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  1. Metabolic Syndrome Lianne Beck, MD Assistant Professor Emory Family Medicine 2007

  2. "Metabolic Syndrome" (AKA: Syndrome X or Insulin Resistance Syndrome) A cluster of CVD risk factors and metabolic alterations associated with excess abdominal fat. Insulin resistance Atherogenic dyslipidemia Elevated blood pressure A prothrombotic and proinflammatory state Definition

  3. Risk Factors • Abdominal Obesity • Insulin Resistance • Physical Inactivity • Older Age • Hormonal Imbalance • Atherogenic Diet*

  4. Table 1. WHO clinical criteria for the metabolic syndrome.

  5. Table 2. NCEP ATP III clinical criteria for the metabolic syndrome.Any 3 of the following:

  6. Associated Abnormalities • Coagulation abnormalities • Hyperuricemia • Microalbuminuria • Polycystic ovary syndrome • Non-alcoholic steatohepatitis (NASH)

  7. Significance • Is characterized by metabolic and hemodynamic abnormalities which each increase the risk of cardiovascular disease. • Is considered an independent risk factor for cardiovascular disease. • Has been identified by NCEP ATP III as a trigger for intensive lifestyle modification, even in individuals with LDL cholesterol <100 mg/dL.

  8. Significance • In diabetics, there is a strong correlation between metabolic syndrome and cardiovascular disease. • Metabolic syndrome patients with T2DM showed a higher prevalence of microalbuminuria or macroalbuminuria. • Metabolic syndrome correlates with small LDL particle size pattern and the occurrence of preclinical atherosclerosis.

  9. Why Treat Metabolic Syndrome? • It holds the same coronary risk as Diabetes. • 50% of patients with IFG will go on to develop diabetes within 10 years.

  10. Epidemiology • Estimates of the prevalence the United States and Europe differ depending on the populations studied and the definition applied. • The prevalence rate of metabolic syndrome in many western countries is 25-35%. • Based on NHANES III data, prevalence in the US is 22-23%. • By 2010, it is estimated that the US will have 50-75 million people with metabolic syndrome.

  11. Etiology • Insulin resistance is thought to be the essential cause of metabolic syndrome. • Models show that the cluster of variables in metabolic syndrome is a result of multiple factors linked by adiposity and not a single etiology. • The characteristic metabolic alterations are associated with an abnormal abdominal (upper-body) fat distribution.

  12. The Fast Wheel

  13. ↑Cytokines: TNF-alpha IL-6 ↑ Prothrombotic mediators: PAI-1 ↓Adipokines: Resistin Adiponectin Inflammation

  14. Alternate Hypothesis • Environmental, perinatal and genetic factors induce neuroendocrine perturbations followed by abdominal obesity with its associated comorbidities. • Chronic stress induces activation of the hypothalamic-pituitary-adrenal axis leading to excess cortisol. Bjorntorp P. Heart and soul: stress and the metabolic syndrome. Scand Cardiovasc J 2001;35:172-7.

  15. Physical Exam BP BMI Waist Circumference Skin tags Acanthosis nigricans Bruits Fundi Labs Fasting Glucose Lipids Homocysteine CRP-HS Uric Acid TSH HbA1C AST/ALT Creatinine EKG Evaluation

  16. Management • Primary Goal is to reduce risk for ASCVD and to prevent Type 2 DM. • First-line therapy directed towards major risk factors: • Elevated LDL • Hypertension • IFG, IGT • Therapeutic Lifestyle Change

  17. Treatment of risk factors should be prioritized • The most common clinical feature of metabolic abnormalities is excess body fat. • Physical activity and diet modifications are indicated for the long-term treatment of metabolic syndrome. • Pharmacotherapy of dyslipidemia is indicated in high-risk groups.

  18. NCEP/ATP III GuidelinesClinical Management of Metabolic Syndrome • Managing underlying cause • Weight control enhances LDL lowering and reduces all other risk factors • Physical activity increases HDL, reduces VLDL, and lowers LDL • Managing lipid and non-lipid risk factors • Treat hypertension • Aspirin in high risk patients • Metformin for diabetic patients • Treat the elevated LDL first, then address elevated TG’s and low HDL

  19. ATP III Guidelines for Treatment of Metabolic Syndrome Treat LDL cholesterol first

  20. ATP III Guidelines for Treatment of Metabolic Syndrome Treat elevated triglycerides and low HDL cholesterol

  21. Dyslipidemia Management Summary • For patients with LDL > 130 mg/dL, treat with a statin first, then assess HDL and TG levels to determine if a fibrate or niacin* is needed. • For patients with LDL < 130 mg/dL, a fibrate or niacin* is first line therapy when HDL is < 40 mg/dL, then reassess the LDL level to determine if a statin is needed. *Niacin should be used with caution in these patients because of its negative effect on insulin sensitivity and blood glucose levels.

  22. Lipoprotein Effects of Lipid- Modifying Therapy TG LDL HDL National Cholesterol Education Program Adult Treatment Panel III (ATP III) Guidelines

  23. Effective Dietary Interventions • Reduce calories • Reduce saturated and trans fats • Reduce sodium • Reduce simple sugars • Increase whole grains • Increase fruits and vegetables • Eat fish 1-2 times per week • Use monounsaturated or polyunsaturated oils • Olive, Canola, and Peanut • Safflower, Sunflower or Sesame seed, Corn, or Soy • Reduce alcohol consumption

  24. DASH Diet * Serving sizes vary between 1/2 cup - 1 1/4 cups.

  25. Nutrient Composition of the Therapeutics Lifestyle Changes Diet • Carbohydrate: 50% to 60% of total calories • Protein: Approximately 15% of total calories • Total Fat: 25% to 35% of total calories • Saturated Fat: Less than 7% of total calories • Polyunsaturated Fat: Up to 10% of total calories • Monounsaturated Fat: Up to 20% of total calories • Fiber: 20 to 30 g/day • Cholesterol: Less than 200 mg/day • Total Calories (Energy): Decrease by 500-1000 kcal/day

  26. Fatty Acids in Oils

  27. Fatty Acids in Fats

  28. Effects of Exercise • Physical activity level is negatively associated with fasting insulin level. • Regular moderate exercise promotes alterations of lipolytic enzymes and a significant increase in plasma HDL. • Should include components that improve cardio-respiratory fitness, muscular strength and endurance.

  29. Caloric Expenditure by Activity Numbers are estimated for a 150 lb. person, and will vary depending on weight, body composition, and level of intensity.

  30. Exercise Prescriptions • Pre-exercise Assessment • Identify patients readiness for starting an exercise program. • Cardiovascular Risk Assessment • 4 Components • Mode – walking, swimming, water aerobics • Duration – 20-30 min initially, goal of 60 min/session • Frequency – 3-7 times/week • Intensity – target heart rate for low, moderate, vigorous (THR 65-90% of MHR) • Incorporate progression, resistance training and flexibility training.

  31. How Do I Help My Patients to Want to Change???

  32. Stages of Change • Precontemplation - “Ignorance is Bliss” • Encourage re-evaluation of current behavior • Encourage self-exploration, not action • Explain and personalize the risk • Contemplation - “Sitting on the Fence” • Encourage evaluation of pros and cons of behavior change • Identify and promote new, positive outcome expectations

  33. Stages of Change • Preparation - "Testing the waters" • Identify and assist in problem solving re: obstacles • Help patient identify social support • Verify that patient has underlying skills for behavior change • Encourage small initial steps • Action - Practicing new behavior • Focus on restructuring cues and social support • Bolster self-efficacy for dealing with obstacles • Combat feelings of loss and reiterate long-term benefits

  34. Stages of Change • Maintenance - Continued commitment to sustaining new behavior • Plan for follow-up support • Reinforce internal rewards • Discuss coping with relapse • Relapse - "Fall from grace" • Evaluate trigger for relapse • Reassess motivation and barriers • Plan stronger coping strategies

  35. Motivational Interviewing Algorithm 1. Assess and Personalize Patient’s Risk Status • "Based on your BMI, WC, labs, physical exam, family history and symptoms, I am concerned about the following: ______, ______, and _____." • "I want to talk to you about how your weight may be affecting your health.“ 2. Stages of Change Evaluation • "How do you feel about your weight?" • "What concerns do you have about health risks?" • "Are you considering/planning weight loss now?" • "Do the pros of changing outweigh the cons?"

  36. Motivational Interviewing Algorithm 3. Educate: Risks and Advise: Weight Goal • Educate: Medical Consequences Tip Sheet (longevity and quality of life) • Advise: Establish a reasonable goal for weight loss using a clear statement. • "A 5-10% weight loss over 6 months for a total loss of ____ to ___ pounds.“ 4. Assess Patient’s Understanding and Concerns • "How do you feel about what I’ve said?" • "On a scale of 1 – 10, with 10 being 100% ready to take action, how ready are you to lose weight?“ 5. Facilitate motivation depending the patients level of contemplation

  37. Precontemplation (1 - 4) 1. Validate the patient’s experience: • "I can understand why you feel that way“ 2. Acknowledge the patient’s control of the decision: • "I don’t want to preach to you; I know that you’re an adult and you will be the one to decide if and when you are ready to lose weight.“ 3. Repeat a simple, direct statement about your stand on the medical benefits of weight loss for this patient: • "I believe, based upon my training and experience, that this extra weight is putting you at serious risk for heart disease, and that losing 10 pounds is the most important thing you could do for your health.“

  38. Precontemplation 4. Explore potential concerns: • "Has your weight ever caused you a problem?" "Can you imagine how your weight might cause problems in the future?" 5. Acknowledge possible feelings of being pressured: • "I know that it might feel as though I’ve been pressuring you, and I want to thank you for talking with me anyway.“ 6. Validate that they are not ready: • "I hear you saying that you are nowhere near ready to lose weight right now.“

  39. Precontemplation 7. Restate your position that it is up to them: • "It’s totally up to you to decide if this is right for you right now.“ 8. Encourage reframing of current state of change - the potential beginning of a change rather than a decision never to change: • "Everyone who’s ever lost weight starts right where you are now; they start by seeing the reasons where they might want to lose weight. And that’s what I’ve been talking to you about." GOAL: Move patient from" NO!" to "I’ll think about it."

  40. Contemplation (5 - 7) 1. Validate the patient’s experience: • "I’m hearing that you are thinking about losing weight but you’re definitely not ready to take action right now.“ 2. Acknowledge patient’s control of the decision: • "I don’t want to preach to you; I know that you’re an adult and you will be the one to decide if and when you are ready to lose weight.“ 3. Clarify patient’s perceptions of the pros and cons of attempted weight loss: • "Using this worksheet, what is one benefit of losing weight? What is one drawback of losing weight?“

  41. Contemplation 4. Encourage further self-exploration: • "These questions are very important to beginning a successful weight loss program. Would you be willing to finish this at home and talk to me about it at our next visit?“ 5. Restate your position that it is up to them: • "It’s totally up to you to decide if this is right for you right now. Whatever you choose, I’m here to support you.“ 6. Leave the door open for moving to preparation: • "After talking about this, and doing the exercise, if you feel you would like to make some changes, the next step won’t be jumping into action - we can begin with some preparation work."

  42. Preparation (8 – 10) 1. Praise the decision to change behavior: • "It’s great that you feel good about your weight loss decision; you are doing something important to decrease your risk for heart disease.“ 2. Prioritize behavior change opportunities: • "Looking at your eating habits, I think the biggest benefits would come from switching from whole milk dairy products to fat-free dairy products. What do you think?“ 3. Identify and assist in problem solving re: obstacles: • "Have you ever attempted weight loss before? What was helpful? What kinds of problems would you expect in making those changes now? How do you think you could deal with them?“

  43. Preparation 4. Encourage small, initial steps: • "So, the initial goal is to try nonfat milk instead of whole milk every time you have cereal this week.“ 5. Assist patient in identifying social support: • "Which family members or friends could support you as you make this change? How could they support you? Is there anything else I can do to help?" GOAL: Provide direction and support

  44. Motivational Interviewing Algorithm 6. Schedule Follow-up • Tell patient when you would like to see them again. • Give patient a referral (to a dietitian / exercise specialist / therapist/ etc) if appropriate.

  45. Old will power   preach  compliance   should, must   limit, restrict prescribe approval expectations       good/bad   diet   exercise regimen Ideal weight New commitment enable exploration consider choose, experience negotiate self-esteem discoveries what works for you eating style activity style healthy BMI + waist circumference Supportive Language Adapted from the work of Linda Omichinski, RD