Metabolic Syndrome and Obesity: Definition, Risk Factors, and Management

Metabolic Syndrome / Obesity  Definition & Epidemiology  Metabolic Syndrome aka Insulin Resistant Syndrome aka Syndrome X  Metabolic syndrome is a cluster of biological factors characterized by:  abdominal obesity (central or visceral)  dyslipidemia,  hypertension, and  Insu...

Metabolic Syndrome / Obesity  Definition & Epidemiology  Metabolic Syndrome aka Insulin Resistant Syndrome aka Syndrome X  Metabolic syndrome is a cluster of biological factors characterized by:  abdominal obesity (central or visceral)  dyslipidemia,  hypertension, and  Insulin resistance with hyperinsulinemia  Metabolic Syndrome often occurs in the general population, mostly in older individuals and in certain ethnicities.  Present in approximately 22.9% of U.S. adults 20 years of age and older  Metabolic Syndrome increases dramatically as BMI increases.  Pathophysiology  Visceral or abdominal obesity leads to insulin resistance.  Prothrombotic and proinflammatory state characterized by increased inflammatory cytokine activity.  State of chronic low grade inflammation as a consequence of complex interplay between genetic and environmental factors.  High plasma glucose and insulin resistance.  Major Risk Factors  Insulin Resistance  Stress  Genetics  Diet  Age  Interrupted Sleep Patterns  Excessive Alcohol Consumption Clinical Presentation  Clinical Presentation  Physical sign: acanthosis nigricans  onset: insidious, first visible change darkening of the skin pigmentation appearing dirty neck axillae Diagnostic Criteria  Complications of Metabolic Syndrome Atherosclerosis Diabetes Heart attack Stroke Nonalcoholic fatty liver peripheral artery disease cardiovascular disease  Management  Nonpharmacological Losing weight: recommendation 10% decrease in 6 month Lifestyle change: fruits, vegetables, low-fat dairy products, refrain from huge consumption of meat or fatty food DASH Diet High Fiber Diet Mediterranean Diet Physically active Moderate Intense Vigorously Intense Aerobic training Cessation of smoking  Management  Pharmacological treatment for the risk factors not specifically for the treatment of metabolic syndrome antihypertensive (alpha-adrenergic antagonists or ACE) HMG-CoA Fibric acid derivatives (lower blood triglycerides) ASA Metformin Weight loss medication  Indication for Referral  Dietitian  assistance with planning and weight loss  Psychologist  support for goals, stress management, behavior modification  Physical therapist  development of safe and effective regimen  Commercial weight loss  Curves for women  Weight Watchers  Patient Education Educating the patient on complications and cardiovascular risks Meal planning Physically active Moderate Intense Vigorously Intense Aerobic training Weight reduction recommendation 10% decrease in body weight within 6 months Mutual Goals  Elderly Consideration  Prevalence increases with age, making its diagnosis necessary due to the 2.5-fold increased risk of cardiovascular disease and five-fold increase for the development of diabetes mellitus.  The prevalence of obesity has increased in recent decades in all age groups, alongside with the population aging.  Depression leads to poor outcomes and compliance.  Education of modified exercising and exercise, particularly resistance exercise, represents an important component of the treatment to slow aging by reducing the prevalence of the metabolic syndrome and decreasing cognitive and depressive syndromes  Obesity Epidemiology  Obesity is a worldwide problem of epidemic proportions.  Over 50% of U..S. non-Hispanic lack women older than 40 years are obese compared with 40% of Hispanic and 33% of non-Hispanic white women.  Level of education is related to obesity an over weight.  Spending for obesity-related illness costs are estimated at $150 million per year in 2013 dollars and $821 million in 2017 dollars for Medicare, Medicaid, and private insurance payers.  Definition Obesity Body Mass Index/Waist Circumference Body Mass Index BMI measure of body fatness, and more accurate than weight alone , is easy, and inexpensive to use in clinical settings. Screening Tool Low Specificity Limitations Does not account for body fat percentage boy fat distribution body frame size capacity for metabolic activity amount of lean tissue such as muscle and bone Does not account for muscularity puberty or menopause Waist Circumference Measuring waist circumference helps screen for possible health risks that come with overweight and obesity. If most of your fat is around your waist rather than at your hips, you’re at a higher risk for heart disease and type 2 diabetes. risk goes up with a waist size that is greater than 35 inches for women or greater than 40 inches for men. To correctly measure your waist, stand and place a tape measure around your middle, just above your hipbones. Measure your waist just after you breathe out.  Obesity Stages Overweight: BMO 25 – 29.9 Class 1: BMI of 30 to < 35 Class 2: BMI of 35 to < 40 Class 3: BMI of 40 or higher  Physical Examination Respiratory Psychological Cardiovascular Central nervous system Obstetric and perinatal Surgical Gastrointestinal Orthopedic Metabolic Cutaneous Extremity  Diagnostics Obesity 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 depended on findings of the history and physical examination.  Treatment Obesity  Healthy eating plan and regular physical activity  Weight management programs  Pharmacological options  Pharmacologic Management  Short–term medication  Phentermine- sympathomimetic/increases satiety  13 weeks  Dose: 15-37.5 mg PO daily  Side effects: tachycardia, HTN, psychosis  Chronic Medications  Orlistat (Xenical)- blocks the digestion and absorption of fat in the stomach and intestines  Dose: 120 mg PO TID during meals or 1 hour after meals containing fat content  Side effects: flatus w/oily discharge, fecal urgency, fatty stools, fecal incontinence  Lorcaserin (Belviq)- activates 5-HT2C receptors  Dose: 10 mg PO BID  Side effects: hypoglycemia (in diabetic pts), hyperprolactinemia, diarrhea, musculoskeletal pain  Pharmacologic Management  Phentermine-topiramate (Qsymia)- sympathomimetic and neurostibilizer; promotes satiety  Dose: 7.5 mg/46 mg PO QAM (start w/half dose x 2 weeks, then increase 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 anti-depressant; promotes satiety and suppresses cravings  Dose: 8 mg/90 mg ER 2 tabs PO BID  Depression/suicide screen Pharmacologic Management Glucagon like peptide-1 agonist (GLP-1)  promotes satiety  Liraglutide (Saxenda)  Dose: Titrated 0.6 mg to 3mg SQ daily SC daily  Tirzepatide (Zepbound)  Dose: Titrated from 2.5mg/wk to 15mg SQ/wk  Semaglutide (Wegovy)  Dose: Titrated from 0.25mg/wk to 2.4 mg SQ/wk  Surgical Management  Bariatric procedures maybe options  for patients with BMI>35 with significant co-morbidities40  For patients with BMI>40  Impact is in obesity as well as restrictive food intake on metabolic and hormonal role  Option after failed dietary and pharmacologic therapy Surgical Management  Common Surgical Procedures:  Adjustable gastric banding  Sleeve gastrectomy  Roux-en-Y gastric bypass  Intragastric balloon Mapping of Obesity Care  Elderly Consideration Obesity Obesity in older adults impacts not only morbidity and mortality importantly impacts quality of life the risk of institutionalization By the year 2030 in the United States, over 20% of the population will be over the age of 65 years Throughout adulthood, a natural increase in body fat develops up to the 8 th decade of life, after which there is a reduction Redistribution of fat from peripheral and subcutaneous sources to a central location leads to increased waist circumference and waist-hip ratio in older adults. natural loss of muscle mass and strength with aging, termed sarcopenia. Obesity is also associated with increased risk of falling in older adults. Over one-third of adults aged 65 years and older fall each year. Community-based physical activity interventions are ways to delay disability and enhance physical function.