Metabolic Syndrome: Factors and Risks

• Metabolic Syndrome is also known as Insulin Resistant Syndrome or Syndrome X.
• Metabolic Syndrome is a cluster of biological factors characterized by abdominal obesity, dyslipidemia, hypertension, and insulin resistance with hyperinsulinemia.
• Metabolic Syndrome often occurs in the general population, especially in older individuals and certain ethnicities.
• Approximately 22.9% of U.S. adults aged 20 years and older have Metabolic Syndrome.
• Metabolic Syndrome increases dramatically as BMI increases.
• Visceral or abdominal obesity can lead to insulin resistance
• Metabolic Syndrome is characterized by a prothrombotic and proinflammatory state with increased inflammatory cytokine activity
• Chronic low-grade inflammation can be a consequence of complex interplay between genetic and environmental factors.
• High plasma glucose and insulin resistance are associated with Metabolic Syndrome.

Major Risk Factors

• Insulin Resistance is a major risk factor
• Stress is a major risk factor
• Genetics is a factor
• Diet contributes to risk
• Age is a risk factor
• Interrupted Sleep Patterns are a risk factor
• Excessive Alcohol Consumption is a risk factor

Clinical Presentation

• Acanthosis nigricans is observable.
• Acanthosis nigricans onset is insidious.
• Acanthosis nigricans causes skin pigmentation appearing dirty.
• Acanthosis nigricans is seen on the neck and in the axillae.

Diagnostic Criteria

• Diagnosis of metabolic syndrome requires the presence of any 3 of the 5 features.
• Abdominal obesity: Waist circumference greater than 40 inches in men or 35 inches in women
• Hypertriglyceridemia: Greater or equal to 150 mg/dL
• Low HDL cholesterol: Less than 40 mg/dL in men or less than 50 mg/dL in women
• Hypertension: Blood pressure greater or equal to 130/85 mm Hg
• High fasting glucose: Greater or equal to 110 mg/dL

Complications of Metabolic Syndrome

• Atherosclerosis
• Diabetes
• Heart attack
• Stroke
• Nonalcoholic fatty liver
• Peripheral artery disease
• Cardiovascular disease

Management

• Nonpharmacological interventions include a 10% weight decrease in 6 months
• Lifestyle changes involving fruits, vegetables, low-fat dairy, and reduced meat/fat consumption
• DASH and Mediterranean Diets are recommended
• Focus on physical activity: moderate/vigorous intensity and aerobic training
• Smoking cessation is helpful

Pharmacological Treatments for Risk Factors

• Antihypertensives like alpha-adrenergic antagonists or ACE inhibitors
• HMG-CoA
• Fibric acid derivatives to lower blood triglycerides
• ASA
• Metformin
• Weight loss medication

Indications for Referral

• Dietitian for assistance with planning and weight loss
• Psychologist for support for goals, stress management, and behavior modification
• Physical therapist for development of safe and effective regimen
• Commercial weight loss programs like Curves for women or Weight Watchers

Patient Education

• Educate patients on complications and cardiovascular risks, meal planning, physical activity
• Physical activity recommendations: moderate/vigorous intensity and aerobic training
• Weight reduction recommendation: 10% decrease in body weight within 6 months
• Establish mutual goals

Elderly Considerations

• Prevalence increases with age.
• Diagnosis is necessary in older adults due to the 2.5-fold increased risk of cardiovascular disease and five-fold increase for the development of diabetes mellitus.
• Obesity prevalence has increased in recent decades in all age groups, alongside population aging.
• Depression leads to poor outcomes and compliance.
• Educating on modified exercising, especially resistance exercise helps slow aging

Obesity Epidemiology

• Obesity is a worldwide problem of epidemic proportions.
• Over 50% of U.S. non-Hispanic Black women aged 40 years or older are obese.
• About 40% of Hispanic women are obese.
• Roughly 33% of non-Hispanic White women are obese.
• Education level is related to obesity and being overweight.
• Spending for obesity-related illness costs was $150 million/year in 2013.
• Spending for obesity-related illness costs was $821 million in 2017 for Medicare, Medicaid, and private insurance payers.

Definition and Assessment of Obesity

• Body Mass Index (BMI) is an easy and inexpensive measure of body fatness in clinical settings.
• BMI serves as a screening tool.
• Limitations of BMI include low specificity, no account for body fat percentage, fat distribution or body frame size.
• Limitations of BMI include not accounting for metabolic activity, amount of lean tissue, muscularity, or puberty/menopause.

Waist Circumference

• Measuring waist circumference helps screen for possible health risks that come with overweight and obesity.
• Increased risk of heart disease and type 2 diabetes stems from fat around the waist.
• Risk increases with waist size greater than 35 inches for women or 40 inches for men.
• Measure waist by standing and placing a tape measure around the middle, just above hipbones, right after breathing out.

Obesity Stages Based on BMI

• Overweight: 25 – 29.9
• Class 1 Obesity: 30 to < 35
• Class 2 Obesity: 35 to < 40
• Class 3 Obesity: 40 or higher

Physical Examination

• Respiratory
• Psychological
• Cardiovascular
• Central nervous system
• Obstetric and perinatal
• Surgical
• Gastrointestinal
• Orthopedic
• Metabolic
• Cutaneous
• Extremity
• The five main steps in the evaluation of obesity are: focused obesity-related history, a physical examination to determine the degree and type of obesity, Assessment of comorbid conditions, determination of fitness level, assessment of the patients readiness to adopt lifestyle changes

Diagnostics

• Urinalysis
• Serum glucose
• Uric Acid
• Blood Urea Nitrogen
• Creatinine concentration
• Complete blood count (CBC)
• Thyroid-stimulating hormone level
• Lipid profile (total cholesterol, LDL, HDL, triglycerides)
• Liver function test
• 2-hour oral glucose tolerance test with inulin levels
• BMI
• Diagnostic studies depend on findings of the history and physical examination

Treatment

• Healthy eating plan and regular physical activity
• Weight management programs
• Pharmacological options

Short-Term Medication

• Phentermine- sympathomimetic/ increases satiety.
  • It can be used for 13 weeks.
  • Usual dose: 15-37.5 mg PO daily
  • Side effects: such as tachycardia, HTN, psychosis

Chronic Medications

• Orlistat (Xenical) blocks fat digestion and absorption from the stomach & intestines.
  • Dose: 120 mg PO TID during meals or up to 1 hour after meals with fat.
  • Side effects: Flatulence, fecal urgency/incontinence, fatty stools, oily discharge.
• Lorcaserin (Belviq) activates 5-HT2C receptors
  • Dose: 10 mg PO BID
  • Side effects: Hypoglycemia, diarrhea, musculoskeletal pain, hyperprolactinemia.
• Phentermine-topiramate (Qsymia) sympathomimetic & neurostibilizer; promotes satiety
  • Usual dose: 7.5 mg/46 mg PO QAM (start w/ half dose x 2 weeks, then titrate to prescribed dose)
  • d/c if less than 5% weight loss after 12 weeks on max dose, taper if at max dose
    • Naltrexone-Bupropion (Contrave)- opioid antagonist and antidepressant
    • Promote satiety and suppresses cravings
    • 8 mg/90 mg ER 2 tabs PO BID
    • Depression/ suicide risks must be screened

Glucagon Like-Peptide 1 (GLP-1) Agonists

• Promotes Satiety
• Liraglutide (Saxenda). Titrated 0.6 mg to 3mg SQ daily SC daily.
• Tirzepatide (Zepbound). Titrated from 2.5mg/wk to 15mg SQ/wk
• Semaglutide (Wegovy) Titrated from 0.25mg/wk to 2.4mg SQ/wk

Bariatric Procedures as Options

• For patients with BMI >35 with significant co-morbidities.
• For patients with BMI >40.
• Impact is in obesity and to restrict food intake based on metabolic and hormonal role.
• Considered after failed dietary and pharmacologic therapy

Common Surgical Procedures

• Adjustable gastric banding.
• Sleeve gastrectomy.
• Roux-en-Y gastric bypass.
• Intragastric balloon.

Elderly Considerations for Obesity

• Obesity in older adults impacts morbidity and mortality, and significantly impacts quality of life
• Risk of institutionalization can occur in the elderly
• By 2030 in the United States, it's estimated that greater than 20% of the population will be over the age of 65
• Fat is redistributed from peripheral to central locations
• A natural loss of muscle mass and strength with aging happens after the eight decade of life, termed sarcopenia
• Elderly obesity can causes a major risk of falling
• Community-based physical activity interventions are ways to delay disability and enhance physical function in the elderly

Explore the factors defining metabolic syndrome, including prevalence, BMI correlation, and pathophysiology. Understand visceral obesity's role and associated inflammatory states. Review related conditions and hormonal influences.