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Understanding Metabolic Effects of Obesity In Patients with Type 2 Diabetes

What is the association between obesity and cardiovascular risks?

It is estimated that 35% of the United States population suffers from obesity. When putting this percentage into perspective, it leads us to expect that more than 75 million people in the U.S. suffer from the number one preventable cause of diabetes, heart conditions, other cardiovascular diseases, and even death. Various studies have focused on the metabolic effects of obesity in certain disease states, such as diabetes, congestive heart failure, myocardial infarction, and stroke. In a study published in the Journal of American Medicine, it was found that non-Hispanic blacks had the highest incidence of obesity at 47.8%. 42.5% of Hispanics are obese, followed by 32.6% of non-Hispanic whites, and 10.8% non-Hispanic Asians. Additionally, it was found that obesity is higher in middle-aged patients (40-59 years), when compared to younger adults (20-39 years) and adults age 60 and above. Obesity is without a doubt a growing concern due to its correlation with major metabolic abnormalities (e.g. hypertension, type 2 diabetes mellitus).

A recent cross-sectional study, conducted by Razieh Anari et al., looked at the association of central and general obesity with the incidence of dyslipidemia in patients with type 2 diabetes mellitus.  A total of 157 patients were included in the study. Biochemical assays were conducted to measure serum cholesterol, HDL-C, LDL-C, and triglycerides; BMI was also obtained from each patient. Those patients with a BMI of greater or equal to 30 kg/cm2 were classified as having central obesity and those with a BMI of less than 30 kg/cm2 were classified as having general obesity.  At baseline, the majority of the study subjects (91.7%) used an oral hypoglycemic agent; 51% used anti-hypertensive medications, and 54.1% used lipid lowering medications. Those patients on insulin were excluded from the study.

Results from this study show that those patients with a BMI > 30 kg/cm2 were at a greater risk of having central obesity when compared to those with a BMI < 30 kg/cm2 (93.1% vs. 54.5% incidence; OR =8.71, 95% CI: 2.71-27.99, p<0.001 after adjusting for age, gender, and energy intake). Those patients with central obesity tended to have higher systolic blood pressure readings (OR= 1.03, p= 0.024) and higher diastolic blood pressure readings (OR= 1.06, p=0.007). Interestingly, there was no difference in serum lipid levels in those patients with central obesity, when compared to those without central obesity. However, confounding factors in the central obesity group, such as the majority of patients being females, could explain this trend. Women have been found to be more receptive to making changes when it comes to their health.

However, this modality has been found to be inversely proportional to their educational status. A higher education level in women has shown to have lower incidence of obesity. Nonetheless, this relationship has no effect on obesity in men.

The prevalence of obesity, regardless of central or general obesity, was found to have no association with diabetes duration or any family history of type 2 diabetes mellitus. However, the relative risk of patients with diabetes developing cardiovascular diseases increased by twofold. This finding can be explained by the effect of endothelial inflammation in the vasculature, which has been seen in visceral adiposity. It was also found that 75.8% of patients with diabetes had hypertension, regardless of their obesity status.  Similar findings were observed in the prevalence of dyslipidemia. There was a 97.5% prevalence of dyslipidemia, regardless of obesity status. The small study sample and patients being all from Iran hinder the ability of this study to be applied to our population. This research study provides a good framework to establish the effects of obesity in diabetes. Therefore, the challenge of managing diabetes in obese patients relies on preventing and controlling the myriad of complications associated with it, which prompts healthcare professionals to prescribe multiple medications. Therefore, with better understanding of the impact obesity has on diabetes and optimizing non-pharmacological approaches, patients can potentially avoid the burden of prescribing cascades for proper disease(s) management.

Practice Pearls:

  • Abdominal obesity does not correlate with the incidence of various metabolic effects associated with insulin resistance.
  • Obesity overall increases the risk of cardio-metabolic complications in patients with type 2 diabetes mellitus, specifically, hypertension.
  • Obese patients with type 2 diabetes mellitus warrant close monitoring and treatment for lipid abnormalities.

 

References:

“Adult Obesity Facts.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 2015. Web. 08 Aug. 2016.

Anari, Razieh, Reza Amani, Seyed Mahmoud Latifi, Masoud Veissi, and Hajieh Shahbazian. “Association of Obesity with Hypertension and Dyslipidemia in Type 2 Diabetes Mellitus Subjects.” Diabetes & Metabolic Syndrome: Clinical Research & Reviews (2016): 1-5. Web.

Genser L, Casella Mariolo JR, Castagneto-Gissey L, Panagiotopoulos S, Rubino F. Obesity, Type 2 Diabetes, and the Metabolic Syndrome: Pathophysiologic Relationships and Guidelines for Surgical Intervention. Surg Clin North Am. (2016): 96(4):681-701. Web

Ogden, Cynthia L., Margaret D. Carroll, Brian K. Kit, and Katherine M. Flegal. “Prevalence of Childhood and Adult Obesity in the United States, 2011-2012.” JAMA 311.8 (2014): 806. Web


Researched and prepared by Pablo A. Marrero-Núñez – USF College of Pharmacy Student Delegate – Doctor of Pharmacy Candidate 2017, reviewed by Dave Joffe, BSPharm, CDE