| Author(s): | Fenn, Peta |
|---|---|
| Issue: | Volume 21(25), 28 February 2007, pp 37-44 |
| Publication Type: | [Learning Zone: Continuing Professional Development: Health Promotion] |
| Publisher: | © Copyright 2007 RCN Publishing Company Ltd. |
| Institution(s): | Peta Fenn is independent diabetes and lifestyle consultant nurse, and cardiovascular disease and diabetes mellitus programme lead and lecturer, Postgraduate Peninsula Health Institute, Peninsula Medical School, Plymouth. Email: enquiries@petafenn.com Date of acceptance: December 12 2006. These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk . For related articles visit our online archive and search using the keywords. |
Cardiometabolic risk factors increase the likelihood of an individual developing metabolic and cardiovascular disease. Individuals with abdominal obesity are at greatest cardiometabolic risk of developing type 2 diabetes. Nurses are increasingly considering how to run health screening clinics for patients at risk of developing type 2 diabetes and coronary heart disease as well as for those who have already developed these conditions. This article examines the importance of considering abdominal obesity as a therapeutic target and the role of nurses in its assessment and management. In particular, the article focuses on abdominal obesity as a risk factor that nurses can assess easily and that is amenable to intervention.
The aim of this article is to update nurses involved in the clinical care of patients with or at risk of type 2 diabetes and cardiovascular disease (CVD) on why waist circumference should be considered a vital sign and recorded in the medical charts of every patient (Després et al 2001). Readers are encouraged to analyse their current practice for assessing obesity - measuring body mass index (BMI) alone - and cardiovascular risk, and change this in the light of new evidence that directly links waist circumference with all-cause mortality (Bigaard et al 2005).
After reading this article you should be able to:
[black right pointing small triangle] Discuss the different types of fat that occur in the body, and understand why visceral fat is considered to be the primary cause of abdominal obesity.
[black right pointing small triangle] Outline the relationship between abdominal obesity, cardiometabolic risk and type 2 diabetes.
[black right pointing small triangle] Appreciate why identifying and measuring visceral obesity is a priority for nurses in primary and secondary care settings.
[black right pointing small triangle] Measure visceral fat and convey the importance of abdominal obesity to a patient.
[black right pointing small triangle] Describe the various therapeutic options available for managing visceral obesity.
Other therapeutic interventions for cardiovascular risk reduction in patients with type 2 diabetes such as lowering blood pressure, cholesterol and glucose levels and antithrombolytic measures are also key components of a holistic package of health care for this population but are not discussed in this article.
Obesity is one of today's most visible yet neglected healthcare issues. Overall, UK figures place the prevalence of obesity at 21% in men and 23.5% in women (Joint Health Surveys Unit 2003). The risk of developing type 2 diabetes is related to increasing obesity and in particular the central (truncal) distribution of fat (Chan et al 1994, Colditz et al 1995). The American Diabetes Association Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (1997) defines diabetes as: 'a group of metabolic diseases characterised by hyperglycaemia resulting from defects in insulin secretion, insulin action or both'. The task of monitoring, educating and managing patients with diabetes and, now, obesity in the UK will probably fall to primary care and to those specialist units in secondary care that deal with the co-morbidities of these diseases. In 2001, the National Audit Office (NAO) stated: 'The NHS provides management of obesity, ranging from general advice on diet and exercise to onward referral for specialist help' (NAO 2001).
There are two types of adipose tissue in the human body. Briefly summarise what they are and what you think their functions are. In addition, make a list of the different types of abdominal fat. Compare your answers with the information in Box 1 and the following text.
BOX 1 Functions of adipose tissue
White and brown fat In adult mammals, fat is a loose association of lipid-filled cells (adipocytes), which are held in a framework of collagen fibres. Adipocytes either contain a single large lipid droplet ('white fat cells'), or multiple smaller droplets of lipids ('brown fat cells'). White fat cells occur in white adipose tissue and brown fat cells occur predominantly in brown adipose tissue. The functions of white and brown adipose tissue are summarised in Box 1. Obesity results from excessive accumulation of triglycerides in adipocytes and a corresponding expansion of white fat mass (Trayhurn 2005).
Abdominal fat There are three types of abdominal fat: intraperitoneal (visceral), retroperitoneal and subcutaneous. Visceral fat surrounds the organs within the peritoneal cavity. Excess visceral fat is strongly associated with an increased risk of CVD, type 2 diabetes and other diseases linked with obesity (Klein 2004).
The generally accepted definition of an obese patient is one who has a BMI of >=30. BMI is frequently the measure of choice in general practice, and recent UK data show that obese patients visit GPs and primary healthcare teams more than non-obese patients (Frost et al 2005). It is also well established that, at an individual level, quality of life is impaired with obesity and there is a concomitant increased need for social support and disability allowance (Lean 2000), together with an exacerbated cost to the NHS (Walker 2003, House of Commons Health Committee 2004). In 2002 in England, the direct costs of obesity to the NHS were estimated as £45.8-49.0 million; and indirect costs were estimated as £2.35-2.6 billion (House of Commons Health Committee 2004). Similarly, in Scotland, of the £171 million annual cost to the NHS of treating obesity and its consequences, only 2% of the cost was due to treating obesity; the remaining 98% being associated with treating its co-morbidities (Walker 2003).
Before reading on, make a list of what you consider to be the main co-morbidities of obesity. Compare your list with that provided in Box 2.
BOX 2 Co-morbidities of obesity
Current evidence is that obesity as measured by BMI is too general a term (Bigaard et al 2005) and more focus should be placed on abdominal obesity and its consequences (Douketis and Sharma 2005, Hu et al 2005). This could be narrowed down further to examine the particular impact of visceral obesity on cardiometabolic risk (Klein 2004, Eckel et al 2005). Thus, data from studies in the 1990s showed that when body weight increased, as defined by an increase in BMI, so too did the risk of developing CVD (Abbott et al 1994, Jousilahti et al 1996, Rexrode et al 1997, Calle et al 1999). However, current evidence suggests that it is the presence of excess visceral fat that is most strongly associated with an increased risk of developing insulin resistance, type 2 diabetes, metabolic syndrome, dyslipidaemia, inflammation, thrombosis (Klein 2004, Eckel et al 2005) and CVD (Després 2001).
Visceral obesity: a new priority for nurses It is important to remember that BMI does not distinguish between 'fat mass' and 'muscle mass' (National Institutes of Health 2007). Furthermore, it is now clear that an individual's BMI does not correlate with the amount of his or her visceral fat, that is, fat distributed around the abdominal organs, whereas waist circumference does (Janssen et al 2002). Waist circumference also correlates well with abdominal fat mass as measured by computed tomography (Pouliot et al 1994). Waist circumference is also a stronger indicator for type 2 diabetes than waist-hip ratio (Wang et al 2005). In terms of predicting insulin resistance, waist circumference was demonstrated to be the strongest indicator of five covariables: BMI, waist circumference, systolic blood pressure, high-density lipoprotein (HDL) cholesterol and log-plasma triglycerides (Wahrenberg et al 2005). Measuring waist circumference provides a more accurate indicator of excess visceral fat than BMI, as shown by the findings from a large Danish prospective study, which examined all-cause mortality in middle-aged men and women (Bigaard et al 2005). The important point in this study was that waist circumference was directly related to all-cause mortality when adjusted for BMI (Bigaard et al 2005). Because individuals with a normal BMI can still show insulin resistance, and because BMI does not distinguish between fat and muscle or differentiate abdominal obesity from more widespread fat deposits, waist circumference as well as BMI should always be measured.
Before reading on think about the best way to measure visceral obesity and then write down how you would do it. Compare your answer with the procedure outlined in Box 3.
BOX 3 Technique for measuring waist circumference
The concept of the hypertriglyceridaemic waist was emphasised in 2001 in a high-profile British Medical Journal article; the authors clearly stating that waist girth should be considered as a vital sign and recorded in the medical charts of every patient (Després et al 2001). Box 3 outlines the technique of how to take an accurate measurement of waist circumference.
Before reading on, write down what you consider to be the cut-off point in centimetres for a waist circumference measurement that you would use to say: 'Yes, this individual is obese'. Will these waist circumference cut-off points vary between males and females and between different ethnic groups? Compare your answers with those listed in Table 1.
TABLE 1 Ethnic specific cut-off values for waist circumference
Interpretation of waist circumference measurements The International Diabetes Federation (IDF 2006) has drawn up a set of cut-off values for waist circumference, which are considered to determine obesity (Table 1). These cut-off values are ones that can be used in your assessment of waist circumference.
The IDF considers abdominal obesity as a prerequisite risk factor for the diagnosis of what is known as 'metabolic syndrome' (Alberti et al 2005). In this sense, being overweight or being abdominally obese is associated with other risk factors, including small, dense atherogenic low-density lipoprotein (LDL) cholesterol, low HDL cholesterol, raised triglycerides, elevated blood pressure, insulin resistance and impaired glucose regulation, including diabetes (Grundy 2000). It is also important to recognise that metabolic syndrome is itself an independent risk factor for CVD and coronary heart disease (CHD) mortality (Eckel et al 2005).
Consider how you would define 'metabolic syndrome'. Compare your answer with that in Box 4.
BOX 4 International Diabetes Federation (IDF) guidelines for the definition of metabolic syndrome
Thus, any patient with a high waist circumference should automatically be monitored for the presence of metabolic syndrome, increased risk of CVD and diabetes. This will require additional determinations for the presence of (Box 4):
Obese patients with any two of these co-morbidities are considered to be at high risk of developing CVD. The joint British societies' second guidelines (British Cardiac Society et al 2005) stated that people with any form of established atherosclerotic CVD, asymptomatic people without established CVD but who have a combination of the risk factors which puts them at high total risk, or people with type 1 or 2 diabetes, require professional lifestyle and multifactorial risk factor management to meet defined lifestyle and risk factor targets.
There is an overwhelming body of current evidence that makes it clear why it is important not only to manage the issue of obesity (Klein 2004, Eckel et al 2005), but also to adopt a holistic treatment approach, which includes lifestyle and behaviour change techniques as well as therapeutic measures, in the clinic to reduce cardiometabolic risk (British Cardiac Society et al 2005).
Consider how you would manage an obese patient, particularly from the viewpoint of reducing his or her risk of CVD. Write down a brief summary of what you would do. Then compare your answer with that suggested in Box 5.
BOX 5 A summary of the joint British societies' second guidelines targets for reducing cardiovascular disease risk
Even a relatively moderate weight loss in patients with abdominal obesity is associated with a preferential mobilisation of visceral adipose tissue, which in turn decreases the metabolic risk profile predictive for CVD and type 2 diabetes (Després 2006). Similarly, other data indicate that improvements in insulin sensitivity/glucose tolerance are much more closely related to a loss of visceral fat than to either a reduction in total body fat or subcutaneous fat (Goodpaster et al 1999, Rice et al 1999, Ross et al 2000).
Weight reduction also results in lower blood pressure (Neter et al 2003), lower LDL cholesterol and triglycerides, higher HDL cholesterol (Dattilo and Kris-Etherton 1992) and an improvement in other elements of metabolic syndrome, such as hyperinsulinaemia and hyperglycaemia (O'Meara et al 1997, Anderson and Konz 2001). Reducing adipose mass via exercise is also known to lower the incidence of type 2 diabetes (Knowler et al 2002, Laaksonen et al 2005). Additionally a 5-10% body weight loss improves endothelial dysfunction, as shown through reduced levels of inflammatory cytokines, cellular adhesion molecules and improved vascular response to L-arginine (Ziccardi et al 2002).
The National Institute for Health and Clinical Excellence will publish guidelines in February 2007 on the prevention, identification, assessment, treatment and weight management of overweight and obesity in adults and children. In the meantime, nurses can adopt two approaches to achieve weight reduction: lifestyle intervention alone or lifestyle intervention in addition to pharmacological therapy. However, the following should be noted:
[black right pointing small triangle] The joint British societies' second guidelines recommend that all people who are considered to be at high risk of developing CVD (which means individuals with established atherosclerotic disease and those with diabetes, as well as asymptomatic individuals at high total risk of developing CVD - greater than 20% in ten years) should be given professional support to make lifestyle changes to prevent first or recurrent atherosclerotic events (British Cardiac Society et al 2005).
[black right pointing small triangle] However, in asymptomatic individuals without a history of CVD, priority should be given to lifestyle interventions. Thus, for many individuals whose total CVD risk is not sufficiently high to justify pharmacotherapy at their present age, lifestyle intervention need be the only approach offered for CVD prevention.
[black right pointing small triangle] In contrast, where the total risk of CVD is sufficiently high to justify more intensive intervention, or when the level of any one particular risk factor is already associated with target organ damage, then lifestyle measures alone are unlikely to be sufficient and medication would be needed to achieve targets (British Cardiac Society et al 2005).
Encouraging people to change their lifestyles There are a number of sources that provide advice on obesity management. The National Service Framework for Coronary Heart Disease (Department of Health 2000) recommends healthy eating advice and weight management as core strategies. Similarly, the Scottish Intercollegiate Guidelines Network, National Obesity Forum and IDF make suggestions for the management of obesity, either directly or as part of the management of related conditions. Diabetes UK offers a weight management pack (Diabetes UK 2006). The joint British societies' guidelines on the prevention of CVD in clinical practice also offer practical guidance on lifestyle intervention targets (British Cardiac Society et al 2005). These include dietary modification and increased physical activity. The reader is referred to the section in the guidelines on 'Lifestyle: smoking, diet, alcohol, physical activity, weight, and body fat distribution' for details (British Cardiac Society et al 2005).
Current initiatives: Dorset Primary Care Trust (PCT) One of the current challenges that staff in practices and PCTs face is deciding how best to identify and provide patients at elevated cardiometabolic risk with a systematic and practical service that supports and effects cardiovascular risk reduction.
The author has been involved in a Dorset-wide project, exploring the possibilities for developing a software package that can 'flag' and rank all patients aged 40-80 years, according to their estimated CVD risk and so alert health professionals to assess and investigate actual risk in these patients.
The aim of the pilot project was to determine the feasibility of using existing practice data in combination with imputed values where actual data were missing and joint British societies' second guidelines, to identify and rank CVD risk in practice populations. The results showed that electronic estimation of risk in the primary care setting offered a practical tool to identify patients in need of further investigation. However, it highlighted that caution should be exercised in handling missing data because imputed values have over estimated actual risk and individual scores need to be verified before clinical action (Fenn et al 2006).
The team is planning to develop a software package which can be used with their existing CHD software package and a diabetes pathway, to help staff provide an equitable, systematic and stepped approach to primary and secondary prevention of CVD. The team would be keen to hear from others who are involved in service initiatives in this disease area.
Consider which services you would include in a care pathway for patients at elevated cardiometabolic risk and how the pathway could be integrated into your existing services for patients with obesity, CHD and diabetes?
Anti-obesity medication In the UK, approved anti-obesity medications include orlistat (an inhibitor of intestinal fat absorption) and sibutramine, which acts on the central nervous system to suppress appetite. In association with lifestyle intervention, current guidelines for obesity recommend that drug therapy should be considered in obese people (BMI>=30), or in those who have a BMI of 27-30 with one or more obesity-related disorders (National Institutes of Health 1998). A meta-analysis has shown that orlistat reduced weight by 2.7kg compared with placebo (Padwal et al 2003). In addition, orlistat given over four years in association with intensive lifestyle change has been shown to reduce progression to diabetes by 39% compared with placebo, the most common side effects being gastrointestinal. A meta-analysis of sibutramine has shown that it reduced weight by 4.3 kg compared with placebo (Padwal et al 2003), but there were concerns about increased pulse rate and increased systolic and diastolic blood pressure (Kim et al 2003). Weight regain is common when orlistat or sibutramine drug therapy is stopped (British Cardiac Society et al 2005).
Rimonabant, an endocannabinoid type 1 receptor blocker (CB1 receptor blocker), has recently become available and is licensed for the management of obesity (BMI>=30) or overweight (BMI>=27) with additional risk factors such as type 2 diabetes or dyslipidaemia. Activation of CB1 receptors in the brain results in increased feeding and the synthesis of free fatty acids in the liver (Lichtman and Cravatt 2005). Rimonabant is the first CB1 blocker to be licensed for the treatment of multiple cardiometabolic risk factors, for example, obesity and dyslipidaemia. To date, and in combination with a hypocaloric diet, rimonabant has been shown to cause a significant reduction in weight, waist circumference and triglycerides, as well as promoting increases in HDL cholesterol and insulin sensitivity in obese patients (Després et al 2005, Van Gaal et al 2005, Pi-Sunyer et al 2006).
When rimonabant is given to patients who are overweight or obese with untreated dyslipidaemia, it promotes increases in plasma adiponectin and LDL-cholesterol particle size (Després et al 2005). This is a beneficial effect as low levels of adiponectin and small dense LDL-cholesterol particles are markers associated with an elevated CVD risk profile.
The advantage that rimonabant appears to offer is that it targets multiple cardiometabolic risk factors and not only individual risk factors for type 2 diabetes and CVD. Common side effects include upper respiratory tract infections and nausea. Rimonabant is contraindicated in patients who are breast feeding and not recommended in patients who are receiving antidepressant medication.
The importance of managing the obesity epidemic is becoming increasingly significant in the UK and globally. This epidemic has a range of associated conditions, such as CVD and diabetes - predominantly type 2 diabetes. Effective assessment and management of patients with obesity and especially abdominal obesity, CHD and diabetes is essential to reduce the cardiometabolic risk profile of at-risk patients. These management strategies will include lifestyle advice and modification and, where required, pharmacological agents. New treatments that target the cluster of cardiometabolic risk factors rather than individual risk factors may present an attractive therapeutic option in the clinical setting for at-risk patients
Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 49.
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Keywords: Abdominal obesity; Cardiovascular system and disorders; Diabetes; Obesity
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