Meena Gella, OMS III

Patient is a 60-year-old male presenting with an 'apple-shaped' body, hypertension, high blood glucose, and dyslipidemia. Inquiry of history reveals smoking 1 pack-per-day for 40 years, four beers a day for 20 years, sedentary lifestyle and limited vegetable consumption. A long differential diagnosis list is formulated including complications of obesity, symptomatic hypertension, diabetes, genetic predisposition, lifestyle problems, and many more. After extensive research, the conclusive diagnosis is metabolic syndrome, a condition that has been on the rise in the last decade.  

Metabolic syndrome is a diagnosis given to patients with at least 3 of these characteristics: hypertension (systolic >130 mmHg, diastolic >85 mmHg, or currently medicated for hypertension,) low HDL (<40 mg/dl in men, <50 mg/dL in women,) high triglycerides (<150 mg/dL,) and high blood glucose (>100 mg/dL). Each of these alone has innumerable complications, but altogether lead to severe, increased risk of complications including cerebrovascular accidents, diabetes, and cardiovascular disease. Patients often present with a central “apple-shape” or “pear-shape” appearance to their abdominal area.

Research is ongoing on the pathophysiology of this condition. Currently, causation appears to be a combination of lack of physical activity and genetic predisposition. The key mechanism of complications is build up of fatty tissue in the viscera and subcutaneous regions, causing the development of insulin resistance. It is believed that insulin resistance is the crucial cause of the metabolic syndrome. Further investigation shows the accumulation of adipose tissue causes a release of inflammatory mediators that further impact the body’s response to insulin. Insulin resistance presents earlier in those with a genetic history of susceptibility.

Insulin resistance leads to microvascular damage, triggering pathophysiological changes to almost every body system.

 Patients are predisposed to endothelial dysfunction, vessel inflammation, and dyslipidemia. Endothelial dysfunction increases the risk of cardiovascular ischemia, hypercoagulability, and hypertension. Vessel inflammation increases the risks of peripheral vascular disease, ventricular hypertrophy, renal impairment. Dyslipidemia increases the risk for atherosclerosis, coronary artery disease, and non-alcoholic steatohepatitis.

Risk factors for metabolic syndrome, include obesity, fruit/vegetable consumption, alcohol intake, smoking, and old age. Metabolic syndrome patients are encouraged to sticking to a health diet, avoiding smoking, and exercising more frequently to avoid complications.

 In addition to avoiding risk factors, new data shows the importance of treating Metabolic Syndrome patients for sleep apnea using continuous positive airway pressure to decrease the risk of complications.

A combination of medications and life-style modifications to maintain consistent and healthy habits in everyday life have been shown to be most effective in prevention.

Metabolic syndrome management is targeted to reduce the risk of atherosclerotic disease. First line pharmaceutical therapy will be directed to mitigate major risk factors such as elevated LDL levels, hypertension, and type 2 diabetes mellitus.

 Patient’s with past medical history inclusive of 

 with concurrent metabolic syndrome will require intensification of therapy management.

Weight reduction is important in the management of metabolic syndrome. Individuals with abdominal obesity will require weight reduction as a first priority in the therapy management plan. In time period of 6-12 months, total body weight should be reduced by 7%-10%, which may require a decrease in caloric intake by 500 to 1,000 calories per day.

 Continuing weight loss thereafter will be beneficial with ultimate goal body mass index of <25 kg/m

. Most weight loss medications have limited effectiveness in management of obesity, but this may be an option to trial as appropriate.

Following an atherogenic diet may assist in weight reduction. Atherogenic diet involves reduced intake of saturated fats, transfat, and cholesterol. Recommendations including saturated fat <7% of total calories, dietary cholesterol < 200mg/dL, total fat 25%-35% of total calories.

 Preferred dietary fat source should be unsaturated fats.

Increasing physical activity is recommended as a part of the therapy management plan for metabolic syndrome. Current recommendations include at least 30 minutes of moderate-intensity exercise such as fast paced walking 5 days a week (preferably daily).

 The more physical activity involved in therapy, better results will follow.

Appropriate drug therapy will be dependent on patient’s work up and atherosclerotic cardiovascular disease (ASCVD) risk. Patients that are found to have metabolic syndrome may require management and follow-up in the clinical setting to overall reduce lifetime risk of ASCVD. Multiple studies have found that middle-aged people with the metabolic syndrome are at increased absolute risk for ASCVD in the near future (10-year risk assessment).

Patients can be classified into 3 different risk categories based on 10 year risk for 

. These categories include high risk (10 year risk >20%), moderate-high (10 year risk 10%-20%), and low to moderate (10 year risk <10%).

 Dependent on which risk category a patient is classified under, different therapeutic lipid lowering recommendations are available.

 Statin therapy will aid in reduction of LDL lowering as appropriate. Elevated triglycerides ≥500 mg/dL may require therapy to help avoid acute pancreatitis. Therapy to reduce elevated triglycerides may include statins, niacin, fibrates (such as gemfibrozil or fenofibrate), and/or fish oil capsules.

Hypertension may resolve with lifestyle medications such as diet restrictions, weight reduction, and increase in physical activity. If blood pressure is elevated >140/90 mmHg for patients with diabetes, medication therapy may be necessary to obtain goal blood pressure of < 140/90 mmHg. The use of angiotensin-converting enzyme (ACE) inhibitors as first-line therapy for hypertension in the metabolic syndrome has been supported by investigators.

Management of metabolic syndrome is multifactorial involving medication therapy and patient efforts. Consistent encouragement of weight reduction through appropriate balance of physical activity and caloric intake will aid in overall management of metabolic syndrome. Ongoing research of metabolic syndrome is key as understanding of genetic and metabolic contributions is lacking.

This article was co-authored by Meena Gella, OMS III.

Swarup S, Zeltser R. Metabolic Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan. Updated October 6, 2017.

VanWormer, J. J., Boucher, J. L., Sidebottom, A. C., Sillah, A., & Knickelbine, T. (2017). Lifestyle changes and prevention of metabolic syndrome in the Heart of New Ulm Project. 

Armstrong C. AHA and NHLBI Review Diagnosis and Management of the Metabolic Syndrome. 

Grundy SM, Cleeman JI, Daniels SR et al. Diagnosis and Management of the Metabolic Syndrome An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. 

Articles

Metabolic syndrome involves multiple disease states including hypertension, hyperlipidemia, and possibly diabetes.