Lose Belly Fat Exercises

Flat Belly Fix

In Flat Belly Fix program, you learn the easy, tested and trusted method that saved the creator of this program (Todd Lamb) beautiful wife Tara from a life battling Type 2 Diabetes and experiencing possibly death. It was a very nasty experience with the couple during those times, but with the determination of Todd, he labored ceaselessly to finding a way out for his depressed and unhappy wife. Now they live together both happy and contented. Having used the same technique for people around (seeing the wonders it did to his wife) and also recording so much success, Todd Lamb wants to relate this secret to the world, to create this same atmosphere of joy produced in his immediate environment. Hence, he was motivated to put together this workable program. You also get to learn the secret to having a flat belly, and a healthy and fit body that has been hidden from you for so long now. The creator if this program is positive about the efficacy of this program and is so excited for you to personally experience what happens when you apply The 21 Day Flat Belly Fix in your life. Read more here...

Flat Belly Fix Summary

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I usually find books written on this category hard to understand and full of jargon. But the author was capable of presenting advanced techniques in an extremely easy to understand language.

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The Metabolic Syndrome

The Adult Treatment Panel (ATP), in recommending guidelines for the treatment of hypercholesterolemia, defined the components of metabolic syndrome as any three of the following (NCEP ATP-III , 2002 Grundy et al., 2004a, 2004b) 5. Waist circumference of 102 cm (40 inches) or greater for men and 88 cm (35 inches) or greater for women. Ruderman and colleagues (1981) defined the concept of metabolic obesity in type 2 diabetes by noting the association of diabetes with hypertriglyceridemia, low HDL, and hypertension, in patients who were not overtly obese. Prevalence of obesity associated with diabetes has greatly increased in the last 30 years, and obesity is now evident in at least 80 of patients with type 2 diabetes. Others noted the connection of high insulin levels with impaired glucose tolerance leading to type 2 diabetes, disordered fatty acid metabolism, hypertension, and increased abdominal fat deposition indicative of visceral obesity (Reaven, 2003). The linkage of these risk...

Metabolic Syndrome

The metabolic syndrome consists of components that are all susceptible to dietary management (NCEP Expert Panel, 2001). Because many patients with the metabolic syndrome are overweight or obese, a focus on modest weight loss with dietary modification and increased activity is important. The dietary recommendations for patients with the metabolic syndrome should be similar to those for patients with diabetes. Additionally, these patients should lower sodium intake, as with hypertension. The Diabetes Prevention Program was a study that evaluated the effect of intensive lifestyle changes it focused on diet and exercise versus the use of standard lifestyle changes with or without metformin (placebo group) in the prevention of metabolic syndrome in over 3000 patients with impaired fasting glucose levels (Orchard et al., 2005). Patients were evaluated over a 3-year period. At the end of 3 years, significantly more patients in the group receiving standard lifestyle change recommendations and...

Diagnostic Criteria For Diabetes Prediabetes And Metabolic Syndrome

Metabolic Syndrome Criteria 2018

Definitions of the Metabolic Syndrome Central obesity (ethnicity-specific) PLUS any Men waist circumference Europid* men waist circumference 94 cm Women waist circumference Europid* women waist circumference 80 cm Adapted from Alberti KG, Zimmet P, Shaw J Metabolic syndrome A new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med 2006 23 469-480. Adapted from Alberti KG, Zimmet P, Shaw J Metabolic syndrome A new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med 2006 23 469-480.

Testosterone effects on fat metabolism

Percent body fat is higher in hypogonadal men in comparison to eugonadal controls (Katznelson etal. 1998). Induction of androgen deficiency in healthy men by administration of a GnRH agonist leads to an increase in fat mass (Mauras et al. 1998). Some studies of young, hypogonadal men have reported a decrease in fat mass with testosterone replacement therapy (Brodsky etal. 1996 Katznelson etal. 1996 Snyder etal. 2000) while others (Bhasin etal. 1997 Wang etal. 1996) found no change. In contrast, long-term studies of testosterone supplementation of older men have consistently demonstrated a decrease in fat mass (Kenny etal. 2001 Snyder etal. 1999 Tenover 2000). Epidemiologic studies (Khaw and Barrett-Connor 1992 Seidell etal. 1990) have shown that serum testosterone levels are lower in middle-aged men with visceral obesity. Serum testosterone levels correlate inversely with visceral fat area and directly with plasma HDL levels. Testosterone replacement of middle-aged men with visceral...

Neurologic Peripheral neuropathy

The underlying mechanism for the increased cardiovascular risk associated with cisplatin-based chemotherapy is not clear. Patients who have GCT treated with cisplatin-based chemotherapy may prematurely develop hyperlipidemia, hypertension, increased body mass index, and metabolic syndrome 25,28,29 . This point underscores that long-term survivors of GCT should have lifelong medical follow-up, especially if treated with cis-platin-based chemotherapy.

Blood Pressure Monitoring

The approach to confirmed hypertension in children should be individualized and should consider variables such as comorbidities and family history. In overweight or obese children, the possibility of metabolic syndrome should be investigated. Lifestyle changes, including diet and exercise, may be sufficient for overweight children with stage 1 hypertension (BP at 95 to 99 plus 5 mm Hg). Children with stage 2 hypertension (BP 99 plus 5 mm Hg) and those with end-organ damage likely require medical therapy (National High Blood Pressure Education Program Working Group, 2004).

Cardiovascular Disease

Metabolic Syndrome and established forms of disease. Despite these efforts, compliance with guidelines remains relatively low throughout the world. As populations age worldwide, as more patients survive acute cardiovascular and cerebrovascular events, and as the incidence of hypertension, dyslipidemia, metabolic syndrome, diabetes mellitus, obesity, and other risk factors continues to increase, the burden on family physicians to identify and effectively manage CVD will continue to escalate dramatically. This chapter addresses issues related to CVD prevention diagnosing and managing the various manifestations of atherosclerotic disease, valvular dysfunction, congestive heart failure, and cardiomyopathy pericardial disease and arrhythmia identification and management.

Cardiovascular Risk Factors

As waist circumference increases, visceral adiposity increases. Visceral adipose tissue is metabolically highly active. An important conceptual shift has occurred in recent years with respect to how adipose tissue is viewed. It is no longer seen as a passive storage site for excess caloric ingestion. Instead, it is clear that visceral adipose tissue displays many features of an endocrine organ (Bradley et al., 2001 Toth, 2005a) (Fig. 27-3). Visceral adipose tissue produces a variety of inflammatory cytokines (tumor necrosis factor, transforming growth factor-p), interleukins (IL-1, IL-6), and effector molecules that regulate appetite (leptin) as well as insulin sensitivity and resistance (e.g., adiponectin, resistin). As the mass of visceral adipose tissue increases, adiponectin production decreases, which is associated with increased insulin resistance in adipose tissue, skeletal muscle, and the hepatic parenchyma (see Fig. 27-3). As adipose tissue becomes more insulin resistant, the...

Cardiovascular Effects

Diabetes induces diffuse atherosclerotic disease throughout the vascular tree. Almost 80 of diabetic patients will die of cardiovascular disease. The hyperglycemic, insulin-resistant milieu of type 2 DM initiates a broad-ranging cascade of pathophysiology that accelerates atherogenesis. Unfortunately, because of increasing obesity and metabolic syndrome in adolescents and young adults, type 2 DM is becoming relatively common in those younger than 21. Diffuse endothelial dysfunction, the accumulation of damaging advanced glyca-tion end products in the vasculature, and a heavy risk factor burden typify the patient with DM. Diabetes induces a pro-oxidative and proinflammatory state. Diabetic patients also tend to have hypercoagulability (Meigs et al., 2000), likely from (1) increased hepatic production of coagulation factors (2) increased platelet reactivity and aggregability and (3) as endothelial dysfunction progresses, the endothelium produces less tissue plasminogen activator (tPA)...

Identification of Sperm Oxidative Stress from Clinical Examination

Physical examination of the infertile male should focus on the salient features of disease processes that are linked with sperm oxidative stress. Measurement of height, weight and abdominal circumference is a useful measure of the degree of obesity and oxidative stress associated with the so called metabolic syndrome . The diagnosis of metabolic syndrome is made in the presence of at least three of the following clinical features waist circumference 102 cm (Caucasian men), BP 130 85, abnormal glucose profile and adverse lipid profile (low HDL or high triglycerides) 147 , Excess adipose tissue releases pro-inflammatory chemicals which activate the immune system and result in a systemic increase in production of ROS, with a resulting damage to sperm function. The presence of a BMI in excess of 30 kg m2 has been linked with sperm oxidative stress 100 and a significant decline in sperm function and increase in sperm DNA damage by several investigators 148, 149 ,

Coronary Artery Disease

The cholesterol threshold for using statins in diabetic patients has been lowered to low-density lipoprotein (LDL) cholesterol greater than 100 mg dL, with a therapeutic target of 70 mg dL. A large statin trial has shown that patients who demonstrate elevated C-reactive protein (CRP) with normal LDL cholesterol values will benefit from statin therapy (Ridker et al., 2008). Many patients had metabolic syndrome with elevated triglycerides, which raises non-high-density lipoprotein (n-HDL) cholesterol, a risk lowered by statin therapy and more pathologic than LDL cholesterol. Aspirin may not be efficacious in all patients because of genetic factors. However, considering the relative safety of low-dose aspirin, many clinicians think the potential benefits outweigh a possible lack of efficacy. As noted, UKPDS showed that beta blockers and ACE inhibitors were equally effective in protecting the heart, brain, and kidney. Beta blockers are known to protect the previously injured heart but...

Children and Adolescents

Side effects (e.g., acne, central obesity, hirsutism, abdominal striae, bruising). Exercise intolerance and fatigue may limit physical activity (Eijsermans et al. 2004 Konstantinidou et al. 2002 Pattaragarn et al. 2004). In addition, school- and peer-related activities may be disrupted by necessary clinic appointments and hospitalizations.

Body composition and sarcopenia

Fat mass, and in particular abdominal fat mass is negatively associated with serum (free) testosterone levels (Van Den Beld etal. 2000 Vermeulen et al. 1999a see also section 16.2.4.1). However, the direction of this association remains unclear, In a majority of controlled trials of several months duration with administration of androgens to elderly men with low or (low) normal serum (bio-available) testosterone, treatment resulted in a modest decrease of total and or abdominal fat mass (Gruenewald and Matsumoto 2003). These findings were confirmed in recent controlled studies in elderly men with transdermal administration of testosterone (Steidle etal. 2003) or DHT (Ly etal. 2001), although in this context growth hormone may have a greater effect than testosterone (Mtinzer etal. 2001).

The Etiology of Prostatic Enlargement

Had preoperatively sterile urine, 38 of specimens grew bacteria when the tissues were morcellated and cultured 37 . Other possible causes of inflammation include noxious dietary constituents, autoimmune mechanisms, oxidative stress associated with androgen action, and systemic inflammation associated with the metabolic syndrome 38 . A retrospective study of 3,942 prostatic biopsies identified as consistent with BPH showed inflammation in 1,700 (43.1 ) 32 . Furthermore, a study of specimens obtained from 80 men who had no symptoms of prostatitis but underwent TURP for treatment of BPH found inflammation to be uniformly present 39 . In another study that evaluated tissue removed with radical prostatectomy, inflammation was found in tissue samples of 35 of 40 patients who had BPH and that inflammation was associated with significantly greater prostatic weight than that observed in patients who had no inflammation 40 . In a prospective study of autopsy specimens obtained from 93 men who...

Patient Care and Monitoring

Determine if history of BMI greater than or equal to 25 kg m . If unavailable or BMI unknown, obtain weight, height, and waist circumference. Calculate the BMI. Assess the patient's willingness to lose weight. 2. If the BMI is greater than 25 kg m or waist circumference greater than 35 in. for females or 40 in. for male patients, determine the presence of risk factors. 3. Prevention of weight gain is recommended in all patients with a BMI greater than or equal to 25 kg m . Weight loss is indicated for patients with a BMI 25 to 29.9 kg m , or an elevated waist circumference with two or more risk factors, or for any patient with a BMI greater than or equal to 30 kg m . 6. Close monitoring should follow to assess weight, BMI, waist circumference, and presence of complications related to the treatment plan. If weight-loss goals are not attained, determine reasons for failure.

CADr clinical atherosclerotic disease CHD coronary heart disease

Step 9 Identify Patients With the Metabolic Syndrome Diagnosis of the metabolic syndrome is made when three or more of the following Waist circumference greater than or equal to 40 in. (102 cm) in men (35 in. 89 cm in Asian males), or 35 in. (89 cm) in women (31 in. 79 cm in Asian females) Patients with the metabolic syndrome are twice as likely to develop type 2 diabetes NCEP ATP III identified the metabolic syndrome as an important target for further reducing CHD risk. Treatment of the metabolic syndrome starts with increased physical activity, weight reduction (which also enhances LDL cholesterol lowering and insulin sensitivity), and moderation of ethanol use and carbohydrate intake, which effectively reduce many of the associated risk factors. Each of the risk factors should be addressed independently as appropriate, including treatment of hypertension and use of aspirin in CHD patients to reduce the prothrombotic state. Patients with metabolic syndrome have an additional lipid...

Abnormal HPG Regulation

White adipose tissue exhibits elevated aromatase activity and secretion of adipose-derived hormones in abdominal and visceral fat. Aromatase is an important cyto-chrome P450 enzyme involved in sexual development and is vital in the biosynthesis of estrogens from its precursor androgens, such as testosterone and dehydropi-androsterone. Ironically, obese men show signs of elevated estrogen levels as well as low levels of testosterone and follicle-stimulating hormone (FSH) 10 . Depleted levels of free and total testosterone are interrelated to aromatase overactivity in both intra-abdominal and subcutaneous fat. This condition of hypotestosteronemia low

Mecanism Of Centripetal Lipid Accumulation Supraclavicular Fat And Face

Seborrhea and hirsutism may be present. In men the most common clinical manifestation of hyperprolactinemia is the progressive loss of libido and impo-tency. Oligospermia and other physical signs of hypogonadism (i.e., muscular hypotrophy, increased abdominal fat) are commonly reported. Galactorrhea or gynecomastia is present in 15 to 30 of male patients.2 Prolactinomas among men and postmenopausal women are often macroadenomas ( 1 cm), because changes in libido are not detected early. Hyperpro-lactinemia in both sexes can also be associated with anxiety, depression, fatigue, emotional instability, and hostility.10,11

Targeting Nadph Oxidase 281011 PDE5 Inhibitors

Angiotensin II promotes endothelial dysfunction by inducing oxidative stress through activation of NADPH oxidase via AT j receptor 67 . ACE inhibitors and AT1 receptor antagonists decrease oxidative stress by preventing the activation of NADPH oxidase and enhancing clearance of ROS 139-141 . Indeed, some (but not all) clinical trials have demonstrated that blocking angiotensin II signaling improves endothelial function in patients with hypertension and metabolic syndrome, and reduces the incidence of death, myocardial infarction, and stroke 22, 142 . Basic science studies demonstrate that several statins, such as rosuvastatin and atorvastatin, improve diabetes- 154, 155 , metabolic syndrome- 156 , and hypertension- 157 related ED and increase the responsiveness to sildenafil by inhibiting RhoA ROCK signaling in the penis. A limited number of clinical studies which evaluated the effect of statin therapy in men with ED have produced mixed results. Some 158-162 , but not all 163, 164 ,...

Regulation Of Srebp Isoform Expression

Plasma Fplc

Taken together, the above evidence suggests that SREBP-lc mediates insulin's lipogenic actions in liver. This observation led to the discovery that SREBP-lc contributes to the development of hepatic steatosis or fatty liver associated with diabetes, obesity, and the metabolic syndrome. Hepatic steatosis is the most commonly encountered liver abnormality in the United States, owing to its strong association with obesity and insulin-resistant diabetes mellitus (Mokdad et al. 200l). Conservative estimates indicate that 40-60 of individuals with obesity or diabetes develop fatty livers. A subset of patients with fatty liver will subsequently develop fibrosis, cirrhosis, and liver failure. Data initially obtained in mice indicate that the fatty liver associated with insulin resistance is caused, in part, by increased SREBP-lc expression. The increased SREBP-lc expression occurs in response to the high insulin levels present in insulin-resistant states. Thus, SREBP-lc levels are elevated in...

Ischemic strokes and transient ischemic attacks caused by low cerebral flow posterior circulation

Transient Cerebral Ischemic Attacks

A 55-year-old woman with risk factors (metabolic syndrome, smoking) presented with a limb shaking of the left leg when standing. The right internalcarotid artery (ICA) was occluded. Occlusion was presumably acute. Territory of the ICA was supplied from the left ICA via the anterior communicating artery. There was no collateralblood flow from the posterior communicating artery. Initially, the symptom was considered to be focal epileptic. Perfusion MR showed reduction of blood flow in the anterior territory of the right middle cerebralartery and the right anterior cerebralartery.

Epidemiology and etiology

Psoriasis is a common inflammatory, skin disorder which is estimated to affect 1.5 to 3 of the Caucasian population. ,2 It may present at any age.3,4 Ethnic factors influence disease prevalence. In the United States, prevalence among blacks (0.45 to 0.7 ) is lower than in the remainder of the U.S. population (1.4 to 4.6 ).1 Between 10 and 30 of patients with psoriasis will also have psoriatic arthritis.5 In 10 to 15 of psoriatic patients with arthritis, joint symptoms actually appear prior to skin involvement.3 Our understanding about comorbidities associated with psoriasis is growing. Associated conditions include well known psychiatric psychological comorbidities such as depression, anxiety and poor self-esteem as well as more recently found medical comorbidities, such as inflammatory bowel disease, diabetes, cardiovascular disease, and lymphoma.6 In 2008 the National Psoriasis Foundation published a clinical consensus on psoriasis comorbidities and recommendations for screening,...

Indications And Contraindications

Complex reconstructive laparoscopic surgery begins with careful patient selection. In cases where urinary diversion is required following radical cystectomy, exclusion criteria for the cystectomy portion of the procedure will generally dominate the decision process. Common exclusion criteria for laparoscopic surgery in general will apply. Multiple prior abdominal surgeries portend extensive adhesions and usually preclude laparoscopic access however, on an individual basis, prior surgery is only a relative contraindication. Obesity must also be evaluated in each individual case. For instance, the exact distribution of subcutaneous abdominal fat differs amongst individuals. In cases where the fat is heavily distributed in the lower abdominal and suprapubic regions, excessive traction on trocars to obtain optimal instrument angles may be a limiting factor. As in open surgery, significant obesity may prevent adequate creation of an everted stoma without excessive mesenteric tension. Prior...

Effects of exogenous testosterone on cardiovascular risk factors

Since low HDL-C is an important coronary artery disease risk factor and since HDL exerts several potentially anti-atherogenic actions, lowering of HDL-C by testosterone is considered to increase cardiovascular risks (Hersberger and von Eckardstein 2003). However, the epidemiological association of low HDL-C with coronary artery disease has not been proven to be causal. Instead, low HDL-C frequently coincides with other components of the metabolic syndrome and markers of chronic inflammation, and may therefore merely be a surrogate marker for a separate but linked pro-atherogenic condition. Moreover, in transgenic animal models, only increases of HDL-C induced by apoA-I overproduction but not by inhibition of HDL catabolism were consistently found to prevent atherosclerosis (von Eckardstein et al. 2001, Hersberger and von Eckardstein 2003). Therefore, the mechanism of HDL modification rather than changes in levels of HDL-C per se appear to determine the (anti)-atherogenicity of HDL...

Patient Encounter Part 1

A 35-year-old female presents to your clinic wanting to lose weight. She reports not following any specific diet as they have all failed in the past. She does admit to eating out frequently. This patient does not exercise as her job and her kids are too demanding. Patient does smoke pack of cigarettes per day and consumes low-calorie, caffeinated and alcoholic drinks most days. Her BMI is 32 kg m and her waist circumference is 38 in.

Apoptosis Oxidative Stress and BPH

An alternative mechanism for BPH may be related to metabolic disturbances. Obesity and elevated fasting glucose are components of the metabolic syndrome 61 Both the obesity and the metabolic syndrome are associated with systemic inflammation and oxidative stress 62 . Inflammation has been previously implicated as a primary stimulus for prostate carcinogenesis 63 , and in the same way, it is possible that BPH represents an alternate, nonmalignant pathway of unregulated prostate growth promoted by oxidative stress, inflammatory mediators, and IGFs 64 Indeed, the analyses of surgical specimens have shown that BPH is usually associated with inflammation and that the extent and severity of the inflammation correspond to the amount of prostate enlargement 65 .

Factors affecting serum testosterone levels in elderly men

In clinical studies, body mass index (BMI) emerges as an important determinant of SHBG levels (Demoor and Goossens 1970). For the whole range of BMI values encountered clinically there is a highly significant negative correlation with SHBG and testosterone serum levels, explained at least in part by increased insulin levels (Giagulli etal. 1994 Khaw and Barrett-Connor 1992 Plymate etal. 1988). In elderly men this inverse relationship between BMI and SHBG levels can be clearly demonstrated notwithstanding the background of an age-related rise of SHBG levels (Vermeulen et al. 1996). Similarly, a negative association of serum SHBG and total testosterone with leptin levels has been observed in elderly men (Haffner et al. 1997 Van den Saffele et al. 1999). Negative associations with serum testosterone levels tend to be most pronounced for indices of abdominal fat (Couillard et al. 2000 Haffner et al. 1993 Khaw and Barrett-Connor 1992 Vermeulen et al. 1999a). Whereas moderate obesity...

Treatment Desired Outcome

Within the first 6 months of therapy. Weight loss is indicated for patients with a BMI of 25 to 29.9 kg m2 or an elevated waist circumference with two or more comorbidities or for any patient with a BMI of 30 kg m2 or greater. Weight then should be maintained (minimal regain of less than 3 kg 6.6 lb and continued reduction in waist circumference of 1.6 in. 4 cm ). If weight loss has been achieved and or maintained for 6 months, further therapy promoting weight loss may be inconsidered. Once maximal weight loss has been attained, any therapy used to promote the weight loss must

Evaluation Guidelines Table211

Cerebrospinal fluid examination may show albuminocytological dissociation with an elevated protein concentration and no pleocytosis in patients with Guillain-Barre syndrome and other acute pandysautonomias. Abdominal fat aspirate, rectal biopsy, or sural nerve biopsy should be considered in

Gender men and post menopausal women

Smoc Blood Clot

Patients with multiple risk factors, particularly those with diabetes, are at the greatest risk for IHD. While there are alternative definitions for metabolic syndrome, it is generally considered as a constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin resistance. Metabolic syndrome increases the risk of developing IHD and related complications by twofold.6 According to the American Heart Association, patients must meet at least three of the following criteria for the diagnosis of metabolic syndrome Increased waist circumference (more than or equal to 40 inches or 102 centimeters in males and more than or equal to 35 inches or 89 centimeters in females).

Associated Neurological Findings

Assessment of vital signs, preferably performed prior to administration of medications, is very important. Fever should always be construed as a sign of organic disease and should trigger consideration of a spinal tap. In a patient taking a neuroleptic, fever may accompany the neuroleptic malignant syndrome and may warrant consideration of this diagnosis. Once the vital signs are known, the general physical examination should be performed with the aim of identifying contributory factors to a behavior disorder. The general appearance may reveal obesity or cachexia. Central obesity and hirsutism suggest endocrine derangements, whereas hair loss may indicate lupus, thyroid disease, or simply an unrelated skin condition. Weight loss may be evident by excessive skin folds or a cachectic appearance and may accompany depressive syndromes. Changes in skin color may suggest endocrine disorders or a neurocutaneous syndrome. Evaluation of the head may reveal evidence of trauma or gingival...

Genetics vs Lifestyle

Influences on Central Obesity Central obesity suggests increased visceral fat deposits, likely caused by increased production of peptides and other metabolic messengers. Hormonal influences most likely play a role in the distribution of fat. Central obesity is believed to result partly from increased androgenic effects, which is why men have a greater tendency for central obesity. Central obesity is also associated with hyperandrogenic states in women, such as polycystic ovary syndrome (PCOS). The increase in visceral deposition of fat that can occur after menopause in women may be related to a decrease in growth hormone and estrogen production (see Chapter 35).

The Goal of Evaluation

Subclinical Cushing

Display some features of the metabolic syndrome such as impaired glucose tolerance, increased blood pressure, and high triglyceride levels. Garrapa and colleagues13 evaluated body composition and fat distribution, as measured by dual-energy x-ray absorptiometry (DEXA), in women with nonfunctioning clinically inapparent adrenal masses and in women with Cushing's syndrome compared with healthy controls matched for age, menopausal status, and body mass index. Women with clinically inapparent adrenal masses had larger waist circumference, reflecting intra-abdominal fat. The blood pressure was higher in patients with these tumors than controls, and 50 of patients were hypertensive. High-density lipoprotein (HDL) cholesterol levels and triglyceride mean values were also higher in patients with clinically inapparent adrenal masses than in controls. If central fat deposition, hypertension, and low HDL are important risk factors for cardiovascular disease, then patients with clinically...

Clinical implications

Significant and independent associations between endogenous testosterone levels and cardiovascular events in men and women have not been confirmed in large prospective studies, even though cross-sectional data suggested cardiovascular diseases can be associated with low testosterone in men. However, hypoandrogenemia in men and hyperandrogenemia in women are associated with visceral obesity, insulin resistance, low HDL cholesterol, elevated triglycerides, LDL cholesterol and PAI-1. These gender differences and confounders render the precise role of endogenous testosterone in atherosclerosis unclear. Exogenous androgens induce both apparently beneficial and deleterious effects on cardiovascular risk factors by decreasing serum levels of HDL-C, PAI-1 (apparently deleterious) Lp(a), fibrinogen, insulin, leptin and visceral fat mass (apparently beneficial) in men as well as women. However, androgen-induced declines in circulating HDL-C should not automatically be assumed to be...

Correlational studies demonstrating the relationship of serum testosterone concentrations and muscle mass and function

Healthy, hypogonadal men have lower fat free mass (FFM) and higher fat mass when compared to age-matched eugonadal men (Katznelson et al. 1996 1998). The age-associated decline in serum testosterone levels correlates with decreased appendicular muscle mass and reduced lower extremity strength in Caucasian as well as African-American men (Baumgartner etal. 1999 Melton etal. 2000 Morley et al. 1997 Roy et al. 2002). Similarly, epidemiological studies have demonstrated an inverse correlation between serum testosterone levels and waist-to-hip ratio and visceral fat mass assessed by CT scan. In a cohort of 511 men aged 30 to 79 years in 1972 to 1974, levels of androstenedione, testosterone, and sex hormone-binding globulin measured at baseline were inversely related to subsequent central adiposity, estimated 12 years later using the waist-hip circumference ratio (Khaw and Barrett-Connor 1992). In another study, total and free testosterone concentrations were negatively correlated with...

The Burden Of The Disease

Several organizations have proposed definitions of the metabolic syndrome that differ not only in the set of criteria included but also in the cutoff values used to define the presence or absence of an individual component of the syndrome (Table 2-2). However, both the concept and the clinical utility of the metabolic syndrome were recently critically appraised.8

Diabetes Mellitus

Diabetes is a rapidly growing worldwide pandemic, and cigarette smoking is responsible for about 10 of the incidence of type 2 diabetes. A dose-response relationship exists, with the risk increasing in direct proportion to the number of cigarettes smoked. People who smoke more than one pack a day have about double the risk for diabetes as nonsmokers, and the risk is still 1.5 times greater for those who smoke only 1 to 14 cigarettes a day (Manson et al., 2000 Willi et al., 2007). Smoking increases the risk for development of the metabolic syndrome and its attendant cardiovascular consequences (Chiolero et al., 2008).

Revascularization In Diabetic Patients With Stable Coronary Disease

In addition to increased periprocedural morbidity and mortality, as well as long-term mortality, diabetes is associated with an increased rate of repeat revascularization after CABG. A prospective analysis on 26,927 patients who were contacted every 5 years up to 25 years after CABG at a single institution in the United States identified diabetes as an independent predictor of subsequent coronary revasculariza-tion (Fig. 2-6).60 As part of the metabolic syndrome, diabetes is frequently associated with obesity, hypertension, and hypertriglyceridemia. The impact of these four factors (the deadly quartet ) on 8-year mortality after CABG was assessed in a single-center database that included 6428 patients.61 Compared with individuals who had no risk factors, the HR for mortality increased from 1.6 among those with one risk factor to 3.9 for those with four risk factors. The yearly mortality rate ranged from 1 in patients with

Risk factor obesity

Lakka HM, Lakka TA, Tuomilehto J, Salonen JT. Abdominal obesity is associated with increased risk of acute coronary events in men. European heart journal, 2002,23 706-713 (cited in Sowers JR. Obesity as a cardiovascular risk factor. American journal of medicine, Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes care, 2001, 24 683-689 (cited in Sowers JR. Obesity as a cardiovascular risk factor. American journal of medicine,

Associations of endogenous testosterone with cardiovascular risk factors

In men testosterone plasma levels were frequently found to have positive correlations with serum levels of HDL-C as well as inverse correlations with plasma levels of triglycerides, total cholesterol, LDL-C, fibrinogen and PAI-1. However, serum levels of testosterone have even stronger inverse correlations with BMI, waist circumference, waist-hip-ratio (WHR), amount of visceral fat and serum levels of leptin, insulin and free fatty acids. After adjustment for these measures of obesity and insulin resistance, the correlations between cardiovascular risk factors with testosterone but not with visceral fat or insulin lost their statistical significance (Hergenc et al. 1999 Tchernof et al. 1996 Tsai et al. 2000). These findings indicate that a low serum level of testosterone in eugonadal men is a component of the metabolic syndrome, which is characterized by the presence of obesity, glucose intolerance or overt type 2 diabetes mellitus, arterial hypertension, hypertriglyc-eridemia, low...

Outcome evaluation

Successful management of overweight and obesity is determined by the ability the treatment plan has to (a) prevent weight gain, (b) reduce and maintain a lower body weight, and (c) decrease the risk of obesity-related comorbidities. Since weight is necessary to calculate the BMI, it, as well as waist circumference, should be determined. Obesity management may encompass more than weight loss or maintenance in the presence of other conditions other pertinent parameters should be assessed at baseline. The presence of hypertension, type 2 diabetes, hyperlipidemia, CAD, sleep apnea, hypothyroidism, osteoarthritis, gallbladder disease, gout, or cancer should be determined. Blood pressure and heart rate should be measured prior to implementation of any therapy. Certain laboratory parameters also should be assessed. A basic metabolic panel, liver function tests, complete blood count, fasting lipid profile, full thyroid function tests, and other laboratory studies as deemed necessary should be...

Clinical presentation and diagnosis

Any interaction between a patient and a healthcare provider presents an opportunity to evaluate the patient's height and weight. From these parameters, the BMI should be determined as well as waist circumference and the presence of comorbidities or associated risks. BMI, waist circumference, comorbidities, and readiness to lose weight are used in the assessment of the overweight or obese patient. The BMI is calculated using the measured weight in kilograms divided by the height in meters squared (kg m ) for all adult patients regardless of gender. The BMI distribution changes with age for children just as height and weight. Percentiles specific for age and gender are used to define overweight and obesity as well as healthy and underweight (pediatrics). The BMI is classified according to Table 102-1. Waist circumference should also be determined for adult patients by placing a measuring tape at the top of the right iliac crest and proceed around the abdomen, ensuring that the tape is...

Physical Manifestations

Despite the well-documented studies that indicate the association of ED to lowered fertility rates and being more prevalent in obese men, evidence and information of the pathophysiological link between obesity and ED remains limited. It has been hypothesized that visceral obesity increases proinflammatory factors and, in doing so, promotes an inflammatory response and contributes to ED 90 , Since an erection depends on hemodynamics and vascular health, any factor that causes endothelial dysfunction or impairs endothelial NO release and the integrity of the vascular bed will contribute to ED. Nevertheless, a report illustrated that changes only in one's lifestyle improved sexual function in nearly one-third of obese men with ED 91 . Sleep apnea is a common disorder in which an individual has one or more pauses in breathing or shallow breaths while sleeping. The chronic condition affects 4 of middle-aged men, but usually goes undiagnosed. Interestingly, it has been reported that about...

Cushings Syndrome Cushings Disease

Hypertension, diabetes, hyperphagia, central obesity moon facies, dorsocervical fat deposition (buffalo hump may cause Mental status changes, idiopathic myelopathy), hirsutism, acne, menstrual disorders evidence of protein cataboism (eg, easy bruising myophathy intracaranial hypertension, visual field

Risk factors

Hormone therapy, poor diet, physical inactivity and obesity and central body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated lipoprotein(a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation and infection. This paper represents probably the most thorough assessment of the prediction and potential for the prevention of stroke.

Late Adulthood

People with schizophrenia, on average, have a shortened life span. This is due to a number of factors, especially suicide and accidents (Siris, 2001). Patients with schizophrenia also have immunological changes as well as an increased prevalence of the metabolic syndrome, that is Type II diabetes, hypertension, other cardiovascular disease, and obesity. Antipsychotic medications certainly contribute to this problem, but it is possible that this is also a consequence of the abnormal development that causes psychotic symptoms.

Future Prospects

The Zucker fatty rat has been used in research as a naturally occurring animal model of spinal ligament ossification. However, because it has genetic characteristics that closely resemble the visceral fat syndrome, in which insulin resistance is associated with visceral obesity in humans, it can be said to deserve attention as a highly suitable animal model from the standpoint of metabolic modulation by leptin and the sympathetic nervous system.

Garment sizing

There are few uniform sizing practices for the design of chemical protective garments. The availability of sizing often depends on the specific type of the garment and the relative volume of garments sold by the manufacturer. Sizing may be based on individual measurements for custom sizing, numerical sizing for regular wearing apparel (chest or waist size), or alphabetic sizing (e.g., small, medium, and large). Partial body garments are likely to be offered in fewer

Causes and Incidence

The incidence of obesity is rising worldwide. With increased mechanization and changes associated with increased food availability and lower average daily caloric expenditure, people are experiencing continuous weight gain with aging. Being overweight and the development of obesity now constitute the second most important preventable cause of mortality. In the United States, 30 of the population is obese, and 70 is overweight. The incidence of obesity is rising among both genders as well as all racial and ethnic groups. An important consequence of obesity is the development of insulin resistance and the metabolic syndrome (Haffner et al., 1990 Haffner and Taegtmeyer, 2003). The metabolic syndrome (or syndrome X ) is defined by a constellation of cardiovascular risk factors and is associated with heightened risk for cardiovascular morbidity and mortality. A variety of definitions of the metabolic syndrome have been developed, Table 27-7 NCEP ATP-III Criteria for Diagnosing Metabolic...

Phenotype

Muscles and physical strength grow under testosterone treatment and the patient develops a more vigorous appearance (e.g. Wittert etal. 2003). Due to its anabolic effects body weight increases by about 5 . Therefore, accurate recording of body weight under comparable conditions is part ofthe routine control of the patient. The increase in lean body mass at the expense of body fat can be measured. Originally this was only possible by sophisticated equipment in the framework of clinical research (Young etal. 1993), but can now be done conveniently by equipment measuring bioimpedance (Rolf etal. 2002). Moreover, the distribution of subcutaneous fat that shows feminine characteristics in hypogonadism (hips, lower abdomen, nates) may change with increasing muscle mass. In particular, testosterone appears to reduce abdominal fat (Rebuffe-Scrive etal. 1991).

Lipid metabolism

Besides lipid profiles other metabolic parameters such as overweight and especially accumulation of abdominal fat predispose men for cardiovascular diseases and diabetes. This condition is more frequent in men with low testosterone and SHBG levels (Tchernof et al. 1996). Leptin, the hormonal product of adipocytes, is a candidate link between these different metabolic systems. Substitution therapy of male hypogonadism normalizes initially elevated leptin concentrations and reduces obesity and therefore could be considered a useful marker of therapeutic effectiveness (Behre etal. 1997a Jockenhovel etal. 1997 Sih etal. 1997).

Cancer

The mechanisms accounting for the increased risk of cancers vary with the primary site. One proposed mechanism for endometrial and breast cancer is an increase in circulating estrogen levels. Central obesity in particular has been associated with breast cancer. Increasing evidence shows an association between obesity and prostate cancer, with the increased risk likely related to changes in testosterone as well as leptin, insulin-like growth factor 1, and interleukin-6 levels.

Fatty Liver Disease

Fatty liver disease is the most common reason for elevated serum liver enzymes and affects an estimated 20 of the U.S. population (Angelico et al., 2005). First described in obese diabetic females, fatty liver disease is widely recognized as a complication of obesity and is associated with the features of the metabolic syndrome. The spectrum of fatty liver disease ranges from nonalcoholic fatty liver disease (NAFLD) to nonalcoholic steatohepatitis (NASH). Fibrosis and cirrhosis can develop in NASH, which has been linked to insulin resistance, as with metabolic syndrome (Choudhury and Sanyal, 2004). The increased insulin level likely causes fatty acid flux from adipose tissue to be deposited in the liver. Inflammatory cytokine release triggered by hyperinsulinemia contributes to the steatohepatitis and fibrosis.

Management in Adults

The benefits of screening for obesity have been examined by a number of organizations. The U.S. Preventive Services Task Force (USPSTF, 2003) recommends screening adults for obesity. The amount of information needed to make the diagnosis and establish the most effective approach is modest and can be handled in the context of a typical office visit. The initial approach can be framed through three questions (Hensrud, 2004) (1) what is the patient's BMI (2) what is the waist circumference and (3) what comorbidities are present Determining comorbidities may involve obtaining fasting blood glucose, thyroid-stimulating hormone (TSH), aspartate transaminase (AST) or alanine transaminase (ALT), and lipid profile, as well as BP and history information suggesting associated disorders (e.g., OSA, DJD). Having identified overweight or obesity as a medical concern, it is important to help patients become aware of the medical implications and to engage them in management. Box 36-1 lists areas to...

Obesity

Have been no controlled studies aiming to rectify any consequent androgen deficiency. A series of studies by Marin has raised interesting questions about the role of pharmacological androgen therapy in obesity. A pilot study reported reduced waist hip circumference and improved insulin sensitivity following three months' transdermal treatment with testosterone (250 mg in 10 g gel daily) in eight men but not with dihydrotestosterone (250 mg in 10 g gel daily) in nine men (Marin et al. 1992). The study design, lacking placebo controls or any dose finding, did not allow any conclusion as to whether this difference arose from differences in skin bioavailability or androgen type (aromatisable or not) or potency. The same investigators then reported a double-blind study in which 27 middle-aged men with abdominal obesity were randomised to placebo, testosterone or dihydrotestosterone treatment by daily topical application of a transdermal gel (125 mg in 5 g gel daily) for nine months (Marin...

Multiple Myeloma

The EDX examination shows evidence of a chronic, acquired SD polyradiculoneuropathy. The presence of an M-protein in the serum or urine occurs in nearly all patients. General laboratory studies in multiple myeloma may sometimes disclose evidence of anemia, chronic renal failure, hypercalcemia and occasionally hyperuricemia, leukocytosis and thrombocytosis. Skeletal survey may disclose osteolytic or occasionally osteoblastic lesions in approximately two thirds of patients. However, the diagnosis of multiple myeloma is made on bone marrow aspiration, which demonstrates increased numbers of immature plasma cells in the bone marrow. As noted earlier, the presence of a polyneuropathy in a patient with multiple myeloma is more likely to be due to amyloidosis. Confirmation of systemic amyloidosis with appropriate biopsy of such tissues as the rectal mucosa or abdominal fat pad may be helpful however, sural nerve biopsy for amyloid may provide definitive evidence of amyloidosis as...

Orlistat

One study evaluated the longer-term effect of orlistat in adolescents. In a group of 12-to 16-year-old individuals, orlistat (120 mg three times daily) in combination with diet, exercise, and behavior modification resulted in a significant reduction in BMI and waist circumference when compared to placebo. In addition, orlistat-treated subjects exhibited minimal weight increase after 1 year (0.53 kg) compared with placebo-treated patients (3.14 kg). Common adverse reactions observed were fatty or oily stools, oily spotting, oily evacuation, or abdominal pain and or flatulence with bowel movements. Soft stools, nausea, increased defecation, and fecal incontinence also were noted.44 to placebo.46 Improvements of waist circumference, HDL cholesterol concentration,

Potential benefits

From the discussion in the preceding sections of this chapter and from literature reviews (Bhasin and Buckwalter 2001 Gruenewald and Matsumoto 2003), it emerges that testosterone administration to elderly men can induce potentially beneficial effects, but the results are often mitigated and there usually is no demonstrated impact on endpoints that are directly relevant for the clinic. Several studies have shown improvement of lean body mass and sometimes also of muscle strength, but whether these changes are sufficient to make a difference in terms of functionality is still unclear. Positive effects on bone mineral density are seen only in men with frankly low serum testosterone and we have no information on the effect of treatment on fracture rates. Abdominal fat may decrease and the insulin sensitivity may improve, whereas high dose testosterone may have direct beneficial effects on heart and arteries, but we have no indication of gains in terms of hard cardiovascular endpoints....

Insulin Resistance

In addition, it is the first measurable metabolic disturbance among individuals who will subsequently develop type 2 diabetes. Insulin resistance describes a reduced sensitivity in body tissues to the action of insulin, which affects both glucose disposal in muscles and fat and insulin suppression of hepatic glucose output. As a consequence, higher concentrations of insulin are needed to stimulate peripheral glucose disposal and to suppress hepatic glucose production in patients with type 2 diabetes than those without diabetes. On a biologic level, insulin resistance has been associated with increased coagulation, pro-inflammation, and endothelial dysfunction, among other conditions.10 In insulin-resistant subjects, endothelium-dependent vasodilation is reduced, and the severity of the impairment correlates with the degree of insulin resistance. Abnormal endothelium-dependent vaso-dilation in insulin-resistant states may be explained by alterations in intracellular...

Body composition

Aging results in a decrease in resting energy expenditure primarily as a consequence of this decline in muscle mass. Fat distribution also alters with aging, such that truncal and intra-abdominal fat content increase. In addition, the reference criteria of stature changes with age. Because of increasing kyphosis, compression of intervertebral discs and even vertebral collapse, stature has usually decreased 1-2 cm by the age of 60 years, with an accelerating decrease thereafter. These important factors need to be considered when physiologic data such as muscle strength or maximal oxygen consumption are normalized to anatomic measures such as body mass.

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