experimental & clinical cardiology

EXPERIMENTAL & CLINICAL CARDIOLOGY

Volume 20, Issue 8, 2014

Title: "Association of Abdominal Adiposity with Diabetes and Cardiovascular Diseases in Adult Saudi Males"

Authors: Rashed Bakr Albakr, Hussein Amin Saad, Mohmmed Gassan Pharaon, Abdullah Nasse Aldosari, Abdullah Saad Alsaleem, Abdurahman Tawfiq Khojah and Hanan Bakr Albackr

How to reference: Association of Abdominal Adiposity with Diabetes and Cardiovascular Diseases in Adult Saudi Males/Rashed Bakr Albakr, Hussein Amin Saad, Mohmmed Gassan Pharaon, Abdullah Nasse Aldosari, Abdullah Saad Alsaleem, Abdurahman Tawfiq Khojah and Hanan Bakr Albackr/Exp Clin Cardiol Vol 20 Issue8 pages 3745-3760 / 2014

Association of Abdominal Adiposity with Diabetes and Cardiovascular Diseases in Adult...

Association of Abdominal Adiposity with Diabetes and Cardiovascular Diseases in Adult Saudi Males. Rashed Bakr ALBakr (1),Hussein Amin Saad (2),Mohammed Gassan Pharaon(1), Abdullah NasserALDosari (1),Abdullah SaadALSaleem (1), Abdurahman Tawfiq Khoja(1), Hanan Bakr ALBakr (3).

(1) College of Medicine, King Saud University, Riyadh, Saudi Arabia. (2)Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia. (3)King Fahd Cardiac Centre, Cardiac Science Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

Abstract OBJECTIVES: To estimate the prevalence of diabetes and cardiovascular diseases among adult Saudi males who did have abdominal adiposity attending the primary health care setting and also to determine the relationship between abdominal adiposity with development of diabetes and cardiovascular disease. BACKGROUND: Abdominal adiposity is defined as an increase in the intra abdominal fat in the abdominal area. Abdominal adiposity is also considered nowadays as one of the predisposing factors that may increase the risk of having diabetes and cardiovascular diseases. METHODS: In this quantitative observational cross sectional study using simple random sampling technique, 245 of adult Saudi male aged 30 years and older who attended primary health care at King Khalid University Hospital during the period from October 2012 to March 2013 are included. Non-Saudi male, Saudi male below than 30 years of age and female are excluded from the study. The body mass index, height, weight and waist circumference was calculatedto define their abdominal adiposity. Lipid profile, fasting blood glucose and hemoglobin A1C was taken from the medical records. Selfadministered questionnaire also was used to provide some personal data about the patient.

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Exp Clin Cardiol, Volume 20, Issue 8, 2014 - Page 3745


RESULTS: Diabetes and cardiovascular disease have almost equal prevalence in patients presented to primary health care clinic with abdominal adiposity by 51% and 57% respectively. Not all patients with abdominal adiposity have diabetes and CVD. 32% have both diabetes and CVD, 25% have CVD only, 19% have diabetes only and 24% have neither diabetes nor CVD. Most of the patients presented to PHC with abdominal adiposity are obese class I (BMI = 30-34.9 kg/cm^2) by 42.4% of all patients, 26% of diabetics and 22.7% of cardiac disease patients. CONCLUSION: Multiple factors can lead todecrease the risk ofCVD including control of blood sugar, improvement of life style, cessation of smoking and lowering BMI levels by physical exercise.

Key Words: Abdominal adiposity, Diabetes and Cardiovascular diseases.

Introduction and Rational: Abdominal adiposity is considered as one of the widespread phenomena and its relation with diabetes and cardiovascular disease is not well known.Abdominal adiposity is defined as excessive abdominal fat around the stomach and abdomen. There is a strong association between abdominal adiposity and the risk of insulin resistance and development of cardiovascular disease [3]. Abdominal fat can be formed by eithermaking more fat cells (adipocytes) or increase the size of the same adipocyte. These fat cells especially large adipocytes are turned tofree fatty acids. These fatty acids over the years will lead to insulin resistance and thus the insulin increase and the islet cell will fail. These adipocytes also will lead to release cytokines like TNF-alpha that can lead to pro inflammatory and hypercoaguable state that may lead to inflammatory conditions such as coronary artery disease. Abdominal adiposity will lead to high cholesterol, higher insulin and glucose levels and thus increases the inflammation and clotting process. Abdominal adiposity also can increase the risk of death even at lower BMI levels [8] [11].

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Methodology: - Methods: This quantitative observational cross sectionalstudy using simple random sampling technique was done to identify the relationship betweenabdominal adiposity, diabetes and cardiovascular disease. This study wasconducted in the primary healthcare setting at King Khalid University Hospital over 6 months from October 2012 to March 2013. 228 adult Saudi malesareincluded in the study assuming that the prevalence of abdominal adiposity and cardiovascular disease respectively, 55% and 40% based on 95% confidence interval and for 90% power.Non-Saudi male, Saudi male below than 30 years of age and female are excluded from the study. Waist circumference (WC) [2] wasmeasured by using “meter tape” in the standing position, midway between the lowest costal rib and the iliac crest where the WC of 102 cm or more will be considered as abdominal adiposity [23].Weight, height and body mass index (BMI) [9] also was calculated by using “Seca scale measuring equipmentmade in Germany”. Lipid profile, fasting blood glucose and hemoglobin A1C was taken from the medical records. Self-administered questionnaire also was used to provide some personal data about the patient.

- Pilot Study: Pilot experiment was carried out by using the same methods that mentioned above over 17 participants; therefore, the total sample size will be different from those that the pilot study was crossed over them. Pilot experiment was done on thoseparticipants to see the validity, reliability, feasibility and safety of our studybefore starting the real research project.

- Data Analysis: Data were analyzed using SPSS V.19. to process the data and analyze it. Descriptive statistics like mean was used as a summery for quantitative data and standard deviation was used as a measure of dispersion. Analytic statistics like Chi-square and Fischer’s exact test were used to relate diabetics,non-diabetics, CVD patients and non-CVD patients with respect to other nominal and numerical data.

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- Ethical Considerations: The informed consent was clear and was indicating the purpose of the study and the right of theparticipant to withdraw at any time without any obligation towards the study team. No incentives or rewards were given to the participants. The study was approved by the institutional review board (IRB) in the college of Medicine at King Saud University.

Results: Most patients presented to PHC with abdominal adiposity,their age range from 51-60 years old by 34.2% of all patients (figure 1), 37.5% of diabetics (figure 6) and 39.0% of CVD patients (figure 7) While the least common age group > 70 by 7.3% of all patients (figure 1), 6.3% of diabetics (figure 6) and 8.1% of CVD patients (figure 7). Prevalence of diabetics and CVD patients respectively was 51% and 57% (figure 5). Most of patients with abdominal adiposity have both diabetes and CVD accounted for 32% more than having diabetes by 19% or CVD only by 25% but 24% have only abdominal adiposity with no diabetes or CVD (figure 4). Mean average for height, weight, waist circumference and BMI levels respectively was 170.02 cm, 93.89 Kg, 115.1cm and 32.4 Kg/cm^2 (figure 2). Most patients presented to PHC who have abdominal adiposity are obese class I (BMI = 30-34.9 Kg/cm^2) by 43% of all patients (figure 3), 26% of diabetics, 16.9 of non-diabetics (figure 8), 22.7% of CVD patients and 20.2% of non-CVD patients (figure 9). Risk factors of CVD among those patients include hypertension by 93.5% followed by family history of CVD by 47.15%, lack of physical exercise by 37.7%, previous history of diabetes by 32% and smoking by 18.7% of CVD patients (figure 10). Diabetic patients with fasting blood sugar ≥ 7mmol/L accounted for 45.9% of all patients, pre diabetics with FBS from 5.66.9mmol/L accounted by 14% for diabetics and also 14% for non-diabetics but those with FBS≤ 5 mmol/L are accounted by 6.7% for diabetics and 19.3% for non-diabetics (figure 11).Diabetic patients with HBA1C > 7% were 65.1% and 34.9% with HBA1C ≤ 7% (figure 12). Patients with controlled lipid profile of LDL ≤ 2.6 mmol/L, HDL ≥ 1.0 mmol/L and triglyceride ≤ 1.7 mmol/L respectively are 58.8%, 66.1% and 68.2% while patients with uncontrolled lipid profile of LDL > 4



2.6 mmol/L, HDL < 1mmol/L and triglyceride > 1.7mmol/L respectively are 41.2%, 33.9% and 31.8% [LDL p-value=0.006, HDL p-value≤0.001, Triglyceride p-value≤0.001](figure 13).

Discussion: Over all obesity and abdominal adiposity are independently predictors of type 2 diabetes [17]. However; reducing WC may reduce the development of type 2 diabetes [7]. Also reducing body weight and improvement of life style may reduce the risk of type 2 diabetes [18]. The cardiovascular disease prevalence is higher among obese individuals [10]. Obesity [13] and abdominal adiposity [16] still as important contributor in the pathogenesis of cardiovascular disease. Waist to hip ratio [9] and waist circumference [6] are good indicators of cardiovascular risk of abdominal adiposity however weight loss may contribute to the improvement of cardiovascular function [11] and prevention of cardiovascular disease [13]. Diabetes type 2 from insulin resistance over all the years may increase the development of cardiovascular disease [14]. Control of cholesterol and other lipids can be considered as secondary prevention for diabetics to decrease the cardiovascular disease and its morbidity but for nondiabetics, primary prevention of CVD will be by smoking cessation, blood pressure control, physical activity and weight management [15]. Intra abdominal fat accumulation could increase the risk of both diabetes type 2 and cardiovascular disease [19]. However, control of obesity will increase the prevention of CHD and diabetes [20] although Improvement of blood glucose was related to the loss of centralized body fat [21] and thus increase prevention of cardiovascular disease.

Conclusion: Multiple factors can lead to decrease the risk ofCVD including control of blood sugar, improvement of life style, lowering BMI levels by physical exercise and cessation of smoking.

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Recommendations: Early screening for diabetes by measuring FBS levels should be undertaken for early detection of pre-diabetics and start to control them before they reach to the diabetic stage. Awareness regarding the importance of physical exercise andharms of smoking can lead to early prevention of diabetes and cardiovascular disease.

Acknowledgments: We thank the family and community department at college of medicine in King Saud University for giving us this opportunity to do such a research. We also appreciate the efforts of our supervisor Dr. Hussein Amin Saad, consultant and assistant professor of family medicine for supervising the overall research project. We also thank Mr. Ameer, the statistician in college of medicine research center (C.M.R.C) for helping us in doing the data analysis.

Conflict of Interest: The author declares that he has neither conflict of interest nor financial support.

References:

1. Daniel J. Rader, Effect of Insulin Resistance, Dyslipidemia, and Intraabdominal Adiposity on the Development of Cardiovascular Disease and Diabetes Mellitus, The American Journal of Medicine (2007) Vol 120 (3A), S12–S18. 2. B LARSSON, K SVARDSUDD, L WELIN, L WILHELMSEN, P BJORNTORP, G TIBBLIN, Abdominal adipose tissue distribution, obesity, and risk of cardiovascular disease and death: 13 year follow up of participants in the study of men born in 1913, Br Med J (Clin Res Ed) 1984;288:1401. 3. Robert Ross, James Aru, Jennifer Freeman, Robert Hudson, and Ian Janssen, Abdominal adiposity and insulin resistance in obese men, doi: 10. 1152/ ajpendo. 00469. 2001.

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4. Aschner P, Ruiz A, Balkau B, Massien C, Haffner SM, Association of abdominal adiposity with diabetes and cardiovascular disease in Latin America, J Clin Hypertens (Greenwich). 2009 Dec;11(12):769-74. 5. Valerio G, Iafusco D, Zucchini S, Maffeis C, Abdominal adiposity and cardiovascular risk factors in adolescents with type 1 diabetes, 2012 Jul;97(1):99-104. Epub 2012 Feb 13. 6. Steven M. Haffner, Abdominal obesity, insulin resistance, and cardiovascular risk in pre-diabetes and type 2 diabetes, Eur Heart J Suppl (May 2006) 8 (suppl B): B20-B25.doi: 10.1093/eurheartj/sul004. 7.

N. Freemantle, J. Holmes, A. Hockey, S. Kuma, How strong is the association between abdominal obesity and the incidence of type 2 diabetes, 28 JUN 2008, DOI: 10.1111/j.1742 1241.2008.01805.x.

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M. Dalton, A. J. Cameron, P. Z. Zimmet, J. E. Shaw, D. Jolley, D. W. Dunstan, T. A. Welborn, Waist circumference, waist–hip ratio and body mass index and their correlation with cardiovascular disease risk factors in Australian adults, 27 NOV 2003, DOI: 10.1111/j.1365-2796.2003.01229.x.

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21. K Z Walker, L S Piers, R S Putt, J A Jones and K O'Dea. Effects of regular walking on cardiovascular risk factors and body composition in normoglycemic women and women with type 2 diabetes. 22. Swati Bhardwaj, Anoop Misra, Ranjita Misra, Kashish Goel, Surya Prakash Bhatt, Kavita Rastogi, Naval K. Vikram, Seema Gulati. High Prevalence of Abdominal, Intra-Abdominal and Subcutaneous Adiposity and Clustering of Risk Factors among Urban Asian Indians in North India. PLoS One. 2011;6(9):e24362. Epub 2011 Sep 20.

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Correspondence to: Rashed Bakr ALBakr College of Medicine King Saud University P.O. 7805, Riyadh 11472 Saudi Arabia Email: [email protected]

Figure 1- Age distribution among patients presented to PHC with abdominal adiposity

40 34.2

35 30 25 20.6

22.6

20

17.3

%

15 10 5.3 5 0 30-40

41- 50

51 - 60

61-70

(N = 245)

9


> 70


Figure 2- Mean average of measurable variables in patients with abdominal adiposity presented to PHC

170.02 180 160

Mean Average

140

115.1

120

93.89

100 80 60

32.4

40 20 0 Height (cm)

Weight (Kg)

waist (cm)

BMI (kg/cm)^2

Figure 3 3- Body Mass Index levels (Kg/cm^2)

43

45 40 30.6

35 30 25 %

20 13.2

15

9.1

4.1

10 5 0

Normal (18.5 - 24.9)

Overweight (25 29.9)

Obese class I (30 34.9)

Obese class II (35 39.9)

(N = 245)


Obese class III (40 and above)


Figure 4- Classification of patients presented to PHC with abdominal adiposity according to their suscetability of having diabetes and CVD

19%

24%

Diabetes only

25%

32%

CVD only Diabetes + CVD None

(N = 245)

Figure 5- Percentage of diabetes and CVD diseases among patients presented to PHC with abdominal adiposity

57

70 51

60 50 %

40 30 20 10 0 (N = 245)

Diabetes

CVD



Figure 6- Age distribution among diabetic patients 37.5 40 35 30 25 %

23.6

22.2

20 10.4

15

6.3

10 5 0 (N = 125)

30-40

41 41- 50

51 - 60

61-70

> 70

Figure 7 7- Age distribution among patients with CVD

39.0 40 35 30 22.8

22.0

25 20 % 15

8.1

8.1

10 5 0 30-40

41 41- 50

51 - 60

61-70

(N = 140)


> 70


Figure 8- BMI (Kg/cm^2) levels among diabetics and non-diabetics non diabetics (p(p value = 0.371)

30

26

25 20 %

16.9

16.9 13.6

15

Diabetic

9.1

10 3.3

5

NonDiabetic

4.5 4.5

4.1 0.8

0 Normal (18.5 24.9)


Obese class I (30 34.9)

Obese class II (35 - 39.9)


(N = 245)

Figure 9- Comparison of BMI (Kg/cm^2) levels between cardiac and non-cardiac cardiac patients (p-value (p = 0.251) 22.7

25

20.2 18.2

20 15

12 with cardiac diseases

% 8.3

10

5

4.5 4.5

1.7 2.5

5 0

Normal (18.5 24.9)


Obese class I (30 - 34.9)

Obese class II (35 - 39.9)


(N = 245)


Non cardiac diseases


Figure 10- Risk factors among patients with CVD presented to PHC with abdominal adiposity.

100

93.5

90 80 70 60 47.15

% 50

37.7

40

32

30

18.7

20 10 0 HTN

Family history

(N =140)

Lack of physical activity

DM

Smoking

Figure 11- Fasting plasma glucose levels (FPG) among patients with abdominal adiposity (p (p-value 2.6

10

Controlled < 1.0

> 1.7

0 LDL (mmol/L)

HDL (mmol/L)

Triglyceride (mmol/L)

(N = 245)
