February 2005

Metabolic syndrome

by Dr. Howard Loomis

Metabolic syndrome is rapidly becoming a major clinical entity in pharmaceutical circles. [1] As a chiropractor, you should become not only aware of it but also very familiar with it since it has the potential of occupying much of your professional time, regardless of the type of practice you have.

By definition, metabolic syndrome is a collection of signs and symptoms that are precursors suggesting a potential pathological development. [2] If you recognize these signs, you can help the patient take preventive measures before a diagnosis of disease can be made and medical treatment initiated. You can then monitor the syndrome's development or improvement, thus becoming a valuable partner in the patient's health care.

Patients are becoming increasingly aware of the harmful side effects of prescription drugs, and they desire health care rather than sick care.

Diagnosis

The purpose for identifying metabolic syndrome is to be able to predict and prevent future heart attacks. [3] The core of the syndrome is recognition of the factors responsible for coronary artery disease. To be diagnosed with metabolic syndrome, a patient must have at least three of the following five signs and symptoms:

***  Abdominal girth is greater than 40 inches in men and 35 inches in women.

***  Blood pressure is 135/85 mmHg or higher.

***  Fasting HDL‑C is less than 40 mg/dL in men and 50 mg/dL in women.

***  Plasma triglycerides is 150 mg/dL or higher.

***  Fasting blood glucose is 110 mg/dL or higher.

Historical development

The conceptual development of this syndrome can be traced back to 1938 when the term "insulin resistance" was first coined. By 1960 it was realized that obesity ‑‑ with or without diabetes ‑‑ was a cause of insulin resistance. Gradually, throughout the 1960s, '70s and '80s, other causes of insulin resistance were being recognized. Elevated levels of triglycerides, cholesterol, and blood pressure were added to the list.

In 1998, the National Institutes of Health issued the first clinical practice guidelines on weight and obesity. [4] In 2001, the National Cholesterol Education program began to promote weight loss and increased physical activity as the basis for treatment of these signs and symptoms. [5] Today, the scope of investigation is being broadened to include the role of inflammation and formation of blood clots. [6‑8]

Lower limits of acceptable levels of blood glucose, triglycerides, and cholesterol are now being recommended. Lower systolic and diastolic blood pressure levels are also now the norm and may be referred to as "pre‑hypertension."

Obviously, this makes more people eligible for pharmaceutical intervention, but it also broadens your scope of preventive care. If 135/85 is PRE‑hypertension, then you should be monitoring and treating to prevent, if possible, the onset of hypertension.

Prevalence

It's estimated that at least 47 million Americans currently have metabolic syndrome. [5] If the lower limit for blood glucose is lowered to 100 mg/dl, as recommended by the American Diabetic Association, the number of affected adults may be 64 million! That means it's possible one‑half of the population over age 60 would meet the criteria for the syndrome.

Looking for a way to increase your practice? Why not begin monitoring your patients for weight, abdominal girth, and blood pressure on every visit? Age, sex and ethnic origin are reliable predictors of those who may fall within the boundaries of metabolic syndrome.

For example, the highest age‑adjusted incidence is found in Mexican Americans (31.9%). [4,9,10] The lowest prevalence is among whites (23.6%), African Americans (21.6%), and people reporting other race or ethnicity (20.3%). Among African Americans, the numbers are very high for women but very low for males.

Taken as a whole, the numbers rise rapidly once past the age of 40, and there is another big spike after age 60, when the occurrence of metabolic syndrome in women surpasses men.

Treatment

Improved diet and increased exercise are key components to preventing the occurrence of coronary artery disease. [11] Thirty minutes of moderate exercise per day is recommended to lose weight and improve circulation. This time can be divided into segments to meet busy schedules. But it should be noted that walking at a moderate pace will be enough for those over 60.

It's interesting to note that many who meet the criteria for metabolic syndrome fall within normal weight range for their age. Abdominal fat distribution is arguably the more sensitive factor.

Summary

Monitoring your patients for weight, abdominal girth, and blood pressure on every visit is quick, easy, and appreciated. It provides you with an excellent opportunity to broaden your service and effectiveness as a health care provider. You can therefore build your practice without increasing fees or overhead. Remember, anytime you increase your service, you increase your income. Patients recognize that you have more expertise than before, and they appreciate that.

References

1. Deen D. "Metabolic syndrome: time for action." Am Fam Physician. Jun 15 2004;69(12):2875‑2882.

2. Fletcher B, Lamendola C. "Insulin resistance syndrome." J Cardiovasc Nurs. Sep‑Oct 2004;19(5):339‑345.

3. Lakka HM, Laaksonen DE, Lakka TA, et al. "The metabolic syndrome and total and cardiovascular disease mortality in middle‑aged men." JAMA. Dec 4 2002;288(21):2709‑2716.

4. Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. "The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988‑1994." Arch Intern Med. Feb 24 2003;163(4):427‑436.

5. Ford ES, Giles WH, Dietz WH. "Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey." JAMA. Jan 16 2002;287(3):356‑359.

6. Das UN. "Metabolic syndrome X: an inflammatory condition?" Curr Hypertens Rep. Feb 2004;6(1):66‑73.

7. Garg R, Tripathy D, Dandona P. "Insulin resistance as a proinflammatory state: mechanisms, mediators, and therapeutic interventions." Curr Drug Targets. Aug 2003;4(6):487‑492.

8. Yaffe K, Kanaya A, Lindquist K, et al. "The metabolic syndrome, inflammation, and risk of cognitive decline." JAMA. Nov 10 2004;292(18):2237‑2242.

9. Burlando G, Sanchez RA, Ramos FH, Mogensen CE, Zanchetti A. "Latin American consensus on diabetes mellitus and hypertension." J Hypertens. Dec 2004;22(12):2229‑2241.

10. Aguilar‑Salinas CA, Rojas R, Gomez‑Perez FJ, et al. "High prevalence of metabolic syndrome in Mexico." Arch Med Res. Jan‑Feb 2004;35(1):76‑81.

11. Reaven GM. "Diet and Syndrome X." Curr Atheroscler Rep. Nov 2000;2(6):503‑507.

(Dr. Loomis welcomes input on the subjects covered in this column. To make a comment or ask a question, write to him at 6421 Enterprise Lane, Madison, WI 53719. Visit www.loomisenzymes.com online or call 800‑662‑2630 for information on upcoming Loomis Institute seminars.)