Metabolic Syndrome

Predisposing Factors of Metabolic Syndrome Medications that cause

Predisposing factors of metabolic syndrome include: genetic predisposition; weight gain, especially central and abdominal obesity; females; smoking; high carbohydrate diet; lack of an exercise; and insulin resistance. Medications: Corticosteroids, Antihistamines, antipsychotics and antidepressants

CRP and Metabolic Syndrome

Inflammatin is major role in atherogenesis CRP is independent CVD risk factor and marker of insulin resistance Increased CRP in metabolic Syndrome

Hypertension and Metabolic Syndrome

Insulin resistance and visceral adiposity main factors in HTN Insulin resistance causes hyperinsulin activates sympathetic NS and renin angiotensin aldosterone system Urinary sodium escretion declines increased sodium reabsorption exapnsion of ECF and renal dilation

Clinical Presentation

Insulin resistance can be suspect that an individual was seen with abdominal obesity, increased triglycerides, low HDL cholesterol, and hypertension. Also look for acanthosis nigricans and skin tags, sign of insulin resistance

Complications associated with Metabolic Syndrome

fatty liver disease, cirrhosis, chronic kidney disease, PCOS, obstructive sleep apnea, and gout.

Dyslipidemia and Metabolic Syndrome

Adipose tissue becomes insulin resistant Impairs adipocytes to take up glucose cant store free fatty acids so they release them Muscle cells take up free fatty acids become saturated and insulin resistant as well Results in low glucose disposal and hyperglycemia and thus hyperinsulinemia Free fatty acids diverted to liver and suppress glucose output, turns into secretion of lipoproteins. Causes plaque and heart disease

First treatment for insulin resistance

Aggressive lifestyle modification, focusing on increased physical activity and weight reduction is a cornerstone for treatment. Dietary recommendations include the Dash diet. It is recommended that they have a weight loss of 5 to 10%.

Microalbuminuria

Association between Microalbumin and Metabolic syndrome is partly because of insulin on renal hemodynamics hyperinsulin causes renal dilation increased plasma flow increased Glomerular hydrostatic pressure and filtration Elevated Glomerular pressure increases microalbumin secretion Microalbuminuria is a strong predicotr of CVD and mortality

What does Pa-1 do

Correlate with insulin resistance. Elevated PA1-1 relfect impaired firinolysis Increased insulin resistance also affects coagulation factors

Diagnostic overview

Diagnosis: Three or more conditions below Insulin Resistance Hypertension (Blood Pressure 130/85 or higher) Seen in up to 40% of Metabolic Syndrome patients Hyperlipidemia 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 G:I Ratio <4.5 considered abnormal

Differential diagnosis

Differential diagnoses for metabolic syndrome include obesity, hypertension, hyperlipidemia, impaired fasting glucose, impaired glucose tolerance, PCOS, type II diabetes mellitus, and hypothyroidism

Measuring Waist Circumference

General Use non-stretchable measuring tape Tape should touch skin, but not compress soft tissue Avoid twists in the tape Waist Circumference Do not measure within 1 hour of large meal Measure patient while supine Measuring tape may fall in standing position Panniculus shifts downward in standing position Measure at natural waist, midway between: Palpated iliac crest or at level of umbilical Hip Circumference Patient stands erect Arms at side Feet together Measure hips at maximum circumference over buttocks

Lifestyle modifications

Prevention of progression to Diabetes 10% decrease body weight in 6 months Moderate aerobic Exercise for 30 minutes 5/wk 150 minutes per week Example: Brisk walking for total of 150 min/week Decreased Caloric Intake 800-1500 calories 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 to 15 gram per 1000 calories Appears to have Insulin-like activity May increase Insulin sensitivity Improves lipid profile

Not all patients with insulin resistance will develop all of the components but the greater the number of associates in the individual the greater risk for developing CVD

The exact cause of metabolic syndrome is unknown however visceral or abdominal obesity leads to insulin resistance. When the cell becomes resistant to the insulin, the body compensates by producing more insulin to overcome the resistance and to maintain normal glucose levels. This results in hyperinsulinemia.

Physical Exam Waist circumference and BMI are most routinely used antropometric indexes

The physical exam should be guided by the patient's medical history and presenting signs and symptoms. Vitals should be taken and should include height, weight, waist circumference, BMI, waist to hip measurement.

What is insulin Resistance

Visceral or Abdominal obesity leads to insulin resistance Impared insulin stimulated glucose uptake by skeletal muscle, adipose tissue or liver. associated with decreased sensitivity to insulin

Interpretation of Higher Obesity Risk Elevated Waist circumference BMI and weight circumference routinely used, easy and reliable

Waist-to-Hip Ratio:Measures fat distribution Pear Obesity (Gynoid Obesity) Apple Obesity (Android Obesity, Beer Belly) Males > 0.9 increased risk Females > .85 increased risk Waist Circumference Males >= 40 inches (94-102 cm) increased risk Females >= 35 inches (80cm increased risk BMI: Greater than 25kg/m2: weight divided by height squared

Diagnostic Testing for Metabolic Syndrome Glucose tolerance Fasting Blood glucose Fasting Plasma Insulin Fasting Lipid Urinalysis C-reactive protein

glucose tolerance test: 75g oral glucose. 2 hours later, value of 140-200 Impaired glucose tolerance fasting blood glucose, : 8-12 hour fast. levels between 100-126 are diagnostic of impaired fasting fasting plasma insulin concentration: 10u/ml is insulin resistant fasting lipid profile, urinalysis, for microalbumin (protein) C-reactive protein: greater than 3 indicates CVD. Also consider a thyroid function.

Characteristics of Metabolic Syndrome

include insulin resistance with hyperinsulinemia, hypertension >75th percentile abdominal obesity dyslipidemia with hypertriglyceridemia, low HDL and high LDL. elevated C-reactive protein levels, increased plasminogen activator inhibitor one levels(PA1-1) microalbuminuria.

Standardized Diagnostic Criteria for Metabolic Syndrome Elevated waist circumference Triglycerides Low HDL High LDL Elevated BP Elevated Fasting Glucose

standardize the diagnostic criteria for metabolic syndrome. These criteria include elevated waist circumference elevated triglyceride 150 mg/dL or specific treatment for this lipid abnormality reduced HDL; less than 40 mg/dL in males less the 50 mg/dL in females or specific treatment for this lipid abnormality; elevated blood pressure systolic 130 mmHg or diastolic 85 mmHg or drug treatment of previously diagnosed hypertension fasting plasma glucose greater than or equal to 100 mg/dL or drug treatment for elevated glucose

General Management and medication guides Diet Statins Ace Inhibitor Asprin

treat each individual diagnoses for the individual. Insulin resistant patients are usually not treated by insulin. Statins may be used for elevated lipids. Triglycerides below 150 LDL below 100 HDL above 40 men and 50 women Gemfibrozil: triglycerides Ace inhibitors may be used for hypertension and the patient may also benefit from a low dose aspirin. Goal Less than 140/90 or 130/80 for high risk Hemoglobin A1C >5.7% despite 3-6 months of lifestyle changes First-line (preferred) Glucophage (Metformin) Initial: 500 mg orally daily Next: 850 mg orally twice daily (indicated if Hemoglobin A1C>5.7% after 3 months) Asprin: Modifies prothrombin proinflammatory sate