Corine den Engelsen

High-sensitivity C-reactive protein to detect metabolic syndrome in a centrally obese population: a cross-sectional analysis.

BackgroundPeople with central obesity have an increased risk for developing the metabolic syndrome, type 2 diabetes and cardiovascular disease. However, a substantial part of obese individuals have no other cardiovascular risk factors, besides their obesity. High sensitivity C-reactive protein (hs-CRP), a marker of systemic inflammation and a predictor of type 2 diabetes and cardiovascular disease, is associated with the metabolic syndrome and its separate components. We evaluated the use of hs-CRP to discriminate between centrally obese people with and without the metabolic syndrome.Methods1165 people with central obesity but without any previous diagnosis of hypertension, dyslipidemia, diabetes or cardiovascular disease, aged 20-70 years, underwent a physical examination and laboratory assays to determine the presence of the metabolic syndrome (NCEP ATP III criteria). Multivariable linear regression analyses were performed to assess which metabolic syndrome components were independently associated with hs-CRP. A ROC curve was drawn and the area under the curve was calculated to evaluate whether hs-CRP was capable to predict the presence of the metabolic syndrome.ResultsMedian hs-CRP levels were significantly higher in individuals with central obesity with the metabolic syndrome (n = 417; 35.8%) compared to individuals with central obesity without the metabolic syndrome (2.2 mg/L (IQR 1.2-4.0) versus 1.7 mg/L (IQR 1.0-3.4); p < 0.001). Median hs-CRP levels increased with an increasing number of metabolic syndrome components present. In multivariable linear regression analyses, waist circumference and triglycerides were the only components that were independently associated with hs-CRP after adjusting for smoking, gender, alcohol consumption and the other metabolic syndrome components. The area under the ROC curve was 0.57 (95%-CI 0.53-0.60).ConclusionsHs-CRP has limited capacity to predict the presence of the metabolic syndrome in a population with central obesity.

Advanced glycation end products measured by skin autofluorescence in a population with central obesity.

Accumulation of advanced glycation end products (AGEs) is enhanced by chronic hyperglycemia and oxidative stress and this process may contribute to the pathogenesis of vascular disease. Skin autofluorescence (AF), a measure of accumulation of AGEs in skin collagen, is associated with vascular disease in patients with diabetes. Because central obesity enhances oxidative stress people with central obesity might already have increased accumulation of AGEs before diabetes or cardiovascular disease become manifest. To test this hypothesis, we compared the distribution of skin AF and its association with clinical and biochemical parameters in individuals with and without central obesity. Skin AF was measured by a validated AGE Reader in 816 persons with and 431 persons without central obesity, aged 20–70 y. Mean skin AF increased with age and smoking and was higher in centrally obese individuals compared with non-obese individuals (p = 0.001, after adjustment for age and smoking p = 0.13). Mean skin AF in the subgroups without central obesity and without other risk factors (n = 106), central obesity without other risk factors (n = 74) and central obesity with other risk factors (n = 742) was 1.63 ± 0.37, 1.74 ± 0.44 and 1.87 ± 0.43 AU, respectively (p for trend < 0.001, after adjustment for age and smoking p for trend = 0.12). In the group with central obesity age, current smoking, alcohol consumption, waist circumference, creatinine clearance and hs-CRP were independently associated with skin AF (R2 = 29.4%). Waist circumference hardly contributed to the explained variance. The relationship between waist circumference and skin AF is not as obvious as we hypothesized.

Improved care of type 2 diabetes patients as a result of the introduction of a practice nurse: 2003–2007

OBJECTIVE The main objective is to examine the effect of the introduction of a practice nurse (PN) on the quality of type 2 diabetes care. METHODS Retrospective cohort study in 397 type 2 diabetes patients recruited from five general practices in the Netherlands. Measurements were performed in 2003, 2005 and 2007, to estimate the effects before (2003) and after the introduction of the PN (2005) as well as the changed diabetes guidelines (2007). Process measures indicated whether measurements of HbA(1c), systolic blood pressure, lipid profile, funduscopy, foot examination and annual check-ups were carried out. Outcome measures comprised actual levels of HbA(1c), systolic blood pressure, lipid levels and BMI. RESULTS All process measures - except performance of funduscopy - improved significantly. Mean HbA(1c) decreased from 6.8% to 6.5% (2003-2007: ns, 2005-2007: p<0.01), mean LDL-cholesterol from 3.2 to 2.7 mmol/L (p<0.0001) and mean total cholesterol/HDL-cholesterol ratio from 4.5 to 3.7 (p<0.0001). For systolic blood pressure, the number of patients reaching targets increased considerably in 2007. Analyses for both study populations at different time points as well as for patients present at all time points showed comparable results. CONCLUSIONS Delegating diabetes care to a PN leads to significant improvements in diabetes care. General practitioners should seriously consider close collaboration with PNs to delegate diabetes care tasks.

Screening for increased cardiometabolic risk in primary care: a systematic review

BACKGROUND Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear. AIM To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy. DESIGN AND SETTING Systematic review of studies performed in primary care in Western countries. METHOD MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities. RESULTS The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995-2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967-2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods. CONCLUSION The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake.

One year follow-up of patients with screen-detected metabolic syndrome in primary care: an observational study.

BACKGROUND Early detection and appropriate treatment of metabolic syndrome (MetS) can modify cardiometabolic risk factors and prevent cardiovascular disease. Optimal screening outcomes require follow-up management of MetS. OBJECTIVE To investigate the natural course of events in the first year after positive screening for MetS in primary care with regard to follow-up behavior, medication prescription and lifestyle changes. METHODS Screening of 1721 apparently healthy primary care patients (20-70 years old) detected 473 new MetS cases. These people were asked to contact their general practice for subsequent advice and treatment. Data about follow-up behavior of the screening participants and prescription of cardiovascular medication were collected from the electronic medical file, and changes in lifestyle were collected by the practice nurse. RESULTS Of the 424 participants with screen-detected MetS for whom data about follow-up were available, 306 (72.2%) spontaneously contacted the practice. Antihypertensive, lipid-lowering and blood glucose-lowering medications were prescribed in 21.5%, 21.2% and 1.9% of the participants, respectively. Half of the participants for whom data about self-reported lifestyle changes were available reported to have increased their physical activity; 16.9% of the smokers quit smoking. Average weight loss was 2.1kg. CONCLUSIONS Screening for MetS followed by the advice to contact the general practice for lifestyle counseling and treatment had a substantial spontaneous follow-up. Although the changes in physical activity, weight loss and smoking abstinence are promising, further research will have to demonstrate whether they are sustainable.

Remission of screen-detected metabolic syndrome and its determinants: an observational study

BackgroundEarly detection and treatment of the metabolic syndrome may prevent diabetes and cardiovascular disease. Our aim was to assess remission of the metabolic syndrome and its determinants after a population based screening without predefined intervention in the Netherlands.MethodsIn 2006 we detected 406 metabolic syndrome cases (The National Cholesterol Education Program’s Adult Treatment Panel III (NCEP ATP III) definition) among apparently healthy individuals with an increased waist circumference. They received usual care in a primary care setting. After three years metabolic syndrome status was re-measured. We evaluated which baseline determinants were independently associated with remission.ResultsThe remission rate among the 194 participants was 53%. Baseline determinants independently associated with a remission were the presence of more than three metabolic syndrome components (OR 0.46) and higher levels of waist circumference (OR 0.91), blood pressure (OR 0.98) and fasting glucose (OR 0.60).ConclusionsIn a population with screen-detected metabolic syndrome receiving usual care, more than half of the participants achieved a remission after three years. This positive result after a relatively simple strategy provides a solid basis for a nation-wide implementation. Not so much socio-demographic variables but a higher number and level of the metabolic syndrome components were predictors of a lower chance of remission. In such cases, primary care physicians should be extra alert.

Comparison of perceptions of obesity among adults with central obesity with and without additional cardiometabolic risk factors and among those who were formally obese, 3 years after screening for central obesity.

BackgroundPerceptions of illness are important determinants of health behaviour. A better understanding of perceptions of obesity might allow more effective interventions that challenge these perceptions through lifestyle modification programs. Although several studies have evaluated causal attributions with regard to obesity, other domains of illness perception, such as the perceived consequences of obesity and perceived controllability, have not yet been studied. The aim of the current study was to explore perceptions regarding causes, consequences, control, concerns and time course of obesity of centrally obese adults, with and without an elevated cardiometabolic risk and with or without weight loss, 3 years after screening for metabolic syndrome, and to compare these perceptions.MethodsThree groups were selected from a longitudinal study dependent on the baseline and 3-year follow-up profiles: individuals with central obesity and metabolic syndrome at both time points (‘persistent cardiometabolic-risk group’, n = 80), those with central obesity but without metabolic syndrome on either occasion (‘persistent obese group’, n = 63), and formerly obese individuals (‘improved cardiometabolic-risk group’, n = 49). Perceptions of obesity were assessed using an adapted version of the Brief Illness Perception Questionnaire (BIPQ, range 0–10). Chi-square and Kruskal-Wallis tests were performed to compare the ‘persistent cardiometabolic risk’ group with the other two groups with regard to patient characteristics and BIPQ scores.ResultsBoth males and females who improved their cardiometabolic risk perceived their obesity as shorter (median (IQR): 3.0 (4.0) vs. 6.0 (3.0), p < 0.001) and experienced greater personal control over their weight (7.0 (3.0) vs. 5.0 (3.0), p = 0.002) compared to those who did not improve. Females who improved their cardiometabolic risk experienced fewer identity and illness concerns, this was not found for males. Other scores did not differ between groups.ConclusionObese adults with an improved cardiometabolic risk profile felt greater personal control and considered their obesity to be of shorter duration. Persistence of central obesity with additional cardiometabolic risk factors had a larger impact on female than male participants with respect to identity and illness concerns. Whether discussing ‘personal control’ is a favourable element in lifestyle intervention should now be assessed in the setting of a controlled trial.

Physical Activity in Patients with Metabolic Syndrome: At Screening and Three Years Thereafter

BACKGROUND Metabolic syndrome is a cluster of risk factors for cardiovascular disease and type 2 diabetes. Physical activity can decrease these risks. Many randomized clinical trials to increase physical activity have demonstrated disappointing results, and implementation in daily practice appeared to be difficult. The aim of this study was to investigate whether 3 years of usual care with available guidelines in a primary care setting result in change in physical activity in patients with screen-detected metabolic syndrome. METHODS After a population-based screening, 473 patients were diagnosed with metabolic syndrome and received advice to increase physical activity. Three years later, they were invited for follow-up. Physical activity was measured by means of the validated SQUASH questionnaire. The primary outcome measure was: % of metabolic syndrome patients that fulfill the Dutch Physical Activity Guideline (DPAG) criterion (30 min of moderately intensive physical activity at least 5 days per week) at screening and follow-up. RESULTS In the final study population (n=168), the proportion of patients fulfilling the DPAG criterion did not significantly increase between screening (56.0%) and follow-up (60.7%) (P=0.29). Female gender [odds ratio (OR)=3.59; 95% confidence interval (CI) 1.24-10.39] and body mass index (BMI) at baseline (OR=0.82; 95% CI 0.69-0.97) appeared to be independent predictors of increase in physical activity. CONCLUSIONS In this real-world setting, despite the advice to increase physical activity, the number of metabolic syndrome patients with sufficient physical activity did not significantly increase after 3 years. This finding confirms the need for an intensified approach to achieve an increase in physical activity in this group, with special attention to men and patients with higher BMI values.

Preventie van diabetes en hart- en vaatziekten

SamenvattingDen Engelsen C, Salomé PL, Rutten GEHM. Preventie van diabetes en hart- en vaatziekten. Huisarts Wet 2014;57(4):174–8. In 2004 adviseerde de Gezondheidsraad gerichte screening op cardiovasculaire risicofactoren onder mensen met obesitas, in plaats van een algemene populatiescreening op diabetes type 2. In het IJSCO-onderzoek nodigden de onderzoekers 11.862 ogenschijnlijk gezonde mensen uit – tussen twintig en zeventig jaar oud en nog zonder diabetes, hypertensie, hart- en vaatziekten of dislipidemie – voor screening op het metabool syndroom, een clustering van risicofactoren. De eerste stap was het thuis meten van de buikomvang. De mensen met een verhoogde buikomvang kregen vervolgens een uitnodiging voor nader onderzoek, om vast te stellen of zij voldeden aan de criteria van het metabool syndroom. Bijna driekwart van de mensen met een bij de screening vastgesteld metabool syndroom nam uit zichzelf contact op met de huisartsenpraktijk voor de uitslagen. Zij kregen een uitnodiging voor een consult en vervolgens een behandeling volgens NHG-Richtlijnen. Dat leidde tot een toename van lichamelijke activiteit en gewichtsverlies in het eerste jaar na screening. Bij meer dan de helft van deze mensen was er na drie jaar geen sprake meer van het metabool syndroom. Een screeningsinterval van langer dan drie jaar lijkt gerechtvaardigd; dat vergemakkelijkt de implementatie. Omdat de screening en daaropvolgende zorg goed zijn in te bedden in de dagelijkse praktijk, kunnen huisartsen op grote schaal het advies van de Gezondheidsraad opvolgen om bij mensen met obesitas op cardiovasculaire risicofactoren te screenen.AbstractDen Engelsen C, Salomé PL, Rutten GEHM. Prevention of diabetes and cardiovascular disease. Huisarts Wet 2014;57(4):174–8.In 2004, the Health Council of the Netherlands recommended targeted screening for various cardiovascular risk factors in obese subjects, instead of a general populationbased screening for type 2 diabetes. In the IJSCO study, 11,862 apparently healthy people aged 20–70 years and not previously diagnosed with diabetes, hypertension, cardiovascular disease, or dyslipidaemia were screened for the metabolic syndrome. The metabolic syndrome, a clustering of several cardiometabolic risk factors, is associated with an increased risk of both cardiovascular disease and type 2 diabetes. The first screening step was self-measurement of the waist circumference. People with an increased waist circumference (≥ 88 cm for women, ≥ 102 cm for men) were invited for further investigations, to see whether they met criteria for metabolic syndrome. Nearly three quarters of the people who met criteria for metabolic syndrome at screening contacted their general practitioners for the results. They were invited for a consultation and treatment according to guidelines of the Dutch College of Gen eral Practitioners. This led to an increase in physical activity and weight loss during the year after screening. After 3 years, more than half the individuals no longer met criteria for metabolic syndrome. A screening interval of more than 3 years seems justified; it facilitates implementation. The screening procedure and subsequent follow- up care can be incorporated into daily practice, so that general practitioners can follow the advice of the Dutch Health Council and screen obese individuals for cardiovascular risk factors.