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Life-long weight gain and metabolic diseasesRetrospective primary care study on the weight gain differences of elderly patients with diabetes and hypertension
Imre RURIK University of Debrecen, Medical and Health Science Center
Department of Family and Occupational Medicine
Hungary
The Future of Primary Care in Europe IV
Göteborg, September 3- 4 2012
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BACKGROUND• Metabolic syndrome (MetSy) is one of the “hot topics”
in medical research • Diabetes and hypertension often related to significant
weight gain • Becoming overweight or obese takes many years,
perhaps decades• Genetic factors, lifestyle and social elements could
also be important, but mainly nutritional habits alone or combined with sedentary lifestyle are the real reasons for growing fat
• A medical setting is required to measure MetSy parameters: (plasma glucose level, lipids, BP etc.)
• Body weight and height are usually checked by the individuals themselves
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AIM and OBJECTIVE
• The aim of this retrospective study is to analyse and to compare the life-long data on weight and BMI of patients with diabetes and hypertension and those without these pathologic conditions.
• Hypothesis: the possible relation between weight gain in the youth and different incidence of hypertension and diabetes in the later age periods.
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METHODStudy design: RetrospectiveSetting: Primary care practices between May and August, 2011. Selection of participants:Elderly people (between 60 and 70y)
consecutively selected.
Data sources: questionnaire.
Ethics:Regional Ethical Committee Form of informed consent.
Exclusion criteria:•Serious impairment of visual, acoustic or mental capacity•Refusal to participate, •Unreliability: Subjects were excluded if the difference between the self-reported and the measured data exceeded 3 kg (108ps)
Quantitative variables:divided into three groups with diabetes (DM), or with hypertension (Hyp) neither diabetes nor hypertension (None), as the control group. Patients with both illnesses were counted among diabetics.
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METHOD The QuestionnaireDear Patient !Please contribute to our international scientific evaluation and provide some information on you filling the boxes of the questionnaire.
Please give data about your body weight in [kg] and height in [cm] at your different age periods, based on your memory, private records ore most preferably medical records, hospital reports, discharge letter etc.
Your date will be handled confidentially, known only by our staff, but because of health regulation we need your signature on a different sheet, as an informed consent.
If you are not sure one of the data, you can leave this box empty. Your Family Physician
Year of born: 19_ _ your gender: Male/ Female Recent body weight according to your measurement
kg Recent body height according to your measurement
cm
Body weight at: 20 years
Body height at
30 years 40 years 50 years 60 years 70 years
your highest body weight
kg
it was measured at the age of _ _ _ years
By FEMALEs Only number of deliveries: last delivery at the age of: year last regular menstruation : at the age of: year Recent body weight measured by the practice staff
kg
cm
Doctors records: : Practice ID: diagnosed diabetes at the age of: year, none hypertonia at the age of: year, none
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RESULTS Descriptive• Refusal: 5 (reasons were not questioned) • Population: 759 persons (337 men, 422 women) • Differences between self-reported and
professionally measured body weight +2.2 Kg men +1.8 Kg women • 14 men and 21 women both hypertensive and
diabetic • mean age of diagnosing: hypertension men: 55.4 (±15.9) (median: 59) y women: 53.8 (±15.7) (median: 56) y diabetes men: 51.3 (±17.1) (median:53) y women: 54.4 (± 13.1) (median: 50) y
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RESULTS 1. Distribution of patients regarding morbidities (diabetes-DM, Hypertension-Hyp, control group-without these conditions-None) and BMI groups
Morbidity DM Hyp None men women men women men women n:759
81 162 94 337 BMI groups [kg/m2] 97 234 91 422 Underweight (< 18.5)
1 3 2 4 10
Normal (18.5 - 24.9)
20 25 61 80 30 26 242
Overweight (25-29.9)
29 35 67 121 51 47 350
Obese (30 <)
32 36 34 30 11 14 157
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RESULTS 2. MENmeans SD of body weight and BMI
decades (Dec)
recently (Act)
maximal (Max)
in the last decade prior to the diagnoses
(p=) values within decades
changes between means of decades (Δ).
MEN Body weight [kg] BMI [kg/m2]
n=337 DM n=81
Hyp n=162 None n=94
DM Hyp None
Dec mean mean mean mean mean mean
[year] ±SD Δ ±SD Δ ±SD Δ p ±SD Δ ±SD Δ ±SD Δ p
20 65.810.4
63.29.8
64.212.1
0.047 22.84.8
21.43.1
20.91.8
0.048
30 69.210.7
3.4 64.010.1
0.8 64.912.1
0.7 0.012 25.24.4
2.4 22.93.2
1.5 22.31.9
1.4 0.032
40 71.8
12.92.6 66.6
9.8
2.6 67.412.0
2.5 0.025 26.94.6
1.7 24.43.1
1.5 23.22.2
0.9 0.054
50 76.1
13.74.3 69.3
9.8
2.7 70.412.8
3.0 0.034 28.93.8
2.0 26.12.7
1.7 26.22.3
3.0 0.033
60 78.8
13.72.7 72.2
10.9
2.9 72.915.3
2.5 0.011 29.33.9
0.4 27.53.9
1.4 27.92.9
1.7 0.088
Max 89.9
13.624.1 86.2
16.7
23.0 83.010.5
18.8 0.042 30.94.1
8.1 29.75.3
8.3 28.43.7
7.5 0.087
Act 88.8
16.323.0 85.4
12.9
22.2 79.89.2
15.6 0.021 29.14.0
6.3 28.63.9
7.2 27.24.2
6.3 0.071
Priorto dg
10.0 6.5 0.005 2.4 1.8 0.039
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RESULTS 3. WOMENmeans ±SD of body weight and BMI decades (Dec)
recently (Act) maximal (Max)
in the last decade prior to the diagnoses(p=) values within decades
changes between means of decades (Δ).
WOMEN Body weight [kg] BMI [kg/m2]
n=422 DM n=97 Hyp n=234 None n=91 DM Hyp None
Dec mean mean mean mean mean mean
[year] ±SD Δ ±SD Δ ±SD Δ p ±SD Δ ±SD Δ ±SD Δ p
20 57.89.9
55.310.9
55.810.3
0.342 21.43.7
20.72.8
21.3 4.9
0.068
30 59.210.1
1.4 56.511.3
1.2 60.410.6
4.6 0.694 22.63.4
1.2 22.43.9
1.7 23.0 4.9
1.7 0.089
40 64.312.1
5.1 60.412.8
3.9 62.88.5
2.4 0.915 25.23.1
2.6 23.94.4
1.5 23.93.9
0.9 0.334
50 71.714.4
8.4 66.912.7
6.5 66.98.4
4.1 0.087 28.24.6
3.0 26.45.4
2.5 25.3 3.6
1.4 0.033
60 74.213.7
2.5 69.912.0
3.0 68.38.4
1.4 0.036 29.23.2
1.0 27.64.9
1.2 24.9 3.6
-0.4 0.088
Max 87.88.9
30.0 78.215.2
22.9 75.110.8
19.3 0.023 32.73.9
11.3 29.76.0
2.1 28.4 3.6
7.1 0.041
Act 78.712.2
20.9 76.215.5
20.9 72.49.6
16.6 0.652 29.94.6
8.4 28.15.2
7.4 28.7 4.8
7.4 0.066
PrDg 12.3 9.5 0.025 2.5 1.8 0.042
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RESULTS 4. changes by gender /co-morbidity IR and HR
Hypertension Diabetes
Decade
range (%) IR Adjusted HR Adjusted HR (95% CI)
20-30y (95% CI) p IR p
q 1-3 66- 1.3 0.4q 4 101- 1.5 1.13 (0.80-1.57) 0.492 0.7 2.05 (1.28-3.31) 0.003q 5 106-171 1.4 1.30 (0.95-1.79) 0.104 0.5 1.38 (0.82-2.32) 0.219Male* 1.2 1.00 0.5 1.00Female 1.4 1.29 (1.04-1.60) 0.018 0.4 0.69 (0.49-0.98) 0.038Co-morb* No 1.2 1.00 0.2 1.00 Yes 1.5 1.49 (1.18-1.88) 0.001 0.5 1.72 (1.07-2.75) 0.023 20-40yq 1 81- 1.3 0.3q 2 101- 1.3 0.91 (0.66-1.24) 0.548 0.4 1.03 (0.58-1.80) 0.931q 3 106- 1.1 0.72 (0.52-0.99) 0.087 0.4 1.12 (0.64-1.98) 0.690q 4 110- 1.3 0.93 (0.96-1.51) 0.677 0.4 1.18 (0.65-2.14) 0.583q 5 117-192 1.7 1.65 (1.20-2.26) 0.002 0.7 2.32 (1.35-3.97) 0.002Female 1.4 1.20 (0.96-1.51) 0.107 0.4 0.66 (0.45-0.95) 0.025Co-morb Yes 1.5 1.32 (10.05-1.68) 0.019 0.2 0.45 (0.28-0.72) 0.118
20-50yq 1 77- 1.3 0.4q 2 104- 1.2 0.97 (0.70-1.34) 0.841 0.2 0.59 (0.31-1.14) 0.117q 3 111- 1.3 1.04 (0.75-1.44) 0.818 0.5 1.63 (0.94-2.83) 0.084q 4 117- 1.2 0.92 (0.66-1.28) 0.624 0.4 1.20 (0.67-2.14) 0.540q 5 130-218 1.6 1.51 (1.09-2.08) 0.012 0.7 2.38 (1.42-4.01) 0.001Female 1.4 1.31 (1.05-1.64) 0.017 0.64 (0.45-0.93) 0.017Co-morb Yes 1.5 1.38 (1.09-1.75)) 0.008 1.63 (1.00-2.65) 0.05020-60y q 1 77- 1.4 0.3q 2 106- 1.2 0.75 (0.54-1.06) 0.101 0.3 0.98 (0.49-1.94) 0.946q 3 115- 1.3 0.89 (0.64-1.24) 0.477 0.4 1.66 (0.87-3.14) 0.122q 4 123- 1.2 0.72 (0.52-1.01) 0.056 0.5 1.95 (1.07-5.35) 0.029q 5 136-209 1.5 1.19 (0.85-1.67) 0.308 0.7 2.97 (1.64-5.35) 0.000Female 1.4 1.29 (1.03-1.61) 0.029 0.66 (0.46-0.96) 0.028Co-morb Yes 1.5 1.39 (1.09-1.78) 0.008 1.62 (1.00-2.63) 0.05220-70yq 1 91- 1.5 0.3q 2 116- 1.5 0.70 (0.27-1.80) 0.455 0.3 0.94 (0.13-6.78) 0.947q 3 128- 1.6 0.37 (0.12-1.14) 0.084 0.7 1.97 (0.13-7.23) 0.429q 4 139- 1.5 0.56 (0.21-1.46) 0.234 0.3 0.98 (0.13-7.23) 0.985q 5 156-191 1.6 1.02 (0.39-2.68) 0.968 0.2 0.52 (0.46-5.90) 0.600Co-morb Yes 2.91 (1.30-6.49) 0.009 0.63 (0.17-2.34) 0.485
Range- upper and lower values of quintiles with equally distributed data (N=127-141 at age 20y),
calculated from weight at respective decade/ weight at 20y
IR- incidence rate of the respective morbidity (expressed in cases per 100 persons-years) (relevant IR for Male* is the same for all decades)
HR- hazard ratio of developing morbidity (diabetes or hypertension) adjusted for gender, age, and co-morbidity
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RESULTS 5. Weight changes between decades and hazard ratios
Dec Hypertension Diabetes20-30y Adjusted HR p Adjusted HR p
(95% CI) (95% CI)10% 1.31 (1.08-1.58) 0.006 1.24 (0.92-1.66) 0.16230% 2.23 (1.26-3.97) 1.89 (0.78-4.59) Male* 1.00 1.00Female 1.28 (1.03-1.59) 0.024 0.69 (0.49-0.98 0.036Co-morNo* 1.00 1.00Yes 1.51 (1.20-1.89) 0.001 1.75 (1.10-2.80) 0.01930-40y 10% 1.16 (1.03-1.30) 0.011 1.35 (1.13-1.63) 0.00130% 1.55 (1.10-2.18) 2.48 (1.43-4.30)Female 1.32 (1.06-1.64) 0.013 0.67 (0.47-0.97) 0.033Co-morb 1.40 (1.11-1.77) 0.004 1.57 (0.98-2.52) 0.06140-50y 10% 1.09 (0.98-1.22) 0.125 1.25 (1.09-1.43) 0.00230% 1.31 (0.93-1.84) 1.93 (1.28-2.92) Female 1.34 (1.07-1.67) 0.010 0.70 (0.49-1.01) 0.056Co-morb 1.42 (1.12-1.79) 0.003 1.66 (1.02-2.68) 0.03950-60y 10% 1.02 (0.91-1.14) 0.791 1.08 (0.90-1.30) 0.39830% 1.05 (0.75-1.47) 1.27 (0.73-2.12) Female 1.34 (1.07-1.68) 0.010 0.79 (0.55-1.14) 0.203Co-morb 1.47 (1.16-1.86) 0.002 1.82 (1.11-2.97) 0.01760-70y 10% 0.85 (0.62-1.17) 0.317 0.92 (0.48-1.77) 0.81130% 0.62 (0.24-1.59) 0.79 (0.11-5.50) Female 1.08 (0.55-2.14) 0.811 0.48 (0.13-1.63) 0.240 Co-morb 2.03 (1.00-4.12) 0.051
Percentage of weight change: weight at examined decade / weight at 20years.
HR- hazard ratio of developing morbidity (diabetes or hypertension) adjusted for gender, age, and co-morbidity Co-morbidity- No: diabetes or hypertension only (*relevant for all decades)Yes: both are present
Cox regression method was used to determine (HR) and 95% CI
Schoenfeld residual test was used to check the proportional hazards assumption.
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Main findings
• Steady weight or slow increases in body weight have been seen more often among persons without diabetes.
• Diabetic women and men had higher body weights in their youth, and they gained significantly more weight in their third and fourth decades.
• Weight gain by diabetics in the decades prior to the diagnosis was significantly higher in both genders,
• Rapid weight gain before 40 years of age was registered more frequently among diabetics.
• The similarities of weight gain between the control and hypertensive groups may be due to the high prevalence of hypertension among the elderly.
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Study limitation
• Reliability of data based on memory and personal records. (The accuracy of data and longevity of follow up need some
compromise.)• Overlap between the different groups with both illnesses • Higher standard deviations in some categories• Therapy and interventions started at a younger age • Genetic elements and other relations remain undiscovered• Diabetic patients without hypertension were preferred for
inclusion, therefore they were over-represented• Study population could not be considered representative (Although both urban and rural inhabitants were involved. Frequent
visitors to primary care surgeries were over-represented; they surely did not belong to the “healthy elderly” population.)
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CONCLUSIONS
• Stability in body weight or limited and slow continuous weight gain was related to lower hazard ratios for some components of MetSy, likely diabetes.
• More reliable data could be retrieved only from cohort follow-up epidemiological evaluations within a larger population, in the frame of international cooperation, comparing ethnically diverse populations, as was recommended earlier in our pilot study.Implication for primary care
• Family physicians should not just be inactive observers of the weight gain of their patients, they must act earlier.
• They have to focus to the younger persons, who rarely visit medical settings, providing advice for body weight maintenance.
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Why primary care?
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Accepted for publication: Kovács E, Jancsó Z, Móczár Cs, Szigethy E, Frese T, Rurik I.
Life-longweight change can predict metabolic diseases. Retrospective primary care study on the weight gain differences
between elderly patients with diabetes and hypertension
Experimental and Clinical Endocrinology & Diabetes, 2012
Thanks for your attention!