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CARDIOMETABOLIC RISK FACTORS AND ITS IMPACT ON CB1 RECEPTOR BLOCKAGE

 Rimonabant, the first selective CB (1) receptor antagonist in clinical use, has been extensively investigated in the rimonabant in Obesity (RIO) programme, comprising rimonabant 20 mg daily consistently reduced body weight, waist circumference, triglycerides, blood pressure, insulin resistance and creactive protein levels, and increased HDL cholesterol concentrations in both non-diabetic and type-2 diabetic overweight/obese patients. Adiponectin levels were increased, an affect that correlated with HDL cholesterol augmentation, while small dense LDL cholesterol levels were decreased in patients receiving rimonabant 20 mg compared with those receiing placebo in RIO Lipids. Furthermore, in RIO Diabetes, a 0.7% reduction in glycated haemoglobin (HbA1c) levels was observed in metformin or sulphonylurea-treated patients with type-2 diabetes. Almost half of metabolic changes occurred beyond weight loss, in agreement with direct peripheral effects. Rimonabant was mostly well-tolerated, but with a slightly higher incidence of depressed mood disorders, anxiety, nausea and dizziness compared with placebo. Overweight/obese subjects with cardiometabolic risk factors and with no major depressive illness and/or ongoing anti depressive treatment, in order to both maximise efficacy and minimise safety issues.

CARDIOMETABOLIC RISK FACTORS AND ITS INPUT ON CB1 RECEPTOR BLOCKAGE

Rimonabant, the first selective CB (1) receptor antagonist in clinical use, has been extensively investigated in the Rimonabant in Obesity (RIO) programme, comprising Rimonabant 20 mg daily consistentl reduced body weight, waist circumference, triglycerides, blood pressure, insulin resistance and creative protein levells, and increased HDL cholesterol concentrations in both non-diabetic overweight/obese patients. Adiponectin levels were increased, an effect that correlated wity HDL cholesterol augmentation, while small dense LDL c

OBESITY CAUSES HYPERTENSION

A relationship between obesity and high blood pressure is in fact, obese people have a higher blood pressure rather than people with a normal blood pressure. The cardiovascular risk is increased with obesity.

Why is there is a relation between obesity and high blood pressure?

Obesity presented an increase in the cardiac out put and the blood volume, and in the arterial resistance. In fact, obesity induces a high secretion of insulin in trying to decrease the excessive sugar concentration in the blood. This insulin secretion is higher as compared to a non-obese subject.

Moreover, the insulin, secreted by the pancreas, is responsible for many alterations in the body:

• It induces a thickening of the vessels which is responsible for an increase in their toughness, thus             increasing the blood pressure;
• It increases the cardiac output because the secretion of adrenalin is increased;
• Process of reabsorption is induced of water and salt by the kidney, which increases the blood volume and thus increases the blood pressure;
• Moreover, obesity is responsible for an over-sensitiveness to sodium, which is known to increase the rigidity of the peripheral arteries.

After some time, the obese subject will develop a natural resistance to the insulin which will guide his body to more insulin, thus generating a rise in the blood pressure by the way of the mechanisms relocate.

HOW TO MANAGE TYPE 2 DIABETES, THE ENDOCANNABINOID SYSTEM

Type 2 diabetes is closely related to abdominal obesity and is generally associated with cardiometabolic risk factor, resulting in a high incidence of cardiovascular complication. In human being endocannabinoid (EC) system is overactivated in presence of abdominal obesity and diabetes, and contributes to disturbances of energy balance and metabolism. Not only it regulates the intake of utrients through central mechanisms located within the hypothalamus and limbic area, but it also intervenes in transport, metabolism and deposit of the nutrients in the digestive tract, liver, adipose tissue, skeletal muscle, and possibly pancreas. Activation of both central and peripheral CB1 receptors promotes weight gain and associated metabolic changes. Conversely, rimonabant, the first selective CB (1) receptor antagonist in clinical use, has been shown to reduce body weight, waist circumference, triglycerides, blood pressure, insulin resistance and C-reactive protein levels, and to increase HDL cholesterol and adiponectin concentrations in both non-diabetic and diabetic overweight/obese patients. In addition, a 0.5-0.7% reduction in glycated hemoglobin (HBA1c) levels was observed in metformin-or sulfonylurea-treated patients with type 2 diabetes and in drug-naive or insulin-treated diabetic patients. Almost half of metabolic changes occurred beyond weight loss, in agreement with direct peripheral effects. Rimonabant was generally well-tolerated, but with a slightly higher incidence of depressed mood disorders, anixiety, nausea and dizziness compared to placebo. In overweight/obse patients with type 2 diabetes and high risk cardiovascular disease.

HAZARDS WITH OBESETY

     Obesity, especially visceral obesity, is associated with a cluster of metabolic complications increasing the risk of type 2 diabetes and CHD. It has been shown that obese patients characterized by a high accumulation of visceral adipose tissue have increased glycemic and insulinemic responses to an oral glucose loan compared to normal weight individuals or to obese individual with a low accumulation of visceral adipose tissue. Viscerally obese patients are also characterized by an unfavourable plasme lipid profile which includes elevated triglyceride and apolipoprotein B concentrations, reduced HDL-cholesterol level as well as in increased poroportion of small, dense LDL  Such changesin the lipid profile are often observed even in the absence of elevated LDL-cholesterol. Metabolic triad of non-traditional risk factors (hyperinsulinemia, elevated apolipoprotein B levels, increased proportion of small, dense LDL particels) was associated with a 20-fold increase in lthe risk of CHD. Indeed, less than 10% of men with a waist circumference below 90 cm and triglyceride concentrations below 2 mmol/l were characterized by the features of the metabolic triad. However, more than 80% of individuals with a waist circumderence above 90 cm and triglyceride levels above 2 mmol/l were carriers of the metabolic triad. Finally, an elevated visceral adipose tissue accumulation has also been associated with a thrombogenic and a pro-inflammatory metabolic profile which would be predictive of an unstable atherosclerotic plaque. Therefore, the stabilisation of the atherosclerotic plaque may represent a legitimate therapeutic objective to reduce the risk of CHD among patients with visceral obesity. It is recommended that a rather modest weight loss (approximately 10%) could contribute to substantially improve the risk profile of these patients.

VISCERAL OBESITY

  Visceral obesity is associated with metabolic abnormalities that increase the risk of type 2 diabetes and CHD. Obese patients with a substantial accumulation of visceral adipose tissue are characterized by higher insulinaemic and glycaemic reponses during an oral glucose challenges as well as by a deteriorated plasma lipoprotein-lipid profile compared with individuals with normal body weights or obese subjects with low levels of visceral adipose tissue. The cluster of metabolic disturbances observed among subjects with visceral obesity (hyperinsulinaemia, hyperapolipoprotein B and small dense low-low density lipoprotein (LDL) particles) is related with a 20-fold increase in the risk of CHD. Therefore, we have developed a simple screening approach in order to help physicians and health professionals indentify at low cost individuals who would be characterized by this cluster of atherogenic abnormalities. We found that the simultaneous presence of an elevated waist girth combined with moderate hypertriglyceridaemia (hypertriglyceridaemic waist) could adequately identify a large proportion (approximately 80%) of carriers of the above triad of atherogenic metabolic abnormalities (hyperinsulinaemia, hyperapolipoprotein B and small, dense LDL particles). Finally, there is evidence suggesting that the risk of an acute coronary syndrome in these viscerally obese patients may not always be related to the extent of CAS, providing further support to the notion that additional markers of thrombosis/infllammation should be considered. Thus, the stabilization of the atherosclerotic plaque, rather than its regression may even become a more legitimate and feasible therapeutic objective for the management of the CHD risk in the viscerally obese patient.