Episode 71 - Metabolic Syndrome - a podcast by Rio Bravo Family Medicine Residency Program

Episode 71: Metabolic Syndrome. 

Dr Yomi defines metabolic syndrome and describes the basic principles of management. Nathan gives updates about aspirin use in primary prevention of cardiovascular disease.

Introduction: Aspirin Update.  
By Nathan Heathcoat, MS3, Ross University School of Medicine.  

Arreaza (comment): This week I was checking the list of the top 10 countries where we have the highest number of listeners, and I’m happy to see the Kingdom of Spain as the number 2 country with the most listeners. Out top 1 country is the United States, we also have listeners in Canada, Mexico, the Netherlands, Brazil, Ireland, Australia, South Africa, Mexico, and England. I send my greetings to you wherever you are. I hope you all enjoy today’s episode, from wherever you are, and please send us an email to rbresidency@clinicasierravista.org if you have any feedback. We would like to hear from you.

 

Hello, my name is Nathan Heathcoat I am a 3rd year medical student at Ross University School of Medicine. I will be giving a quick update on aspirin. 

 

Aspirin has been examined quite a bit by the USPSTF recently. In episode 68, Doctors Arreaza and Civelli discussed the continued recommendations for the use of aspirin for the prevention of preeclampsia in high-risk patients. 

 

Now as of October 12, 2021, The USPSTF has been working on draft changes on how we utilize aspirin for the prevention of cardiovascular disease (CVD) events.

 

The previous guideline from 2016 gave aspirin use as CVD event prophylaxis a grade B (as in Bravo) recommendation in patients aged 50-59 who’s 10-year ASCVD risk was 10% or greater. Additionally, for those patients aged 60-69 with a 10-year risk of 10% or more, aspirin use is said to be an individual based approach and received a grade C recommendation. (1)

 

Now with these new draft recommendations, those patients aged 40-59, aspirin only adds marginal benefit. Its recommendation has been tentatively changed to grade C and its use should be an individual based approach. Most notably, for those patients aged 60-69, the USPSTF is suggesting that aspirin confers no net benefit for primary prevention of CVD, and they changed its recommendation to grade D as in delta. (2)

 

So going forward keep in mind that these practice guidelines are under draft review and the official recommendation should be finalized mid to late November 2021. 

 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

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Metabolic Syndrome.    
By Timiiye Dawn Yomi, MD; and Hector Arreaza, MD.  

 

INTRODUCTION                                                                                                                                                            Obesity, especially abdominal obesity, is associated with an increase in insulin resistance which causes abnormal glucose and fatty acid utilization in peripheral muscles, among other consequences. 

Obesity can often result in type 2 diabetes. 

The hyperinsulinemia and hyperglycemia resulting from insulin resistance can result in vascular endothelial dysfunction, abnormal lipid profile, hypertension, and vascular inflammation and together, can increase the risk for developing ASCVD. 

A constellation of metabolic risk factors for type 2 diabetes and cardiovascular disease is what constitutes metabolic syndrome or insulin resistance syndrome.

What is a syndrome? It is a group of symptoms that are present together, or a condition characterized by a set of associated symptoms.

DEFINITION

The National cholesterol education program ATP III updated its definition of metabolic syndrome in 2005 and defined it as the presence of any 3 of the following 5 traits.

 

Abdominal obesity: waist circumference ≥ 102cm (40in) in men and 88 cm (35in) in females 

Serum triglycerides ≥150 mg/dl (1.7 mmol/L) or drug treatment for elevated triglycerides.

Serum high density lipoprotein (HDL) cholesterol < 40 mg/dl (1mmol/l) in males and < 50 mg/dl (1.3mmol/l) in females or drug treatment for low HDL cholesterol.

Blood pressure ≥ 130/85 mmHg or drug treatment for elevated blood pressure.

Fasting plasma glucose 100mg/dl or drug treatment for elevated blood glucose.

The International Diabetes Federation: 2009 – same criteria, except waist circumference has specific cut off points based on ethnicity and OGTT. 

 

Increased waist circumference with ethnic-specific cut off points (Look for table 2 in this handbook).

Serum triglycerides ≥150 mg/dl (1.7 mmol/L) or drug treatment for elevated triglycerides.

Serum high density lipoprotein cholesterol < 40 mg/dl (1mmol/l) in males and < 50 mg/dl (1.3mmol/l in Females or drug treatment for low HDL cholesterol.

Systolic blood pressure ≥ 130, diastolic blood pressure ≥85 or treatment for hypertension.

Fasting plasma glucose 100mg/dl (5.6 mmol/l) or previously diagnosed type 2 diabetes or oral glucose tolerance test which is recommended for patients with an elevated fasting plasma glucose.

As a side note, metabolic syndrome cannot be diagnosed in children <10 years but clinicians must be vigilant if waist circumference is ≥ 90th percentile for age

 

 

Risk factors

Weight is the most important risk factor: Increased body weight is a major risk factor in developing metabolic syndrome. In the National Health and Nutrition Examination Survey III, metabolic syndrome was present in 5 percent of those at normal weight, 22 percent of those with overweight, and 60 percent of those with obesity.

 

Other risk factors include age, race, postmenopausal status, smoking, low household incomes, high carbohydrate diet, no alcohol consumption, physical inactivity/poor cardiorespiratory fitness, soft drinks and sugar sweetened beverages, atypical antipsychotics– clozapine, and family history/genetics.

 

Clinical implication

A diagnosis of metabolic syndrome would help clinicians identify patients who are at increased risk for developing Type 2 DM and or CVD and as such helps to identify those needing aggressive lifestyle modification which focuses on weight loss and increased physical activity ultimately reducing the risk of developing Type 2 DM and CVD.  

It has become increasingly prevalent in our society. According to the 2001 Adults Treatment Panel III (ATP III) criteria, which evaluated about 8,800 adults in the US, who participated in the National Health and Nutrition Examination Survey (NHANES) from 1988-1994, 22% of participants met criteria for metabolic syndrome with an age dependent increase. 

Mexican Americans were found to have the highest age-adjusted prevalence of 31.9%, and prevalence was higher in females than males amongst the African and the Mexican Americans. 

Data from NHANES from1988 to 1994, 1999 to 2000 and from 2017 to 2018, revealed that obesity increased from 22.9 to 30.5 to 42.4 percent respectively in each studied period. The implication of this is an increase in the prevalence of metabolic syndrome and its attendant morbidities and mortality

The ASCVD score which assesses patient's 10-year risk for developing CVD, Framingham Risk Score and the Systematic Coronary Risk Score Evaluation Score are useful tools in targeting individuals needing medical intervention to help lower the blood pressure and cholesterol.

Management

In 2001, ATP 3 recommended two major therapeutic goals in patients with metabolic syndrome and these goals were reinforced by the National Institutes of Health (NIH) and American Heart Association (AHA) 

 

Treat underlying causes such as overweight/obesity and physical inactivity though aggressive lifestyle modification, weight lost and increase physical activity.

Treat CVD risk factors if they persist despite lifestyle modification.

 

Weight loss: This can be achieved through changes in eating habits (instead of “diet”), increased physical activity (instead of “exercise”), medications, behavioral therapy, or surgery. 

Examples of healthy eating to promote weight loss are the Mediterranean diet, the DASH diet, ketogenic diet, and intermittent fasting. If you would like to know more about the keto diet, listen to our episode 59, on The Keto diet. 

 

Exercise: The physical activity guidelines recommends that patients exercise daily minimum 30 minutes of moderate intensity exercise (150 minutes a week of brisk walking, for example) plus strengthening exercise twice a week. Exercise is important for health, even when it is not the best tool to lose weight.

Why are clinicians not diagnosing metabolic syndrome amongst patients?

The American Diabetes Association and the European Association for the Study of Diabetes published a joint statement raising questions about whether the components of metabolic syndrome, as defined above, warrant classification as a true "syndrome". Some arguments raised include:

Lack of clarity of definition

Multiple different phenotypes included within the syndrome

Not enough evidence for setting thresholds for the components of the syndrome.

Unclear pathogenesis.

Other risk factors for CVD that are not components of the syndrome, such as, inflammatory markers.

CVD risk associated with metabolic syndrome has not been shown to be greater than the sum of its individual components.

 

Whether patients will benefit from a diagnosis of metabolic syndrome with such uncertain characteristics remains a topic of debate. However, the consensus is to treat individual risk factors when present in patients with obesity and multiple risk factors, and to promote aggressive lifestyle modification with the focus on weight loss and increased physical activity.

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Conclusion: Now we conclude our episode number 71 “Metabolic Syndrome.” Think about metabolic syndrome in patients with enlarged abdomen, elevated glucose and triglycerides, low HDL, and high blood pressure. By identifying and treating these patients you may decrease mortality in your community. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Timiiye Yomi, and Nathan Heathcoat. Audio edition: Suraj Amrutia. See you next week! 

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References:

Bibbins-Domingo, K. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2016 Jun 16; 164(12): 836-845 https://doi.org/10.7326/M16-0577.

 

Guirguis-Blake, J. et al. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: An Evidence Update for the U.S. Preventive Services Task Force. AHRQ Publication No. 21-05283-EF-1. 2021 Sep. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/document/draft-evidence-review/aspirin-use-to-prevent-cardiovascular-disease-preventive-medication on October 12, 2021.

 

James BM. Metabolic syndrome (insulin resistance syndrome, syndrome X). In: Lisa K, ed. UpToDate. Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com/contents/metabolic-syndrome-insulin-resistance-syndrome-or-syndrome. Accessed Aug 1, 2021.

 

The IDF consensus worldwide definition of the METABOLIC SYNDROME, International Diabetes Federation, published in 2006, last update July 29, 2020. PDF available for download: https://www.idf.org/e-library/consensus-statements/60-idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html. 

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