LIFESTYLE AND CHRONIC DISEASES

Dr. V. Ravi Andrews Consultant Nephrologist

Apollo Health City

“I’m tired of all this nonsense about

beauty being only skin-deep.

That’s deep enough! What do you want …….. adorable kidneys ? ! ? !”

- Jean Kerr

LIFESTYLE

DIET EXERCISE BEHAVIOUR

SUBSTANCE PERSONALITY STRESS

ABUSE

CHRONIC / LIFESTYLE DISEASES

• Cardiovascular Disease• Cerebrovascular Disease• Diabetes• Hypertension• Cancer• Chronic Kidney Disease• Dyslipidemia• Metabolic Syndrome

IMPACT OF LIFESTYLE DISEASES

- United States Data - 2004

• 12% attributed to lack of exercise

- American Heart Ass, 2004

C a r d i o v a s c u l a r D i s e a s e - 3 6 . 3 %

C a n c e r - 6 . 5 0 %

S t r o k e - 2 2 . 7 0 %

O t h e r C a u s e s - 3 4 . 5 %

ALL DEATHS

IMPACT OF DIABETES

Diabetes increases the risk of coronary events :-• Two-fold in men• Four-fold in women

- ADA 2002, Diabetes Care 25:S71-73

DIABETES A TICKING TIME BOMBOver the next 24 hours:

2200 diabetics will be diagnosed

512 diabetics will die

66 diabetics will go blind

77 diabetics will be diagnosed with ESRD

153 – diabetes related amputations will be performed

Centre for Disease Control and Prevention. 2000

IMPACT OF KIDNEY DISEASE….

Risk of dying is 100 times more in a 20 year old with kidney disease as compared to a healthy 80 year old

-Oxford Textbook of Clinical Neph, 3rd Ed, (2005)

IMPACT OF METABOLIC SYNDROME

Metabolic Syndrome (Syndrome X) rated as equivalent to smoking in magnitude of risk for Coronary Artery Disease.

Four fold risk of Death from CAD- National Cholesterol Education Program /

Adult Treatment Panel III (NCEP / ATP III)

Major impact on CVS, CNS, CKD

Clinical Criteria for Metabolic Syndrome

3 / 5 needed – NCEP, Circ. 166:3143 – 3421, 2002

Metabolic Syndrome

Waist CircumferenceMen > 102 cm (40 inch)

Women > 88 cm (35 inch)

BP 130 / 85 mm Hg

FBS 110 mg / dl

HDL Chol. Men < 40 mg/dl Women < 50 mg/dl

Triglycerides 150 mg/dl

Pathogenesis of Metabolic Syndrome

- Bagby et al JASN 15:2775 – 91, 2004

Abdominal Fat

Obesity Physical Inactivity Genetics

Tissue Resistance to Leptin Pro – infl. Cytokines

+ +

Adiponectin FFA

FFA Breakdown

Insulin Resistance

Insulin Glucose

Abdominal Fat

Prevalence of Metabolic SyndromeLooking at various studies around the world the prevalence varies from 8% (India) to 24% (United States) in men and from 7% (France) to 46% (India) in women.

* Gogia A et al. Ind Journ of Medical Sciences. 2006; 60 (2): 72-81

0

1 0

2 0

3 0

4 0

5 0

6 0

%

M S O b e s i t y E le v a t e d T G H y p e r t e n s io n E le v a t e d P la s m aG lu c o s e

P r e v a le n c e d a t a f r o m J a ip u r & C h e n n a i

J a ip u r

C h e n n a i

Legend: Prevalence of MS 13% in Jaipur and 41% in Chennai.The prevalence of obesity was quite similar (31% versus 33%). Prevalence of elevated triglycerides (46% vs. 30%), hypertension (55% vs. 39%) and elevated fasting plasma glucose (27% vs. 5%).

Treatment of Individual Metabolic Risk factors

Weight, Activity (Lifestyle) & Metformin, TZDs

Dyslipidemia Lifestyle & Statins, Fibrates

Hyperglycemia (A1c< 7%)

Hypertension

Prothrombotic state

Proinflammatory state

Lifestyle & Insulin / OHA

Lifestyle & ACEI, ARB, BB, CCBs, diuretics

Lifestyle & ASA

Lifestyle & statins, TZDs, ACEI/ARB

Insulin resistance (Abd. Fat )

- Grundy et al, Circ. 109:433-38 (2004) - AHA

CLASSIFICATION OF BP FOR ADULTS 18 YEARS

(Mean of 2 or more seated B.P readings on each of 2 or more office visits)

NORMAL : SBP < 120 AND DBP <80 PREHYPERTENSION: SBP = 120 – 139

OR DBP = 80 – 89 STAGE 1 HYPERTENSION: SBP = 140 – 159

OR DBP = 90 - 99 STAGE 2 HYPERTENSION: SBP 160 OR

DBP 100- A.V Chobanian, et al

JNC – 7, May 2003

Benefits of lowering BP ….

10 mmHg reduction of SBP over 10 years will prevent 1 in 10 deaths!!!

Chobanian et al, JAMA,

289,No.19(2003)

Event Average Percentage Reduction

Stroke 35 – 40 %

M.I 20 – 25 %

CHF 50 %

IMPACT OF LIFE–STYLE MODIFICATIONS ON HTN ….

- JNC VII, JAMA (2003)

MODIFICATION APPROX SBP REDUCTION

Wt. Reduction 5- 20 mmHg/10Kg wt. Loss

DASH Diet 8-14 mmHgDietary Sodium Restriction

2- 8 mmHg

Physical Activity 4- 9 mmHg

Moderation of Alcohol 2- 4 mmHg

LIFESTYLE CHANGES

Diet ExerciseBehaviour

The DASH Diet: -

Salt – 6gm/day

High K+, High Ca++

Low fat, low Cholesterol Less alcohol, less coffee

(Equivalent to one Anti – HTN drug)

- National Heart,Lung and Blood Institute (USA) –2003

“To date, the only intervention to delay aging is caloric restriction by 30-40%. This has been proved conclusively in rodents but not yet in humans”

- Resnick et al, Harrison’s Principles of

Internal Medicine 16th Ed. Pp.44(2005)

EXERCISE: -30-45 MINS OF BRISK WALKING – 5 DAYS A

WEEKReduces BP

Reduces Weight

Controls Sugars

Controls Lipids, HDL

Endorphins / Enkephalins – Well Being, TCR Activation

Reduces Cardiovascular Risk

Reduces Osteoporosis

Sleep better, energises

Reduces Diet Restrictions

- JNC VI – Arch. Int.Med. 157:2413-46 (1997)

BEHAVIOURAL CHANGES: -

Stop Smoking Reduce Alcohol, Coffee Avoid Substance Abuse Reduce Stress

Chronic Disease

HTN

DyslipidemiaCYTOKINES

Endothelial Damage

ROS

Smoking

CHRONIC / LIFESTYLE DISEASE MANAGEMENT

Medication V/S

Lifestyle Modificatio

n

DISEASE MEDICATION

Cardiovascular Disease Anti-HTN, Digoxin,ASA, Nitrates, Interventions

Cerebrovascular Disease Anti-HTN, ASA,

Thrombolytics etc Diabetes Insulin, OHA Hypertension Anti-HTN Cancer Surgery,

Radiation, Chemotherapy

Chronic Kidney Disease Anti-HTN, Vit. D3, Calcium,PPI,

Dialysis, EPO Metabolic Syndrome OHA, Anti-HTN,

Statins

Lifestyle ModificationsUniversal applicabilityPreventiveNo adverse effectsCheap and easily availableNo bitter pills to swallowCost – effectiveNo age restrictionsFun

The Choice is clear………..

STYLE LIFE

BEHAVIOUR

DI ET

EXER CISE

Use the ‘Poly - Pill’!

How soon to start ? ? ?

“Children who cycle to school are

8 % more fit than children who use

other modes of transport”

- Anderson, BMJ 334:1173(Editorial June 2007)

''Those who think they do not have time for exercise will sooner or later have to

find time for illness''.

-Edward Stanley

“Di-eting or

Di-eating …Its up to you”

- Ravi Andrews