2. METABOLIC SYNDROME

3. Metabolic Syndrome Synonyms • Insulin resistance syndrome • (Metabolic) Syndrome X • Dysmetabolic syndrome • Multiple metabolic syndrome

4. Case presentation: • 46-year-old man (for new job) • denies: • any complaints • recent history of illness or injury • except: "few aches&epigastric pain on and off." • PMH: • Negative • last P/E: 10 years ago for a job-related injury to his knee • D.HX: • negative

5. cont.. • F/H: mother and brother having heart disease, hypertension, and obesity. • Social /H: • High-fat, high-cholesterol diet • Moderatetobacco use •  P/E: • moderately obese(central), white man • V/S : • Temp: 37.1°C • HR:88 beats /minute • RR:16 breaths /minute • Average BP :144/90 mm Hg in both arms • Wt: 107.7 kg • Ht: 173 cm • BMI: 36 kg/m2.

6. Cont... • W/C: 112 cm • The rest of P/E: unremarkable • Diagnostic Assessment Results: • ECG:NL • Fasting lipid profile: • Total C = 282 mg/dLLDL-C = 152 mg/dLHDL-C = 36 mg/dLTG= 248 mg/dL • FBS: 116 mg/dL • CBC:NL • U/A:NL

7. Metabolic syndrome • combination of medical disorders , increase the risk of developing CVD & diabetes. • Prevalence: • one in five people(U.S) • increases with age • History: • 1950 • 1970

8. PATHOGENESIS: Endothelial Systemic Complex Dysfunction Inflammation Dyslipidemia TG, LDL HDL Athero- sclerosis Insulin Disordered Resistance Fibrinolysis Hypertension Visceral Obesity Type 2 Diabetes

9. Metabolic Syndrome Causes • Acquired causes • Overweight and obesity • Physical inactivity • High carbohydrate diets (>60% of energy intake) • Endocrine disorders such as:polycystic ovarian syndrome • Aging • Genetic causes

10. *Dx: 3 of these R.F †Abd.obes: more highly correlated with metabolic risk factors than BMI. ‡Some men develop metabolic risk factors when circumference is only marginally increased.

11. Risk factors continues • Overweight and obesity • Sedentary lifestyle • Aging • Diabetes mellitus • Coronary heart disease • Lipodystrophy

12. Risk factors cont...

14. THERAPEUTIC GOALS FOR MANAGE OF METABOLIC SYN...

15. Diabetes mellitus

16. Overview of Diabetes in the United States

17. Overall, 20% of the Iranian aged 30yr/old& over at risk of DM more than 1.5 million: DM in Iran the prevalence of DM in Yazd: 7.3% Now,145000pts are affected,estimated to be 400000,in 2030 Prevalence of `DM in 30 yr old & over in various locations of IRAN

18. Diabetes mellitus • Diabetes mellitus, which is characterized by high concentrations of blood glucose resulting from defects in insulin secretion and/or insulin action • type 2 diabetes • most common : • 90% to 95% • type 1 diabetes: • 5% to 10%. • Other forms( 1% to 2% ): • specific genetic syndromes • surgery • Drugs • Malnutrition • infections

19. Diabetes mellitus… Who are at risk? ethnic groups Latin Americans African Americans strong F.HX PCOS, or GDM IGT,IFG:(25-40% in5later) dyslipidemia Hypertension central obesity

20. Prevalence of R.F for DM2 in Iran

24. Dx & Classification of D.M

25. CVD &DM: • IN pts with DM: • CVD:primary cause of death(55%) • IHD:40% of death • Risk of mortality 2-4 times higher than others

26. With Type 2 Diabetes With or Without Previous MI

27. Treatment goals:D.M… Degree of glycemic control: Preprandial70–-130mg/dL; <110 ideally Postprandial (1 to 2h) <180 minimal; <140 ideally HbA1c <7% minimally; 6% or less if possible in selected patients early in disease course Management of CV risk factors: BP<130/80 LDL <100mg/dL; optional <70mg/dL Non-HDL <130mg/dL; optional <100mg/dL HDL >40mg/dL (men); >50mg/dL (women) Triglycerides <150mg/dL

28. Treatment continue.. Non-pharmacologic therapy Diet Exercise Intensive lifestyle modification Medical therapy

31. ABDOMINAL OBESITY

33. CLASSIFICATION

37. Dyslipidemia • Elevated Cholesterol, Triglycerides… • Major modifiable R.F for CHD

38. New Features of ATP III (continued) Screening/Detection: • Complete lipoprotein profile : • Fasting total chol, LDL, HDL, TG • Secondary option: • Non-fasting total cholesterol and HDL • If TC 200 mg/dL or HDL <40 mg/dL: • Proceed to lipoprotein profile

39. NCEP/ ATP III Lipid Classification STEP1:determine LDL Cholesterol (mg/dL) <100 Optimal 100–129 Near optimal/above optimal 130–159 Borderline high 160–189High 190 Very high

40. ATP III Lipid Classification (continued) step1 Total Cholesterol (mg/dL): <200 Desirable 200–239 Borderline high 240High HDL –c (mg/dL): <40 low >60 High

41. New Features of ATP III Step 2: CHD equivalents risk factors: (10-year risk for hard CHD >20%) • Diabetes • Framingham projections of 10-year CHD risk(age,HTN,T-chol&HDL) • metabolic syndrome • Symptomatic carotid artery dx • Peripheral artery dx • Abdominal aortic aneurysm

42. Step 3 :Major CHD factors other than LDL New Features of ATP III (continued) • Cigarette smoking • HTN : • BP 140/90 mmHg or on Rx • Low HDL chol(<40 mg/dL) • F.H of premature CHD: • CHD in male first degree relative <55 years • CHD in female first degree relative <65 years • Age: • (men 45 years; women 55 years) † HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

43. Step 4 : initiate therapeutic lifestyle change(TLC)& drug Tx

44. New Features of ATP III (continued) Treatment: • Therapeutic Lifestyle Changes (TLC) • Drug therapies

45. Lifestyle … • TLC Diet Reduced intake: • Saturated fats <7% of total calories • Dietary cholesterol <200 mg / day LDL-lowering therapeutic: • Plant sterols (2 g /day) • Viscous (soluble) fiber (10–25 g / day) • Weight reduction • Increased physical activity

46. Treatment: DIET • Limit intake of food rich in cholesterol and saturated fats

47. Treatment: DIET • fish more than meat or poultry • Limit intake of egg yolks to 3-4 times a week • more of dried beans, peas and legumes • more cereals and grains

48. Treatment: EXERCISE • 30-60 min of aerobic exercise 3-4 times a week • Increase physical activity at home and at work

49. Visit 3 Visit 2 LDL response? not :add drug Tx Visit I LDL response? not: Treatment Lifestyle Therapeutic Lifestyle Changes (TLC): Visit N 6 wks 6 wks 4-6 mo MonitorTLC • saturated fat &chol • moderate ph.act • refere • Reinforce saturated • Increase fiber intake • Refere • Tx MetabolicSyndrome • Intensify wt &ph.act • refere

50. Medications: