1. Metabolic Syndrome Warren Heffron MD Professor EmeritusFamily Medicine
University of New Mexico

2. Goal
Share information about a common condition that has significant impact on the health of a huge number of people globally, yet if identified early permits physicians to intervene and improve the health of many patients while decreasing morbidity and mortality.

3. New Patient RC 45 Y/O Man Healthy, says no identified health problems.
Just retired from the airforce, divorced
Past History, no hospitalizations or surgery
No known drug allergies
No current medications
Family history: both parents had diabetes and hypertension late in life
Social History, divorced, actor, smokes
System review, nocturia 2X, frequent cough

4. Exam Findings General, Obese, Abdominal girth=146 CM, 42 inches
Weight = 110 Kg. BMI = 33, Pulse 84, Resp 14,
T=36.7, BP= 160/90
His heart and lung exam is normal as is his abdomen except for truncal obesity. The rest of his physical is basically normal, except for a few skin scars from trauma.

5. Laboratory Assessment
Hematology and chemical screens are all normal except
HDL-C 40
Triglycdrides 575

6. What Are His Problems? HTN Obesity I’ll loose wt, diet consult.
> Triglycerides
Start antihypertensive Rx

7. Management 2 years later
BP 140/80
Weight the same
Triglycerides 850
Abdominal girth the same
Another dietary consult
Exercise program
Add Lopid and nicotinic acid toRx.

8. 5 years later age 52 BP controlled
Obese, abdominal girth still increased
Promises to lose weight and exercise
Triglycerides 1,500. TC= 220. LDL =160, HDL 24
Over next 10 years BP and chloesterol controlled , diet, exercise, Rx. still had >Triglycerides and < HDL

9. 11 years later, age 63
BP 140/88, Cholesterol controlled, abdominal girth 146 cm. BMI 31, wt. 100 kg.
New Labs. Hgb A1-c 9.2
Start management with Metformin, nutritional counseling. 12 years relative control with A1-c upper 6’s to 7’s. Increasing insulin regimins up to 60u Lantus with variable Humalog

10. 12 years later, age 75
BP, Cholesterol, and diabetes reasonably controlled. No renal failure. Triglycerides still elevated, ranged , wt < minimally, 100Kg. Abdominal girth unchanged.

11. Same Patient Age 79 Interval history Continued truncal obesity
Hyperlipidemia now controlled
Hypertension controlled
Diabetes developed, reasonable control
2 MI’s with multiple stents
Mitral and Triscupid valve replacement, atrial fibrillation
2 CVA’s, onset mild dementia

12. Enter ex wife. Compulsive lawyer, caregiver
Pushed PT, Rx,
Gave her control of everything that went between his lips.
Visits full of computer generated data and reports. Became expert in nutrition.

13. Next two years Weight became normal
Mentation improved, ambulation <
Abdominal girth became normal.
Insulin requirement decreased, stopped.
BP Rx decreased by half
Lipids stable on minimal Rx

14. What are his problems? What does he have?
Is he one of 120,000,000 people whose health you could help, even prolong his life?
What is the Metabolic Syndrome?

15. Criteria. Any 3 of the following
Abdominal Obesity
Increased waist circumference
Men > 102 CM (40 IN)
Women > 88 CM (35 IN)
Less for Asian patients
China = 85 CM men 80 CM women
Some consider positive if waist circumference is greater than hip.

16. Body Mass Index Measure of relationship of weight to height
Weight in KG divided by the square of height in meters.
Or Google. Body Mass Index calculator and enter.
Low < 18, Normal to 25, Overweight to 29, obese >30

17. Criteria Glucose Intolerance Fasting plasma glucose > 100 mg/dl
Some say 110mg/dl
Hgb A1-c (NCEP)
Hypertension
Elevated blood pressure
Systolic > 130 mm Hg
Diastolic > 85 mm Hg

18. Criteria Atherogenic Lipid profile Serum Triglyceride > 150 mg/dl
Decreased HDL (high density Lipoprotein) Cholesterol
Men < 40 mg/dl, Women < 50 mg/dl
Elevated LDL Cholesterol (>130)
varies by risk factors

19. Also Known As
Syndrome X
Deadly quartet
Insulin resistance syndrome

20. Issues Obesity Diabetes Hypertension Dyslipidemia
Common abnormalities of lipid and glucose metabolism that is associated with truncal obesity.

21. Prevalence
39% of Americans meet criteria. > in elderly, men, Hispanic and African Americans.
Relation to weight
Normal weight =5% prevalence
Overweight = 22%
Obese = 60%

22. Prevalence China 9.8 %, Overweight 26.9 % Higher in northern China
Higher in urban than rural China
Interpretation, large numbers call for detection, prevention and management.
Gu, et al. Lancet, 2005

23. Prevalence in China
13%
Diabetes, hypertension other risk factors becoming more common in China.
Obesity is principle factor for Met. Synd.
Incidence of cardiovascular disease > when the basal metabolic index > 23. Mean BMI in China is 18.
Chang, Circulation 2003

24. Why Important Metabolic Syndrome; Cardiovascular events and death
All cause mortality.
Early recognition of risk factors for cardiovascular disease permits intervention before clinical manifestation and reduces mortality and morbidity

25. Metabolic Syndrome and Cardiovascular Disease
1209 Finnish men 49-60, no CVD, cancer or diabetes on entry to study.
11.5 year follow up
Results
3X rate of death from CVD
2X death rate from all causes
18% all cause mortality vs. 8% at 13.7 years.

26. Insulin Resistance Factors
Obesity
Hypertension (50%)
Dyslipidemias
Impaired Glucose tolerance
Diabetes II
Hyperuricemia
Atheroscerosis
Thrombosis ( decreased thrombolytic activity)
Acanthosis Nigricans

27. Insulin Resistance
Increased free fatty acids impair glucose dependent secretion and infiltrate liver, muscle and pancreas which impairs cellular use of glucose production, hence increases glucose production in the liver.
Result, less peripheral cellular glucose use, > plasma glucose, increased insulin secretion

28. Insulin Resistance
Leads to intravascular inflammation, endothelial dysfunction,
Leads to hypercoaguable state,
Leads to atherogenesis, (cardiovascular, stroke and cellular level dysfunction in liver and muscle, and other organs)

29. Treatment Obesity Weight loss 10% in first year
Caloric restriction 1000 Kcal / day
< saturated fat, (7%) Cholesterol 300 mg/d
Total fat 25% of daily calories
Exercise
Behavior Modification
Manage cardiovascular risks
hypertension, glucose intolerance, lipids

30. 我爱吃文昌鸡

31. Treatment Dyslipidemia
LDL Cholesterol Target Goal
High Risk <100
Moderate Risk <130
Low Risk <160
If CAD
Use diet, exercise and statins.
Risk factor estimation, based on age, Total Cholesterol, Smoker, HDL Different scale for women. (Framingham = one scale)

32. Treatment Low HDL Target LDL first. HDL less responsive
Treat to normal <40 male and <50 female
Exercise, diet, weight loss, smoking cessation, post menopausal estrogen replacement, Rx Niacin and Fibrates.
Niacin may < LDL by 15%, < triglycerides 20-50%, > HDL by 35%

33. Treatment of Glucose Intolerance Hypertension
Treat to Hgb A1-c < 7%
Diabetes if develops -usual treatment
Treat Hypertension to 130/80
Treat into older age. Treatment into the 80’s still reduced cardiovascular disease by 30% compared with untreated.

34. Treatment of Non HDL Cholesterol Also Independent Risk Factor
Total Cholesterol – HDL
Treat to target level 30 mg above the LDL

35. Summary Met Syndrome is associated with CV Disease
Physician awareness is important in preventing CVD
Identification allows intervention before the ravages of disease are present
Management decreases morbidity and mortality. Improve health of 120,000,000 People ????

36. Value
Long term relationship.