Disclosure The contents of this presentation were developed with support from educational grants from the Department of Education, NIDRR grant numbers H133B090005, H133B970011 and H133G010160. However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.
Rehabilitation and Research Training Center on Secondary Conditions in Individuals with SCI James S. Krause, PhD
Rehabilitation Research and Training Center on Aging with Spinal Cord Injury Cardiovascular Disease in Women with Spinal Cord Injury and Its Affects on Participation in Community Activities.
Rehabilitation and Research Training Center on Secondary Conditions in Individuals with SCI Rehabilitation Research and Training Center on Aging with Spinal Cord Injury Cardiovascular Disease in Women with Spinal Cord Injury and Its Affects on Participation in Community Activities
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Approved for 1 contact hour of CME which will automatically approve it for SC PT CEUs Activity will provide 1.0 ANCC contact hour
Metabolic Syndrome & Spinal Cord Injury
Rehabilitation and Research Training Center on Secondary Conditions in Individuals with SCI Risk of Metabolic Syndrome: A 17 year longitudinal study Follow-up Rehabilitation Research and Training Center on Aging with Spinal Cord Injury
Metabolic Syndrome
Risk of Metabolic Syndrome: A 17 year longitudinal study Risk Factors for Cardiovascular Disease associated with Metabolic Syndrome: A 17 year longitudinal study
Metabolic Syndrome, or Reaven s Syndrome Metabolic Syndrome X Syndrome X Insulin Resistance Syndrome
metabolic syndrome, the constellation of symptoms including high cholesterol, hypertension and diabetes that are associated with excessive weight gain. TIME.com 03/26/2010
General definition of Metabolic Syndrome: A combination of risks factors for cardiovascular disease and type 2 diabetes
What Risk Factors?
Metabolic Syndrome Risk Factors 1. Central Obesity 2. Abnormal Carbohydrate Metabolism 3. Hypertension 4. Abnormally High Triglycerides 5. Abnormally Low HDL Cholesterol
European Group for the Study of Insulin Resistance (EGIR) (1999) World Health Organization (WHO) (1999) US National Cholesterol Education Program Adult Treatment Panel III (NCEP) (2001) American Heart Association/National Heart Blood and Lung Institute (AHA/NHBLI/NCEP)(2004) International Diabetes Federation (IDF) (2006)
IDF requires central obesity (defined as waist circumference with ethnicity specific values*) AND any two of the following *Body Mass Index (BMI) >30 kg/m 2 Europids, South Asians, Chinese, Japanese Women 80cm (88cm) Men 94cm (102cm) 90cm Ethnic South & Central Americans, Sub- Saharan Africans, and Eastern Mediterranean & Middle East (Arab) populations
Central Obesity WHO - Central obesity: waist/hip ratio > 0.90 (male); > 0.85 (female), and/or BMI > 30 kg/m2 EGIR - central obesity: waist circumference 94 cm (male), 80 cm (female) NCEP & AHA central obesity: waist circumference 102 cm or 40 inches (male), 88 cm or 36 inches {35 inches AHA} (female)
Insulin/Glucose abnormalities WHO requires the presence of diabetes mellitus, impaired glucose tolerance, impaired fasting glucose or insulin resistance, AND two of the following EGIR - requires insulin resistance defined as the top 25% of the fasting insulin values among non-diabetic individuals AND two or more of the following
Insulin/Glucose abnormalities IDF- fasting plasma glucose : (FPG)>100 mg/dl (5.6 mmol/l), or previously diagnosed type 2 diabetes; If FPG >5.6 mmol/l or 100 mg/dl, an oral glucose tolerance test is strongly recommended but is not necessary to define presence of the Syndrome NCEP - fasting plasma glucose 6.1 mmol/l (110 mg/dl) AHA - fasting glucose: Equal to or greater than 100 mg/dl (5.6 mmol/l) or use of medication for hyperglycemia EGIR - fasting plasma glucose 6.1 mmol/l
Other Risk Factors common to all Definitions (and 2 of the following or at least 3 of the following ) IDF - Raised blood pressure : systolic BP > 130 or diastolic BP >85 mm Hg, or treatment of previously diagnosed hypertension. WHO - Blood pressure: 140/90 mmhg EGIR - hypertension: blood pressure 140/90 mmhg or antihypertensive medication NCEP - blood pressure 130/85 mmhg AHA - blood pressure 130/85 mmhg or use of medication for hypertension
Other Risk Factors common to all Definitions (and 2 of the following or at least 3 of the following ) WHO - triglycerides (TG): 1.695 mmol/l and high-density cholesterol (HDL-C) 0.9 mmol/l (male), 1.0 mmol/l (female) EGIR - dyslipidemia: TG 2.0 mmol/l and/or HDL-C < 1.0 mmol/l or treated for dyslipidemia
Other Risk Factors common to all Definitions (and 2 of the following or at least 3 of the following ) NCEP/AHA - TG 150 mg/dl (1.695 mmol/l) IDF - triglycerides : > 150 mg/dl (1.7 mmol/l), or specific treatment for this lipid abnormality NCEP/AHA - HDL-C < 40 mg/dl (male), < 50 mg/dl (female) IDF - HDL cholesterol: < 40 mg/dl (males) (1.03 mmol/l), < 50 mg/dl (females) (1.29 mmol/l) or specific treatment for this lipid abnormality
Richard Kahn (2008). "Metabolic syndrome what is the clinical usefulness?". Lancet 371: 1892 1893
PubMed search last 2 years Metabolic Syndrome 7200 Reaven s Syndrome 3170 Metabolic Syndrome X 3170 Syndrome X 7158 Insulin Resistance Syndrome 10759
Major Components of Metabolic Syndrome 1. Central Obesity (definition?) 2. Abnormal Carbohydrate Metabolism fasting plasma glucose 100 mg/dl or use of medication for hyperglycemia 3. Hypertension 130/85 mmhg or use of medication for hypertension 4. Abnormally High Triglycerides 150 mg/dl or specific treatment for this lipid abnormality 5. Abnormally Low HDL Cholesterol < 40 mg/dl (men), < 50 mg/dl (women) or specific treatment for this lipid abnormality
Working Definition any combination of three of the following: 1. Central Obesity 2. Abnormal Carbohydrate Metabolism 3. Hypertension 4. Abnormally High Triglycerides 5. Abnormally Low HDL Cholesterol
Spinal Cord Injury
Central Obesity Waist Measurement SCI Labor Intensive & probably inaccurate Indicator for Abdominal Fat & more specifically for Inter-Abdominal or Visceral Fat cardiometabolic risk In people without SCI correlations range from.35 to.56
Central Obesity BMI SCI Labor Intensive & Height measurement may be inaccurate Indicator for Abdominal Fat & more specifically for Inter-Abdominal or Visceral Fat cardiometabolic risk In people without SCI correlation.53
Central Obesity DXA DEXA as an indicator of Visceral Fat In people without SCI correlations range from.65 to.79 BMI & DXA in people with SCI (N=165) BMI & Fat Correlations Total Trunk Complete Tetraplegia.64.71 Complete Paraplegia.65.71 Incomplete Tetraplegia.07.18 Incomplete Paraplegia.47.59 Overall.48.55
BMI > 30 kg/m 2 % of Cases Aging Study Women s Study 40 35 30 25 20 15 Inc Para Com Para Inc Tetra Com Tetra 10 5 0
Percent of Trunk Fat by DXA % 30 20 10 Inc Para Com Para Inc Tetra Com Tetra 0
Percent Abdominal Fat (DXA) by HDL in Men with SCI r = -.42, p<.001 HDL 100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 Percent of Abdominal Fat
BMI by HDL in Women with SCI HDL r = -.18, p<.021 100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 BMI
Percent Abdominal Fat by Triglycerides in Men with SCI r =.32, p<.001 Triglycerides 700 600 500 400 300 200 100 0 0 10 20 30 40 50 60 Percent of Abdominal Fat
HDL 600 500 400 300 200 100 BMI by Triglycerides in Women with SCI r =.33, p<.001 0 0 10 20 30 40 50 60 BMI
Blood Pressure & SCI Hypertension
A common problem for people with Tetraplegia due to SCI is persistent Hypotension often with bouts of uncontrolled, extreme Hypertension Krassioukov A, Claydon VE. The clinical problems in cardiovascular control following spinal cord injury: an overview. Prog Brain Res 2006;152:223-9.
Systolic BP Impairment by BMI Category Effect of Deficit on Exercise (F=9.9, p=.003) Deficit Overall (F=19.1, p<.0001), Deficit by BMI (F=8.9, p=.005) 180 170 160 150 140 130 120 110 100 90 Resting Systolic Maximum Systolic Normal Tetra Normal Para OvrWGT Tetra OvrWGT Para
BMI by Maximum Systolic BP Paraplegia (r=+.46, p<.01) Tetraplegia (r=-.78, p<.05) 220 Paraplegia Tetraplegia 200 180 160 140 120 100 80 15 20 25 30 35 40 45
Abnormal Carbohydrate Metabolism
Fasting Plasma Glucose 100 mg/dl Aging Study 20.1% Women s Study 23.9 % Bauman & Spungen SCI 22% Controls 6% Bauman WA, Spungen AM Disorder of carbohydrate and lipid metabolism in veteran with paraplegia or quadriplegia: A model of premature aging. Metabolism 1994;43:749-756.
Aging Study OGTT N=201 28.8% (56) Impaired Glucose Tolerance 13.4% (27) DM (OGTT-WHO) Of the 27 meeting the OGTT criteria for DM, 19 (70%) had Normal Fasting Glucose Bauman WA, Adkins RH, Spungen AM, Waters RL. The effect of residual neurological deficit on oral glucose tolerance in persons with chronic spinal cord injury. Spinal Cord 1999;37:765-771.
OGTT Glucose 190 180 170 160 150 140 130 120 110 100 90 0 30 60 90 120 Inc Para Com Para Inc Tetra Com Tetra
OGTT Insulin 200 180 160 140 120 100 80 60 40 20 0 0 30 60 90 120 Inc Para Com Para Inc Tetra Com Tetra
Abnormally Low HDL Cholesterol
< 40 mg/dl (men), < 50 mg/dl (women) Aging Study Women's Study 52.0% 47.9%
HDL < 40 mg/dl (men), < 50 mg/dl (women) % of Cases Aging Study Women s Study 70 60 50 40 30 20 Inc Para Com Para Inc Tetra Com Tetra 10 0
Abnormally High Triglycerides
150 mg/dl Aging Study Women s Study 24.1% 21.4%
Any Combination of 3 of 4 of the Major Components of Metabolic Syndrome 1. Central Obesity BMI >30 kg/m 2 2. Abnormal Carbohydrate Metabolism fasting plasma glucose 100 mg/dl 3. Hypertension 130/85 mmhg 4. Abnormally High Triglycerides 150 mg/dl 5. Abnormally Low HDL Cholesterol < 40 mg/dl (men), < 50 mg/dl (women)
Any Combination of 3 of 4 of the Major 35 30 Components of Metabolic Syndrome % of Cases Aging Study Women s Study 25 20 15 10 Inc Para Com Para Inc Tetra Com Tetra 5 0
Any Combination of 3 of 4 No Yes Live 84% 86% Dead 16% 14%
Intima/Medial Thickness of Carotid Artery wall (CIMT) Surrogate for CVD in epidemiologic studies Non-invasive Reliable & Reproducible
Factors Associated with CIMT in Women with SCI Age Carbohydrate Metabolism Triglycerides
AGE & CIMT Age 68 58 48 38 28 18 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 CIMT r =.65, p<.0001
IMT & HbA1c HbA1c 9 8 7 6 5 4 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 IMT r =.21, p=.0049
IMT & Triglycerides Triglycerides 515 415 315 215 115 15 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 IMT r =.17, p=.0261
Change in Fasting Glucose 106 101 96 91 Normal Treated 86 81 76 Baseline One Year
Change in HDL 65 60 55 50 45 Normal Treated 40 35 Baseline One Year
Change in CIMT 0.75 0.7 Normal Treated 0.65 Baseline One Year
Change in Triglycerides 190 170 150 130 110 90 70 50 30 Baseline One Year Normal Treated
Annualized Percent Change 20 18 16 14 12 10 8 6 4 2 0-2 IMT Glucose HDL Triglyc Normal Treated
IMT & SWL SWL 35 r = -.26, p=.0038 30 25 20 15 10 5 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 IMT
BMI & SWL r = -.20, p=.0185 SWL 35 30 25 20 15 10 5 16 21 26 31 36 41 46 BMI
Results (cont.) However, no predictors of IMT and BMI were correlated directly with SWL. SWL & Age, HbA1c, Triglycerides, Fasting Glucose, r = -.07, n.s. r = -.01, n.s. r = -.12, n.s. r = -.10, n.s.
SWL & MaxVO 2 r =.312, p<.0064 SWL 35 30 25 20 15 10 5 0 5 10 15 20 25 30 35 MaxVO 2
SWL & IMT Among Those with MaxVO 2 r = -.308, p<.0071 SWL 35 30 25 20 15 10 5 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 IMT
Results (cont.) The Primary Significant Predictor of MaxVO 2 was impairment (p=.0088). However, differences in SWL scores between impairment groups did not approach significance. The only other Significant Predictor of MaxVO 2 was BMI (p=.0179)
BMI & MaxVO 2 r = -.28, p=.0179 BMI 46 41 36 31 26 21 16 0 5 10 15 20 25 30 35 MaxVO 2
Diet Exercise Fat Abdominal Glucose Metabolism Triglycerides Cardiovascular Heath IMT MaxVO2 SWL
Evidence for CVD in SCI Agency Healthcare Research and Quality Wilt TJ, Carlson FK, Goldish GD, MacDonald R, Niewoehner C, Rutks I, Shamliyan T, Tacklind J, Taylor BC, Kane RL: Carbohydrate & Lipid Disorders & Relevant Considerations in Persons with Spinal Cord Injury. Evidence Report/Technology Assessment No. 163 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 08-E005. Rockville, MD. Agency for Healthcare Research and Quality. January 2008. PMID: 18457480
Prevalence of CVD in the General Population based on CIMT CVD CIMT White Women Black Women.77 mm.78 mm MI CIMT White Women.82 mm Black Women.83 mm Burke GL, Evans GW, Riley WA, Sharrett AR, Howard G, Barnes RW, Rosamond W, Crow RS, Rautaharju PM, Heiss G. Arterial Wall Thickness Is Associated With Prevalent Cardiovascular Disease in Middle-Aged Adults. Stroke. 26(3):386-91, 1995. PMID: 7886711
Prevalence Estimates Burke s Highest Women s Study CVD 13.0% 25.2% p<.01 MI 4.9% 10.6% p<.03
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