Metabolic syndrome is an emerging diagnosis in the medical field that has effects on patient care. Becoming familiar with it and having it become a common part of patient care will, if used appropriately will increase the lives of those who have become affected with or are at risk of becoming diagnosed with metabolic syndrome. Metabolic syndrome is a constellation of risks factors of metabolic origin that are accompanied by the increased risk of cardiovascular disease and type 2 diabetes.
There are five major factors to look for; out of these five a person only needs three to be diagnosis with metabolic syndrome. They are obesity, mainly that of the waistline, insulin resistance, hypertension, dyslipidemia, and systemic inflammation. Once a person has three or more of these a medical professional can take the necessary steps in order to begin treatment. Allowing an improved and more efficient way to help patients that are at risk of metabolic syndrome would only improve their lives.
In today’s world of self-indulgence, people have sacrificed their health for fleeting pleasures. Overeating and decreased activity have contributed to the decline in health of many Americans. Medical professionals are beginning to see increases in abdominal obesity, high blood pressure, and insulin resistance. This has caused some medical professionals to use the term metabolic syndrome to describe what they are seeing. Metabolic syndrome is a group of risk factors for diabetes and cardiovascular disease that have metabolic origins.
It is important for medical professionals to be aware of what metabolic syndrome is, how it affects the body, how to treat it, and the legitimacy of the syndrome. As Dr. Grundy has indicated in his article written in 2001, the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) introduced the metabolic syndrome as a risk partner to elevated low-density lipoprotein (LDL)-cholesterol in cholesterol guidelines.
In one study of just over 3400 people, approximately 34% of adults in the study met the criteria for having metabolic syndrome (Ervin, 2009) making this a common occurrence in the clinical setting. The impressive numbers of almost half are shocking really when compared to an article by Vanderploeg where she writes, “Metabolic syndrome affects 50 million Americans, about 34% of adults older than age 20.” Heart disease has stretched across America and many people have found themselves hospitalized and as the number one killer in the states some have even died from it.
Since heart disease is the number one cause of death in the United States (American Heart Association (AHA), 2010), reducing those factors that contribute to heart disease should be the emphasis of every clinician practicing in health care. One of every three deaths in the United States can be directed attributed to some form of cardiovascular disease (American Heart Association, 2010). With these high percentages metabolic syndrome can longer go unnoticed or ignored by medical professionals for the health of the American people. Definition
Physicians have long understood the health risks of obesity, insulin resistance, hypertension, and high cholesterol; but it has only been recently that they have begun to group these health risks together. Metabolic syndrome was first proposed in the 1980s when the association between metabolic disorders and cardiovascular disease was more clearly defined than it had been previously. Other names for metabolic syndrome that have been used are syndrome X, obesity dyslipidemia syndrome and insulin resistance syndrome.
Metabolic syndrome is a cluster of various metabolic states that have been shown to directly relate to cardiovascular disease: abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, and insulin resistance with or without glucose intolerance. The ATP III guidelines further separate these characteristics into underlying, major and emerging risk factors (Grundy, Brewer, Cleeman, Smith, & Lenfant, 2004).
The underlying risk factors include obesity, physical inactivity and an atherogenic diet. The major risk factors for cardiovascular disease in this syndrome are smoking, hypertension, increased LDL cholesterol and low HDL cholesterol, aging and a family history of coronary events. The emerging risk factors are increased triglycerides, small LDL particles, insulin resistance, a pro inflammatory and prothrombotic state as well as glucose intolerance.
The combination of these factors in one person is a predictor of that person having a future cardiovascular event or the onset of type 2 diabetes (Meigs, 2010). With so many risk factors laying down a set of defined parameters can be daunting. It is no wonder researchers often argue over set guidelines. However with more and more people developing these problems, it is necessary to start somewhere.
The World Health Organization (WHO) was the first to attempt to standardize the criteria 1998. “WHO published criteria to define the metabolic syndrome in an attempt to harmonize reporting of prevalence through epidemiologic studies. The criteria included a measure of insulin resistance, by a hyperinsulinemic euglycemic clamp, impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes, obesity (BMI >30kg/m), hypertension (> 140/90 mm Hg), and microalbuminemia” (Gallagher, LeRoith, Karnieli 2008).
However, the use of a hyperinsulinemic euglycemic clamp proved to be difficult in studies. In 2001 The National Cholesterol Education Program (NCEP) attempted to improve and simplify the WHO definition and developed the Adult Treatment Panel III (ATP III). The NCEP ATP III guidelines require that a person have at least three of the following listed criteria: waist circumference for men of greater than or equal to forty inches or for women greater than or equal to thirty-five inches, triglycerides greater than or equal to 150mg/dL, an high density lipoprotein- cholesterol (HDL-C) of less than 40mg/dL for men and less than 50mg/dL for women, hypertension greater than or equal to 130/85mm Hg and a fasting glucose greater than or equal to 100mg/dL.
The International Diabetes Federation defines metabolic syndrome as having the abdominal obesity plus any two of the other risk factors listed by the NCEP ATP III guidelines (Bansal, S., Blaha, M., Blumenthal, R., DeFilippis, A., Golden, S., & Rouf, R., 2008). These criteria proved to be more useful in the clinical setting and easier for primary physicians to use.
Although the criteria for each organization differ slightly, the metabolic processes driving those criteria are essentially the same. Having a genetic predisposition, a particular body fat distribution and a decreased level of physical activity make the likelihood of developing cardiovascular disease or diabetes greater than if these characteristics were not present.
In the National Health and Nutrition Examination Survey III, increased body weight was directly correlated with metabolic syndrome. It was found in sixty percent of those who were obese, in contrast to only five percent of those having a normal weight (Meigs, 2010). Disease Process
Why should medical professionals be concerned with metabolic syndrome? Inside most studies there is ample evidence, which if taken into account, could help them to better serve the general public. With early identification patients can take the steps needed to stop the progression of diabetes and heart disease and hopefully be able to prevent long-term complications. The disease processes of metabolic syndrome are deeply intertwined and have a cascading effect on each other.
Obesity is generally the first indication that a problem is present. Vanderploeg (2008) points out in her article, ” A person is more likely to develop many of the underlying conditions of metabolic syndrome if he or she is overweight and if that extra weight is around the waist, producing an apple-shaped body.” This is the only component of metabolic syndrome that can be visually seen by medical professionals, making obesity an easy point to engage with the patient about.
The abdominal obesity is important because it usually indicates fat around the abdominal organs called visceral fat. This is the fat that increases a patient’s waist size. These fat cells not only release fatty acids into the blood but can also act as an endocrine organ, releasing hormones that induce insulin resistance (Gallagher et al., 2008). Obesity also increases the “production of inflammatory cytokines that result in insulin resistance, dyslipidemia, hypertension and production of prothrombotic factors” (Gallagher, et al., 2008). Being overweight is just the beginning of issues that seem to follow it around.
Another sign of metabolic syndrome is that of becoming insulin resistant. “Obesity increases lipolysis, which leads to insulin resistance. The high levels of circulating insulin can increase fat storage in the abdomen by decreasing growth hormone and replacing lean muscle mass with fat. (Vanderploeg, 2008). Simply becoming insulin resistant does not make a person a diabetic.
However, that being said, it does not help with a person’s health. Bernstein (2003, p.39) wrote, ” Obesity, particularly visceral obesity and insulin resistance- the inability to fully utilize the glucose-transporting effects of insulin- are linked. For reasons related to genetics a substantial portion of the population has the potential when overweight to become sufficiently insulin-resistant that the increased demands on the pancreas burns out the beta cells that produce insulin.” Even those who feel obesity does not need to be in the criteria for metabolic syndrome recognize that it has a strong correlation with insulin resistance and are therefore intertwined (Buse, et al., 2005).
The cell’s resistance to insulin results in less uptake of glucose in the blood. High levels of glucose in the blood cause the blood vessels walls to be more permeable to lipids, resulting in plaque build up. The increased level of insulin in the blood has effects on the liver’s production of cholesterol, causing more smaller, denser low-density lipoproteins (LDL) to be produced. It also causes platelet activation where the platelets swell and become sticky (Vanderploeg, 2008).
The LDL and activated platelets also contribute to the build of plaque in the blood vessels. Ironically one of the best treatments for insulin resistance is weight loss. Most would agree that some simple weight loss would improve their quality of life. Avoiding the nightmare of becoming a diabetic is well worth the life style change.
Hypertension is commonly referred to as high blood pressure, easily making it onto the list of issues involving metabolic syndrome, casting itself into the pool with obesity and insulin resistance. It is a common condition in which the force of the blood against the artery walls is high enough that it may eventually cause health problems, such as heart disease. Blood pressure is determined by the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries.
The more blood the heart pumps and the narrower the arteries, the higher the blood pressure. A person can have high blood pressure (hypertension) for years without any symptoms. Uncontrolled high blood pressure increases the risk of serious health problems, including heart attack and stroke. This again leads into why it is so vital that medical professionals learn all they can about it and the relationship it has with metabolic syndrome.
Dr. Bernstein (2003, pp.39-44) wrote, “Insulin resistance by its nature increases the body’s need for insulin, which therefore causes the pancreas to work harder to produce elevated insulin levels (hyperinsulinemia), which can indirectly cause high blood pressure and damage the circulatory system”. The high levels of insulin causes the blood vessels to respond more readily to angiotension II, a vasodilator, and decreases the blood vessels response to nitric oxide, a vasodilator (Vanderploeg, 2008). The blood vessels constrict and are smaller but do not respond to the body’s efforts to dilate.
This causes an elevation in blood pressure. Counter-regulatory hormones also go into overdrive in an attempt to control the high levels of insulin in the blood but their effect also cause vasoconstriction and hypertension (Vanderploeg, 2008). It is no wonder that once insulin resistance enters the picture hypertension is soon to follow.
Dyslipidemia is another problem associated with metabolic syndrome that is related to insulin resistance. Too many lipids in the blood stream or high cholesterol tend to lead towards bigger issues such as cardiovascular disease. “Fasting hypertriglyceridemia is caused by increased hepatic very low density lipoprotein secretion, which may be driven by increased delivery of free fatty acids to the liver coming from both visceral fat and upper body subcutaneous fat.
The reduced high-density lipoprotein cholesterol concentrations and the increased small, dense low-density lipoprotein particle concentrations associated with upper body obesity are likely to be an indirect consequence of elevated triglyceride-rich very low density lipoprotein.” (Ausiello & Goldman, 2008).
The liver begins producing more LDL cholesterol and less HDL cholesterol. HDL helps clear the blood of excess cholesterol and also interferes with the inflammatory response of macrophages. Both of these functions help to decrease the risk of plaque build up. With the decrease production of HDL the body is at increased risk for cardiovascular disease. It is noteworthy for any medical professional to see these things and take appropriate actions to better ensure the health of their patients.
Inflammation is generally the body’s response to injury or damage to cells. However inflammation is seen in both diabetes and coronary artery disease (CAD), giving it a place in assessing patients with metabolic syndrome. “Sometimes inflammatory chemicals are elevated in the blood of people who are not overtly sick or injured.
This low-grade chronic inflammation is associated with increased risk of heart disease, diabetes, cancer, autoimmune disorders, and other health problems” (Rosedale, 2004, p.176). Vanderploeg (2008) pointed out that “Chronic inflammation is a feature of atherosclerosis and CAD mediated by angiotension II, proinflammatory cytokines, and free fatty acids.” As seen earlier insulin resistance causes the liver to produce more LDL as well as causing the blood vessel walls to become more permeable to lipids, resulting in atherosclerosis.
The body’s inflammatory response causes macrophages to ingest the lipids and can rupture the plaque build up in the blood vessels. In short this inflammatory response has changed stable plaque into unstable plaque (Vanderploeg, 2008).
The rupture of the plaque can result in completely clogged blood vessels, which can cause a heart attack or stroke. The macrophages also release cytokines that cause the liver to produce C-reactive protein (Vanderploeg, 2008). “One of the best markers for systemic inflammation is highly sensitive C-reactive protein (CRP), a protein that is produced during inflammation…a high level of CRP is a highly accurate predictor of future heart attack” (Rosedale, 2004, p. 176).
High levels of CRP are signaling increased levels of inflammation in the body and without a person having an illness or injury this could indicate macrophages breaking down lipid plaque, placing that person at risk for a heart attack or stroke. The understanding of inflammation’s role in cardiovascular disease and diabetes is still being developed. Although CRP levels are not one of the criteria for metabolic syndrome, it is still important to assess, as it too is closely related to the cascade of metabolic syndrome.
Having the ability to diagnose a person with metabolic syndrome early in the clinical presentation allows early intervention to lower or prevent the cardiovascular events that may lead to premature death. The therapeutic goals of early intervention are to treat the underlying causes of metabolic syndrome by increasing physical activity, provide intensive weight management assistance, and to treat the cardiovascular risk factors as they arise, or if they persist after lifestyle modifications (Meigs, 2010).
Managing metabolic syndrome starts with a thorough assessment of risk factors and recognition of the condition. Blaha has suggested that a formal diagnosis of the syndrome in the medical record may lead to better management of the syndrome itself.
After diagnosis, a standardized risk assessment tool such as the Framingham risk score should be used to calculate the 10-year risk of cardiovascular disease (Blaha et al., 2008). Classifying the patient to low, medium or high risk of a cardiovascular event within ten years also emphasizes the necessity of lifestyle changes.
Blaha et al. (2008) have proposed an “ABCDE” approach for the management of metabolic syndrome in a systematic method that delineates each factor and how to treat it. It is a simple way to verify that all metabolic states and interventions have been addressed. The “A” is a reminder to prescribe aspirin therapy for anyone with a greater than 6% 10-year risk when using the Framingham tool. The “B” relates to keeping the patient’s blood pressure below the defined criteria.
First-line therapy for pressure control is the use of an angiotension-converting enzyme (ACE) inhibitor, or if not tolerated, an angiotension receptor blocker (ARB). The use of thiazide diuretics and beta blockers for pressure control may increase the risk of diabetes in people with metabolic syndrome, so is not advised as a first-line treatment option in these patients (Hilgers & Mann, 2008).
The “C” in the Blaha et al (2008) approach to metabolic syndrome management is to remind the clinician to manage cholesterol appropriately. Statins are to be prescribed to achieve an LDL-C of less than 100mg/dL in those categorized as high risk by a standardized scoring tool or an LDL-C less than 130 mg/dL in intermediate risk categories.
To target a lowering of non-HDL-C to less than 130mg/dL in high risk patients, a fenofibrate may be considered in addition to the regimen. If the patient is in the intermediate risk category the non-HDL-C should be less than 160mg/dL. Omega-3 fatty acids may be added for cholesterol control.
“D” is a reminder to prevent or control diabetes in patients with metabolic syndrome. Lifestyle management with the addition of pharmacotherapy should be pursued. Lifestyle modifications include dietary changes and weight loss as needed. The biguanide metformin is considered to be first-line therapy for diabetes control with the addition of pioglitazone if fasting blood sugars cannot be controlled with metformin alone.
Lastly, the “E” in this approach is a reminder of the necessity of exercise, as exercise has been shown to improve cardiovascular risk and increase insulin sensitivity. Increasing the amount of exercise in an individual also reduces obesity and lowers systolic blood pressure (Blaha et al., 2008).
Buse and colleagues (2010), on behalf of the ADA and EASD, question whether the metabolic syndrome is clinically useful. Without doubt, because of the increased prevalence of the underlying causes of the metabolic syndrome (e.g., obesity and sedentary lifestyles), the clustering of risk factors portends an enormous increase in CVD and type 2 diabetes worldwide. The fact that diabetes itself, when combined with the metabolic syndrome, is associated with greater CVD risk represents a great challenge for the management of patients with diabetes. At the same time, CVD also has significant public health implications for the prevention of CVD and type 2 diabetes.
It is likely to provide a useful practical tool that reminds healthcare professionals of the metabolic consequences of obesity, and identifies individuals at risk for CVD and diabetes that are likely to benefit from (lifestyle) interventions. The clustering of CVD risk factors is a call to action for preventive medicine, as it is clearly not satisfactory just to treat the major risk factors once they have reached categorically increased levels. This would be a prescription for widespread use of drug therapy in primary prevention and would be a huge burden on economically developed societies, and an even greater burden on developing nations.
Few would disagree that it is better and more economical to detect the clustering at an earlier stage of development and to introduce lifestyle interventions to prevent progression to a more advanced risk. This is a task for both public health and clinical sectors of the healthcare system. An additional benefit of the new IDF criteria is that the initial screening test is simple and low-cost, i.e., measurement of waist size. (Alberti & Zimmet, 2005).
As with a lot of studies in the medical field this too falls into controversy over the usage of the metabolic syndrome scale. Not to belittle the idea of everything that has been stated, but to only point out that not all medical professionals fall into the same line of thinking and practice. As Krans (2010) writes, “No unifying pathophysiological basis has been established for the metabolic syndrome. It should only be considered as a pre-morbid condition and should (in epidemiological studies) exclude persons with established diabetes or known CVDs.
In addition to central obesity and insulin resistance, the following factors all contribute to DM or CVD: activation of the immune system; disordered hypothalamic-pituitary-adrenal axis; altered glucocorticoid action; involvement of cytokines, hormones and other molecules from adipose tissue; prenatal and early life influences; hypertension; changes in blood lipids; multiple gene combinations, and stress. The risk factors for CVD and DM are not equivalent across the different risk combinations that contribute to the metabolic syndrome.
The equivalence of the risk factors for CVD and DM has not been established in various populations. CVD and DM have multiple causes, of which some do not involve the metabolic syndrome, though they do increase the risk of developing this syndrome.” (Krans, 2010). Yet even with all the negatives pointed out by Krans he still ends with a positive note saying that all the combined factors increase the risk of developing metabolic syndrome. Krans is by no means alone with this line of thinking.
An article by the American Diabetes Association and the European Association for the Study of Diabetes wrote by Buse et al., (2005) points out, “While there is no question that certain CVD risk factors are prone to cluster, we found that the metabolic syndrome has been imprecisely defined, there is a lack of certainty regarding its pathogenesis, and there is considerable doubt regarding its value as a CVD risk marker” (Buse et al., 2005).
They go on to write “Clinicians should evaluate and treat all CVD risk factors without regard to whether a patient meets the criteria for diagnosis of the metabolic syndrome.” (Buse et al., 2005). Despite their stance on metabolic syndrome all can agree that the individual components of metabolic syndrome should be taken seriously and treated according to current standards. They also agree that weight reduction, exercise and a healthy meal plan are the most beneficial treatment plan for those at risk for cardiovascular disease and diabetes (Kahn et al., 2005). Conclusion
With an alarming percentage of American Adults being diagnosed with metabolic syndrome it would prove prudent for medical professionals to learn more about it. Medical professionals, who find they are looking at a patient with familiar trends in their health, should at the minimum bring it up in conversation during their care. To ignore the trends may result in more medical problems that may have been preventable had they been treated earlier.
In general most agree that at home treatments such as better eating habits and exercise can reduce the risk of falling into the diagnoses of metabolic syndrome. Furthering the education of patients is only part of the treatment; educating medical professionals to see things that can bring about better lifestyle and living conditions of their patients is a worthwhile cause.
Alberti, G., Zimmet, P., (2005) The Metabolic Syndrome: Perhaps an Etiologic Mystery but Far From a Myth- Where Does the International Diabetes Federation Stand?
From the World Wide Web: March 24, 2011
American Heart Association: From the World Wide Web: March 25, 2011 http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/
Ausiello, D. Goldman, L., (2008) Cecil Medicine Twenty-Third Edition,
Bansal, S., Blaha, M., Blumenthal, R., DeFilippis, A., Golden, S., & Rouf, R., (2008). A Practical “ABCDE” approach to the metabolic syndrome. Mayo
Clinic Proceedings, 83(8). From the World Wide Web: March 24, 2011 http://www.mayoclinicproceedings.com/content/83/8/932.long Bernstein, R. (2003) Dr. Bernstein’s Diabetes Solution Revised & Updated. The Complete Guide to achieving Normal Blood Sugars. New York: Little, Brown and Company. Buse, J., Ferrannini, E., Kahn, R., Stern, M. (2005)
The Metabolic Syndrome: Time for a Critical Appraisal Joint Statement From the American Diabetes Association and the European Association for the Study of Diabetes.
From the World Wide Web: http://www.medscape.com/viewarticle/512071. Galleragher, E., LeRoith, D., Karnieli, E. (2008). Endocrinology and Metabolism Clinics- 37 (3). The Metabolic Syndrome from Insulin Resistance to Obesity and Diabetes. From the World Wide Web: March 24, 2011.
http://www.mdconsult.com/das/article/body/237897632-4/jorg=clinics&source=&sp=20975453&sid=0/N/ Grundy, S., (2006). Center for Human Nutrition and Metabolic Syndrome: Connecting and Reconciling Cardiovascular and Diabetes Worlds. Journal of the American College of Cardiology, 47 (6), 1093-1098. Krans, R. (2010) From the Faculty of 1000. The Metabolic Syndrome: Useful Concept Or Clinical Tool? Report of a WHO Expert Consultation: “Exceptional” and “Changes Clinical Practice”
From the World Wide Web: http://www.medscape.com/viewarticle/720790. Meigs, J. (2010). The metabolic syndrome (insulin resistance syndrome or syndrome X). From the world wide web: March 24, 2011 http://uptodate/com/online/content/topic.do?topicKey=diabetes/
Rosedale, R. (2004). The Rosedale Diet: Turn off Your Hunger Switch New York: HarperCollins. (p.176). Vanderploeg, E. (2008). Mosby’s Nursing Consult. The metabolic syndrome: Why Your Patient Is at Risk. From the World Wide Web: March 24, 2011 http://www.nursingconsult.com/das/stat/view/2388049052/cup?nid=192939&sid=1142497922&summaryresults=true&SEQNO=1
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TOPICS IN THIS DOCUMENT
Atherosclerosis, Diabetes mellitus, Hypertension, Insulin resistance, Low-density lipoprotein, Metabolic syndrome, Myocardial infarction, Obesity
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