Casualties on the rise as we lose battle of the bulge

National Heart Foundation medical director Norman Sharpe shows a projected image of a blood clot that caused a fatal heart attack. Picture / Dean Purcell

Do try this at home - probably best in your bedroom with the door shut. Encircle your waist with a tape measure. For those who have been unable to locate that perimeter for some time, the latitude is midway between the top of the pelvis and bottom of the ribs.

For men the circumference should not be more than 94cm. For women a girth of more than 80cm is too much. Body type and ethnicity don't make any difference - except that for Asian men the circuit is 90cm.

What's surprising about this measure - politely referred to as "central obesity" - is just how many, who would not normally be called rotund, stout, tubby, fat belly or lard guts, exceed the cut-off.

For those who do, it's one of the first signs you may have metabolic syndrome - a collection of conditions that increase the risk of heart and vascular disease, stroke and type 2 diabetes.

"The important thing about the waist circumference is that it conveys something about what the problem actually is," says Wellington Hospital clinical support services director Robyn Toomath. "It's fat packed around the viscera, and there is something bad about the fat in the gut."

Something bad that's having far-reaching effects. Young and early middle-aged adults are dying of heart disease at a faster rate than their parents.

"A lot of people have changed their diet to eat more healthily and become more active, and smoking is down," says Heart Foundation medical director Norman Sharpe.

"Yet we're seeing this new wave of disease almost certainly related to obesity and diabetes - which were always relevant but much less common 20-30 years ago."

Sharpe shows a salutary picture of the problem - a magnified cross section of a coronary artery narrowed by a large fatty plaque which had developed over many years, finally leading to a blood clot which suddenly completed the blockage and caused a fatal heart attack.

Along with the projected upswing in mortality rates is another alarming trend - more people arriving at our hospitals with heart attacks. Most worrying is a significant increase in men and women in the 25 to 44 years age group.

"I wonder whether it's a combination of being overweight and smoking - younger people are still smoking about the same as they were," says cardiologist John Elliott of the Christchurch School of Medicine.

But the trinity of obesity, heart disease and type 2 diabetes is an incomplete gospel. The causality is disrupted by a complex mix of other factors - not the least of which is the genes we are born with.

"Obesity to my mind is probably 80-90 per cent genetically determined," says Toomath, who is also spokesperson for Fight the Obesity Epidemic. "Except that the genetics don't explain the big change - so we have to look for something outside genetics to explain that."

The big change is that while people today are smoking less, and blood pressure and cholesterol levels are down, the population is getting heavier - in Auckland by about 5kg on average for adults compared to 20 years ago. More of us are getting obese.

In 1977, 9.4 per cent of males and 10.8 per cent of women were obese. By 2003 those numbers had more than doubled to 19.9 per cent and 22.1 per cent respectively according to the Ministry of Health.

With a fatter populace, type 2 diabetes - the lifestyle disease - is also on the rise. The Ministry of Health says diabetes affects about 200,000 people in New Zealand, but only half of these people have been diagnosed. The incidence is predicted to increase by 31 per cent for Europeans and by 50 per cent for Maori and Pacific Islanders by 2020.

But University of Otago professor of medicine and nutrition Jim Mann says the figures are underestimated. "We have no idea of how much diabetes we have in New Zealand - the estimates are totally wrong." He has little doubt that "we are dealing here with one of the great epidemics of our time".

But as Sharpe points out, other influences and disparities also have to be taken into consideration - that, for example, men and women in the poorest two socioeconomic groups are two to three times more likely to die of heart disease in middle age compared to those in the most affluent.

"If you're poorly educated, poorly informed, actually poor - and you don't know where to start and don't care - your heart disease risk and also general health status are likely to be much worse," says Sharpe.

Sharpe agrees that stress is also important - more so than was thought previously, but still difficult to measure and change.

A recent Finnish survey of 6400 English civil servants found that those who felt they were fairly treated at work were at a 30 per cent lower risk of coronary heart disease incidents than those who felt they were unjustly treated by their bosses.

The findings appeared to be independent of the levels of conventional job strain and stress, cholesterol, body mass index, hypertension, smoking, alcohol consumption and physical activity.

"Stress causes excess adrenalin, and adrenalin we know is not a good thing over a sustained period," says Gerard Devlin of the department of Cardiology at Waikato Hospital. "Is it involved in the silting up of the arteries? Possibly, but I think stress has got much more to do with why, when you've got a silted up artery, the plaque ruptures."

Genetics, socio-economics, stress and other factors aside, there is a common theme - New Zealand is in the grip of an epidemic involving, one way or another, heart disease, type 2 diabetes, smoking and obesity.

"Our observations suggest an epidemic in acute coronary syndromes is in progress," say cardiologist John Elliott and colleague Mark Richards in last month's New Zealand Medical Journal. "The ageing population contributes to this epidemic but increases have occurred in men and women of all age groups."

The raw research highlights several alarming statistics: 58 more men aged 25-34, and 193 extra women aged 35-44, were admitted to hospital with heart attacks in 2000 compared to 1990.

And in the five years between 1995 and 2000, Maori heart disease hospitalisations increased 15 per cent per year, and Pacific Islanders by 25 per cent, compared with 5 per cent a year in all other New Zealanders.

Elliott would like to see more research but thinks smoking is still playing a big role. "Unfortunately if you look at smoking rates in the young, it really hasn't changed much in the past 10 or 20 years - the trends have been older people stopping."

In particular he notes increased smoking among young Maori and Pacific Islanders, plus a jump, 10 to 15 years ago, in the number of women smoking.

In a draft paper, Sharpe and his colleagues discuss what might be causing heart disease death rates to rise among not just baby boomers born in the 1950s and 1960s, but also, the group born in the 1970s.

The paper speculates that the rise could reflect changing proportions of different ethnic groups in the population, or the emergence of a hardcore group of people non-responsive to health promotion messages such as not smoking.

But it concludes: "A more likely explanation relates to the emergence, since the 1970s, of the epidemic of obesity (and consequential type 2 diabetes) in New Zealand and indeed throughout the developed world."

Otago University's Mann also predicts an increase in heart disease. He says although some of the traditional risk factors for heart disease, such as high cholesterol and blood pressure, are improving, diabetes-related risk factors are not.

Things like the level of blood fats known as triglycerides are on the rise. So too are the levels of insulin in the blood, a sign of insulin resistance - the inability of your cells to use insulin to absorb blood sugar. All are known heart disease risk factors.

Add to the picture an even more dramatic increase in the precursors to the disease - metabolic syndrome - and there is really only one conclusion. "It would be surprising if heart disease didn't also start to increase," says Mann.

There is still considerable debate about how exactly to define and intervene with metabolic syndrome. And just where the waist circumference cut-off should be.

The American Heart Association, for example, has it at 102cm for men and 88cm for women. Others argue the waist-to-hip ratio is a better obesity indicator - calculated by dividing the waist measure by the hip measure. The cut-off point for this ratio is less than 0.85 for women and 0.90 for men.

What is known is that those who have metabolic syndrome are at much higher risk of developing type 2 diabetes and heart disease. It's also clear that central abdominal obesity alone does not a metabolic syndrome make.

Fat guts need at least two other markers - such as insulin resistance, high triglycerides, or high blood concentration of the amino acid homocysteine or the blood clotting substance, fibrinogen.

Then there's C-reactive protein, which is known to increase during inflammation of the linings of the arteries from the build-up fatty deposits.

The good news for those suffering heart attacks is the treatment today is much better than before - so much so that until now, mortality has been steadily declining since its peak in the 60s and 70s.

Even so it's still our No 1 killer - cardiovascular disease including stroke accounts for 40 per cent of deaths in New Zealand compared to 29 per cent for all cancers.

A key to the improvement is much more sensitive tests to determine whether a threatened heart attack is actually in progress and, following recently established guidelines, much more aggressive treatment - in some cases by applying clot dissolving treatment urgently and in others by immediate angioplasty (feeding a catheter into the artery and and inflating a tiny balloon to disintegrate blood clots and reopen clogged arteries).

The bad news is that getting the procedure depends very much on where you live.

"The system is not able to cope," says Waikato Hospital's Devlin. "Someone may sit in a regional centre for 10 days waiting for transfer to Waikato for an angiogram."

The hospital, which services the Midland region, has the lowest rate of angioplasty and surgery (coronary revascularisation) in New Zealand. The remedy is not simple. Catheterisation laboratories start at $1 million and then there's the problem of attracting cardiologists to work in regional centres.

"It's not simply clinicians bleating this time - we've got a real problem, particularly as we move forward with the burden of cardiovascular disease ahead of us," says Devlin.

Sharpe says it's no coincidence the lowest revascularisation rates are in the poorest areas of the Midland and Mid Central regions. But he points out too that the overall national rate is lower than Australia's.

With concerns about the impact of the diabetes and obesity epidemic, the foundation and others are calling on the Government to act now to develop and implement a heart disease control plan covering prevention and treatment.

"For preventive purposes there is agreement to do away with jargon and consider cardiac disease and diabetes as the same problem," says Sharpe.

"The healthy lifestyle messages required for this need to be clear and consistent."

Others are more alarmist and hardline. "There is no country in the world that can afford to treat what is coming our way. We can barely afford to treat it at the moment," says Wellington Hospital's Toomath, pointing out that the health costs of obesity in New Zealand are projected to balloon to $1 billion a year by 2020.

"Things we are asking for will be the norm in the not-too-distant future," she says, with reference to Fight the Obesity Epidemic goals, which include restricting TV advertising of junk food, banning soft drinks from schools, differential taxes on calorie-dense and nutrient-poor foods, and the removal of GST from fresh fruit and vegetables.

"We are going to have to look at how we can restructure society to protect people from the development of obesity."

Toomath sees a time when stairwells in offices are required by law to be accessible for exercise; when there will be restrictions on the fat and sugar contents of manufactured food which will routinely carry health warnings; and when marketing techniques that encourage people to eat more - upsizing or packaging together (Do you want fries with that?) - are banned.

She argues that such a change is necessary because humans have a genetic determination to eat more. "Starvation has been the biggest threat to survival and we are genetically programmed to eat to avoid this."

All of which makes the battle of the bulge a losing fight. And not just for the socio-economically deprived. Toomath says the epidemic hits highly intelligent and successful businesses people too.

"Everything in their life is under control except their weight. They have every reason in the world - vanity exceeding every other one by about a million times - to lose weight.

"They know what the link is with health and diabetes and they want to be thin more than anything in the world, but can they do it? Hell no - their only way is to buy themselves a bariatric [stomach stapling] operation."