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Metabolic Syndrome Symposium. Dar Al-Kalima Health and Wellness Center Bethlehem, Palestine Oct. 2005. Metabolic Syndrome:. What is it? Is it important? How common is it? What should be done about it?. Metabolic Syndrome Concept - Not New :.

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metabolic syndrome symposium

Metabolic SyndromeSymposium

Dar Al-Kalima Health and Wellness Center

Bethlehem, Palestine

Oct. 2005

metabolic syndrome
Metabolic Syndrome:
  • What is it?
  • Is it important?
  • How common is it?
  • What should be done about it?
metabolic syndrome concept not new
Metabolic Syndrome Concept - Not New:
  • 1923 - Kylin first to describe the clustering of hypertension, hyperglycemia, hyperuricemia
  • 1936 - Himsworth first reported Insulin insensitivity in diabetics
  • 1965 - Yalow and Berson developed insulin assay and correlated insulin levels & glucose lowering effects in resistant and non-resistant individuals
history cont
History (cont.)
  • 1988 - Reaven in his Banting lecture at the ADA meeting coined the term Syndrome X and brought into focus the clustering of features of Metabolic Syndrome
  • Reaven now prefers the name, Insulin-Resistance Syndrome - feels insulin resistance is the common denominator for Metabolic Syndrome
  • Literature now extensive
other names used
Other Names Used:
  • Syndrome X
  • Cardiometabolic Syndrome
  • Cardiovascular Dysmetabolic Syndrome
  • Insulin-Resistance Syndrome
  • Metabolic Syndrome
  • Beer Belly Syndrome
  • Reaven’s Syndrome
  • etc.
clustering of components
Clustering of Components:
  • Hypertension
  • Hypertriglyceridemia
  • Low HDL-cholesterol
  • Obesity (central)
  • Impaired Glucose Handling
  • Microalbuninuria (WHO)
is it a syndrome
Is it a Syndrome?
  • The Metabolic Syndrome: Time for a Critical Appraisal.
    • Joint Statement from the American Diabetes Association and the European Association for the Study of Diabetes
    • Kahn, R, et al. Diabetes Care 2005;28:2289-2304
is it a syndrome8
Is it a Syndrome?
  • “…too much clinically important information is missing to warrant its designations as a syndrome.”
  • “Until much needed research is completed, clinicians should evaluate and treat all CVD risk factors without regard to whether a patient meets the criteria for diagnosis of the ‘metabolic syndrome’.”
criteria for diagnosis
Criteria for diagnosis:
  • World Health Organization
  • International Diabetes Federation (IDF) - European Association for the Study of Diabetes (EASD)
  • National Cholesterol Education Project, Adult Treatment Panel (NCEP-ATP III)
  • Others
hypertension
Hypertension:
  • IDF:
    • BP >130/85 or on Rx for previously Dxed hypertension
  • WHO:
    • BP >140/90
  • NCEP ATP III:
    • BP >130/80
obesity
Obesity:
  • IDF:
    • Central obesity - waist circumference >94 cm for Europid men, >80 Europid women with ethnicity specific values for other groups
  • WHO:
    • Waist-hip ratio >0.9 - men or >0.85 - women
  • ATP III:
    • Waist circumference >40 in. - men, 35 in. - women
glucose abnormalities
Glucose Abnormalities:
  • IDF:
    • FPG >100 mg/dL (5.6 mmol.L) or previously diagnosed type 2 diabetes
  • WHO:
    • Presence of diabetes, IGT, IFG, insulin resistance
  • ATP III:
    • FBS >110 mg%, <126 mg% (ADA: FBS >100)
dyslipidemia
Dyslipidemia:
  • IDF:
    • Triglycerides - >150mg/dL (1.7 mmol/L)
    • HDL - <40 mg/dL (men), <50 mg/dL (women)
  • WHO:
    • Triglycerides - >150 mg/dL (1.7 mmol/L)
    • HDL - <35 mg/dL (men), >39 mg/dL) women
  • ATP III:
    • Same as IDF
necessary criteria to make diagnosis
Necessary Criteria to Make Diagnosis:
  • IDF:
    • Require central obesity plus two of the other abnormalities
  • WHO:
    • Also requires microalbuminuria - Albumen/ creatinine ratio >30 mg/gm creatinine
  • ATP III:
    • Require three or more of the five criteria
linked metabolic abnormalities
Linked Metabolic Abnormalities:
  • Impaired glucose handling/insulin resistance
  • Atherogenic dyslipidemia
  • Endothelial dysfunction
  • Prothrombotic state
  • Hemodynamic changes
  • Proinflammatory state
  • Excess ovarian testosterone production
  • Sleep-disordered breathing
resulting clinical conditions
Resulting Clinical Conditions:
  • Type 2 diabetes
  • Essential hypertension
  • Polycystic ovary syndrome (PCOS)
  • Nonalcoholic fatty liver disease
  • Sleep apnea
  • Cardiovascular Disease (MI, PVD, Stroke)
  • Cancer (Breast, Prostate, Colorectal, Liver)
prevalence of metabolic abnormalities
Prevalence of Metabolic Abnormalities:
  • Global - approx. 314 million people with impaired glucose metabolism (500 million by 2025)
  • Palestine: (Hanan F. Abdul-Rahim, MSC)
    • HTN - 25.4%(R) vs 21.5% (U)
    • Diabetes - 9.8%(R) vs 12%(U)
    • IGT -8.6%(R) vs 5.9%(U)
    • (17% of both groups had either DM or IGT!!)
    • Hypertriglyceridemia - 22.6%(R) vs 34.8%(U)
prevalence palestine cont
Prevalence - Palestine: (cont.)
  • Low HDL - 28.3%(R) vs 61.2% (U)
  • Overall Obesity - 28.2%(R) vs 41.5%(U)
  • Central Obesity - 65.7%(R) vs 39.0% (U)
  • Clustering of components with and without diabetes were similar in both populations.
  • Individuals with DM or IGT - 73.4% also had two additional components of Met. Syn.
prevalence in u s
Prevalence in U.S.:
  • Varies with ethnicity:
    • Native Americans with diabetes - 55.2%
    • Metabolic syndrome more prevalent in Mexican/Americans and African Americans than non-Hispanic caucasians (ATP III)
    • Prevalence increasing in juveniles as well as adults due to overnutrition and sedentary life-styles, smoking
  • Prevalence increases with aging
insulin resistance
Insulin Resistance:
  • Etiology is polygenic and environmental (overnutrition, sedentary life-style)
  • Sensitivity to insulin varies widely in the general population
  • Insulin-mediated glucose uptake by cells is compromised
  • As beta cells fail and insulin is insufficient, hyperglycemia occurs
insulin resistance21
Insulin Resistance:
  • Hyperinsulinemic individuals are at risk for developing diabetes, hyperlipidemia, HTN, & ultimately cardiovascular disease
  • Patients with Metabolic Syndrome are 3.5 times as likely to die from CVD as normal people
multiple risk factor management
Multiple Risk Factor Management
  • Obesity
  • Glucose Intolerance
  • Insulin Resistance
  • Lipid Disorders
  • Hypertension
  • Goals: Minimize Risk of Type 2 Diabetes and Cardiovascular Disease
diabetes control how important
Diabetes Control - How Important?
  • For every 1% rise in Hgb A1c there is an 18% rise in risk of cardiovascular events & a 28% increase in peripheral arterial disease
  • Evidence is accumulating to show that tight blood sugar control in both Type 1 and Type 2 diabetes reduces risk of CVD
  • Goals: FSBS - premeal 90-130, postmeal<180. Hgb A1c <7%
bp control how important
BP Control - How Important?
  • MRFIT and Framingham Heart Studies:
    • Conclusively proved the increased risk of CVD with long-term sustained hypertension
    • Demonstrated a 10 year risk of cardiovascular disease in treated patients vs non-treated patients to be 0.40.
    • 40% reduction in stroke with control of HTN
  • Precedes literature on Metabolic Syndrome
  • Goal: <130/80
lipid control how important
Lipid Control - How Important?
  • Multiple major studies show 24 - 37% reductions in cardiovascular disease risk with use of statins and fibrates in the control of hyperlipidemia.
  • Goals: LDL <70 mg% (<2.6 mmol/l)
  • Triglycerides <150 mg% (<1.7 mmol/l)
  • HDL >40 mg% (>1.1 mmol/l)
medications
Medications:
  • Hypertension:
    • ACE inhibitors, ARBs
    • Others - thiazides, calcium channel blockers, beta blockers, alpha blockers
  • Hyperlipidemia:
    • Statins, Fibrates, Niacin
  • Platelet inhibitors:
    • ASA, clopidogrel
insulin resistance diabetes
Insulin Resistance/Diabetes:
  • Insulin Sensitizers:
    • Biguanides - metformin
    • PPAR α, γ & δ agonists - Glitazones, Glitazars
    • Can be used in combination
  • Insulin Secretagogues:
    • Sulfonylureas - glipizide, glyburide, glimeparide, glibenclamide
    • Meglitinides - repaglanide, netiglamide
insulin
Insulin
  • Insulin Analogues:
    • Lys-pro/Aspart/glulysine used with meals
    • Glargine as basal insulin
  • Continuous Subcutaneous Insulin Infusion (CSII)
  • NPH/Regular, NPH/logs - Mixed or in fixed combinations (70/30, 75/25, 50/50)
  • Insulin combined with oral agents
new pharmacologic agents
New Pharmacologic Agents:
  • Incretin Mimetics:
    • GLP-1 agonist - exenatide
  • Dual PPAR Dual Agonists:
    • Glitazars
  • CB1 Endocannabinoid Receptor (Appetite) Antagonist:
    • Rimonabant
antihypertensive medications
Antihypertensive Medications:
  • Angiotensin-converting Enzyme Inhibitors (ACEI)
  • Angiotensin II Receptor (ARB) Blockers
  • Combination with Thiazides, Calcium Channel Blockers, Cardioselective Beta Blockers
  • Target BP: <130/80
life style modification is it important
Life-Style Modification: Is it Important?
  • Exercise
    • Improves CV fitness, weight control, sensitivity to insulin, reduces incidence of diabetes
  • Weight loss
    • Improves lipids, insulin sensitivity, BP levels, reduces incidence of diabetes
  • Goals: Brisk walking - 30 min./day
  • 10% reduction in body wt.
smoking cessation avoidance
Smoking Cessation/Avoidance:
  • A risk factor for development in children and adults
  • Both passive and active exposure harmful
  • A majorrisk factorfor:
    • insulin resistance and metabolic syndrome
    • macrovascular disease (PVD, MI, Stroke)
    • microvascular complications of diabetes
    • pulmonary disease, etc.
screening public health approach
Screening/Public Health Approach
  • Public Education
  • Screening for at risk individuals:
    • Blood Sugar/Hgb A1c
    • Lipids
    • Blood pressure
    • Tobacco use
    • Body habitus
    • Family history
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