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Metabolic Syndrome
Aka: Metabolic Syndrome, Metabolic Syndrome X, Insulin Resistance Syndrome, Impaired Glucose Tolerance, Impaired Fasting Glucose, Insulin Resistance, Glucose Intolerance, Prediabetes, Prediabetic
- See Also
- Diabetes Mellitus
- Type I Diabetes Mellitus
- Type II Diabetes Mellitus
- Glucose Metabolism
- Diabetes Mellitus Education
- Diabetes Mellitus Complications
- Diabetic Ketoacidosis
- Hyperosmolar Hyperglycemic State
- Diabetes Mellitus Control in Hospital
- Diabetes Mellitus Glucose Management
- Hypertension in Diabetes Mellitus
- Hyperlipidemia in Diabetes Mellitus
- Diabetic Retinopathy
- Diabetic Nephropathy
- Diabetic Neuropathy
- Definitions
- Prediabetes (Impaired Fasting Glucose, Impaired Glucose Tolerance)
- Inadequate Carbohydrate Metabolism to process intake, but not meeting Diabetes Mellitus criteria
- Insulin Resistance
- Insulin with decreased effectiveness in lowering Blood Sugar levels
- Metabolic Syndrome
- Collection of multiple metabolic risk factors (e.g. abdominal Obesity, sedentary, Family History, Hyperlipidemia, Hypertension)
- Associated with Insulin Resistance, prothrombotic and proinflammatory states with risk of Diabetes Mellitus, MI, and CVA
- Epidemiology
- Prevalence in U.S.
- Total estimated at 86 million
- Affects 33% of adults and 4% of teens (90% of adults are unaware of diagnosis)
- Pathophysiology
- Diminished Insulin response results in hyperinsulinemia
- Fewer Insulin receptors on cells
- Less Glucose transporter (Glut 4) in cells
- Hyperinsulinemia predisposes to cardiovascular disease
- Precursor to Type II Diabetes Mellitus
- Risk Factors
- Strong Family History of Diabetes Mellitus
- Prior Gestational Diabetes Mellitus or Fetal Macrosomia
- Obesity
- Body Mass Index 30 kg/m2 or higher
- Waist to hip ratio increased
- Men: 1.0 or higher
- Women: 0.8 or higher
- Waist Circumference
- Men: >40 inches or 102 cm
- Women: >35 inches or 88 cm
- Diagnosis: Metabolic Syndrome - Three or more conditions below
- Insulin Resistance (see labs below)
- Hypertension (Blood Pressure 130/85 or higher)
- Seen in up to 40% of Metabolic Syndrome patients
- Hyperlipidemia (see labs below)
- Coronary Artery Disease
- Polycystic Ovary Syndrome
- Acanthosis Nigricans
- HAIR-AN Syndrome
- Abdominal Obesity
- Men with Waist Circumference >40 inches or 102 cm
- Women with Waist Circumference >35 inches or 88 cm
- Labs: Screening Indications (repeat every 3 years)
- See Risk Factors above
- Body Mass Index >25 kg/m2 (>23 kg/m2 in asian patients)
- Family History of Diabetes Mellitus
- Prior history of Gestational Diabetes
- Age over 45 years
- HDL Cholesterol <35 mg/dl
- Serum Triglycerides >250 mg/dl
- Polycystic Ovary Syndrome
- Hypertension
- Overweight Teens (Puberty or over age 10 years old) with at least one other risk (e.g. diabetes Family History)
- Labs: Diagnosis
- Impaired Glucose Metabolism Criteria
- Hemoglobin A1C 5.7 to 6.4%
- Fasting Glucose: 100 to 125 mg/dl
- Known as Impaired Fasting Glucose
- New guidelines suggest bottom cut-off of 100 mg/dl
- Metabolic Syndrome defined as 110 mg/dl or higher
- Two hour Glucose Tolerance Test (75 g): 140-199 mg/dl
- Known as Impaired Glucose Tolerance
- Lipid Profile
- Serum Triglycerides >150 mg/dl
- Serum very Low Density Lipoprotein (VLDL) increased
- Serum HDL Cholesterol decreased
- Men <40 mg/dl
- Women <50 mg/dl
- Best lab markers for Insulin Resistance
- Plasma Insulin level (or Glucose to Insulin Ratio)
- Plasma Triglyceride levels
- Triglyceride to HDL ratio
- McLaughlin (2003) Ann Intern Med 139:802-9 [PubMed]
- Management: Prevention of progression to Diabetes
- Key goals: 7% weight loss and 150 min/week Exercise
- Consider referral to intensive lifestyle intervention program
- Example: National Diabetes Prevention Program
- https://www.cdc.gov/diabetes/prevention/index.html
- May delay type 2 diabetes by 4 years and decrease overall diabetes Incidence 34% in 10 years
- Knowler (2009) Lancet 374(9702):1677-86 [PubMed]
- Weight Reduction of 5-10% (if Overweight)
- Lose 7% of body weight
- Moderate aerobic Exercise for 30 minutes every day
- Example: Brisk walking for total of 150 min/week
- Encourage 60 minutes of Physical Activity in children and teens per day (and less Screen Time)
- Decreased Caloric Intake
- See Healthy Eating Plate
- Keep fat intake <30% with saturated fat <10%
- Salad, vegetables, fruits
- Whole grains and legumes
- Fish high in Omega-3 Fatty Acids and lean meats
- Reduce intake of simple sugars
- Foods associated with improved Insulin sensitivity
- Dietary Fiber
- Increase to15 gram per 1000 calories
- Coffee
- Salazar-Martinez (2004) Ann Intern Med 140:1-8 [PubMed]
- Tuomilehto (2004) JAMA 291:1213-9 [PubMed]
- Cinnamon (1/2 teaspoon per day)
- Studies used 1-3 g/day of cassia cinnamon (chinese cinnamon, C. aromaticum, C. cassia)
- Appears to have Insulin-like activity, may increase Insulin sensitivity and may improve lipid profile
- May decrease Fasting Glucose by up to 25 mg/dl
- (2017) Presc Lett 24(12): 71
- Costello (2016) J Acad Nutr Diet 116(11):1794-1802 [PubMed]
- Khan (2003) Diabetes Care 26(12):3215-8 +PMID:14633804 [PubMed]
- Moderate Alcohol consumption
- Howard (2004) Ann Intern Med 140:211-9 [PubMed]
- Consider pharmacologic agents for Glucose control
- Indications
- Hemoglobin A1C >5.7% despite 3-6 months of lifestyle changes
- First-line (preferred)
- Glucophage (Metformin)
- Initial: 500 mg Glucophage XR orally daily
- Next: 1000 mg Glucophage XR orally daily (indicated if Hemoglobin A1C>5.7% after 3 months)
- Hostalek (2015) Drugs 75(10): 1071-94 +PMID:26059289 [PubMed]
- Second-line (indicated if Glucophage contraindicated or not tolerated)
- Pioglitazone (Actos)
- Acarbose (Precose)
- Management: Cardiac Risk Management
- Same as Diabetes Mellitus and Coronary Artery Disease
- Aspirin 81 mg PO qd
- Hyperlipidemia
- LDL Cholesterol <100 mg/dl
- HDL Cholesterol >40 mg/dl (50 mg/dl in women)
- Triglycerides <150 mg/dl
- Statins are preferred agents
- Sowers (2003) Am J Cardiol 91:14B-22B [PubMed]
- Hypertension
- Goal Blood Pressure < 125/75 mmhg
- Consider ACE Inhibitor or Angiotensin Blocker
- Course
- Metabolic Syndrome or Prediabetes is high risk for progression to Type II Diabetes Mellitus
- Up to 15-30% of Prediabetes patients will develop Diabetes Mellitus within 5 years
- Diabetes Prevention Program (DPP)
- Basic diet and Exercise: 11% develop diabetes per year
- Diet, Exercise, and weight loss maintained for 3 years prevents Diabetes Mellitus (NNT 7)
- Metformin
- Metformin 850 twice daily with diet and Exercise: 7.8% develop DM per year
- Metformin maintained for 3 years prevents Diabetes Mellitus (NNT 14)
- Intensive diet, Exercise: 4.8% develop diabetes per year
- Classes and coaches
- Weight Reduction of 7%
- Reference
- (1999) Diabetes Care 22:623-34 [PubMed]
- Resources
- CDC Prediabetes Basics
- https://www.cdc.gov/diabetes/basics/prediabetes.html
- References
- (2021) Presc Lett 28(3): 16-7
- Koenigsberg (2017) Am Fam Physician 96(6):362-70 [PubMed]
- (2015) Diabetes Care 38(suppl):S4 +PMID:25537706 [PubMed]
- (1997) Diabetes Care 21:310-4 [PubMed]
- (2001) JAMA 285:2486-97 [PubMed]
- (2002) N Engl J Med 346:393-403 [PubMed]
- (2006) Lancet 368:1096-105 [PubMed]
- Goutham (2001) Am Fam Physician 63(6): 1159-66 [PubMed]
- Scott (2003) Am J Cardiol 92(2 suppl):35i-42i [PubMed]