HerzkatheternDicke mehr Muskelmasse?TNFalpha -Schutz durch Fettgewebe (Rezeptoren)?Veränderte Zytokine-BalanceLeptin, Adiponektin, Anti-Inflammation?
24Adipositas Paradox – Zusammenfassung Es spricht mehr dafür als dagegen!Kein Anhalt für Gewichtsreduktions-Empfehlung bei Dicken mit KHK und HerzinsuffizienzDiabetiker?Was empfehlen wir den Normal-gewichtigen/Untergewichtigen mit KHK oder Herzinsuffizienz?Katabolismus Bremse?Ernährungs-Empfehlungen?