Metabolic Syndrome—A Common and Dangerous Health Problem
Francisco Lopez-Jimenez Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine
Patients need to be informed of the risks related to MetSx. Few things surprise
patients more when they are diagnosed with MetSx than realizing that they
have a risk equivalent to smoking two packs of cigarettes a day. Unfortunately,
most patients are completely unaware of their condition; this is not surprising,
as it has been demonstrated that physicians tend to ignore risk factors such as
obesity. Patients need to receive specific instructions about how to start an
exercise program, with details of the type, duration, intensity, and frequency of
the exercise they need. It is not uncommon for patients to overestimate the
amount of exercise they do, especially when they consider low-intensity
activities such as playing golf or walking the dog as moderately intense
activities. A few supervised exercise sessions usually help patients to gain selfconfidence
in the way they can exercise. Some people benefit from joining a
fitness center that provides convenience and motivation. Because about half of
the general population declare that they hate exercise, it is also imperative that
patients recognize lifestyle changes as an investment in their future health. In
the same way that saving money for retirement is not an activity that people
love and look forward to, behavioral changes should be recommended to
patients as a valuable investment for a healthy (future) life and retirement.
Nutritional recommendations should include instructions for portion
control, creating an understanding of the basic principle of thermodynamics
that weight loss requires a negative balance between energy intake and
expenditure. Without minimizing the importance of exercise, patients need
to know that 30 minutes of exercise does not justify the extra muffin or the
extra bagel with cream cheese. These latter two food choices have far more
calories than a 190lb man can burn in 30 minutes of brisk walking.
Recent data show that diets rich in vegetables and protein with some
restriction in carbohydrates—particularly refined carbohydrates—can
improve insulin sensitivity regardless of changes in weight.
Recommendations should always include limiting the intake of saturated
fat, trans-fatty acids, and salt. Because dietary changes are also difficult, it
is sometimes necessary for patients to see a nutritionist, attend a cooking
demonstration class, or join a commercial program for weight loss with a
good reputation. Patients need to understand that focusing on dietary
changes and a more active lifestyle is more important than focusing on the
amount of weight loss.
At Mayo Clinic Rochester, we have implemented the Cardiometabolic
program, a six-week commitment that includes several of the key elements
of behavioral change listed above. For example, patients watch a DVD
about MetSx that emphasizes the risks associated to it and the role of the
patient’s lifestyle for improving it. They receive an exercise prescription with
detailed instructions on how to start a program and attend at least three
supervised exercise sessions. They also attend a modified LEARN program
with group-based sessions focused on sustainable weight loss. They attend
a bi-monthly cooking demonstration class and learn about the incredibly
high content of (added) sugar in common foods. They receive extensive
patient education material with information about facilitating behavioral
change, nutrition, and exercise. Although the commitment for such a
program is high, most patients are able to attend two to three times a week
for one to two hours each time. The feedback that participants provide has
been extremely positive, and the majority of participants are able to
maintain a more active life and a healthier diet.
Medications
Some components of MetSx may be completely out of control and require
pharmacologic therapy. If blood pressure values exceed 140mmHg systolic
or 90mmHg diastolic in more than one visit, they may need to start an
antihypertensive medication or to add another one if they are already
receiving one. The management of dyslipidemia should be guided by the
underlying risk for or presence of cardiovascular disease, and the focus
should be on maintaining low-density lipoprotein (LDL) cholesterol in
target values. Attempts to increase high-density lipoprotein (HDL) levels or
to reduce triglycerides with medications should be guided by the NCEP ATP
III guidelines if there is little change in these two lipid parameters after
lifestyle modification.
The evidence for the long-term efficacy of pharmacological intervention in
weight loss is limited to three medications: sibutramine, orlistat, and
rimonaban. Treatment with sibutramine produces significantly more
maintained weight loss at two years than placebo, but the drug is
contraindicated in patients with CHD. Orlistat, a medication that blocks the
absorption of fat, causes weight loss of about 2.2kg greater than placebo
at four years, with significantly more patients achieving >10% loss of initial
body weight (26.2% and 15.6%, respectively).
Rimonaban, a canabinoid-receptor blocker with central anorexigenic
properties, has been studied in several multicenter, randomized controlled
trials. Rimonaban has shown excellent results in inducing weight loss and
improving all of the components of MetSx. Side effects, which were mild
and well tolerated, were mainly limited to dizziness, nausea, and diarrhea.
Because the endocanabinoid system may also play a role in mood control,
long-term safety data need to confirm that patients taking rimonaban do
not develop higher rates of depression or suicide than controls. This drug is
now available in several countries and is expected to be widely available in
most of Europe and North America within two years.
Bariatric surgery has also been shown to improve the metabolic syndrome
by causing major weight loss due to significant decrease in caloric intake.
Typically, all of the elements of MetSx improve after surgery, although the
most dramatic improvement occurs to glucose intolerance/insulin
resistance. One year after the surgery, almost 70% of patients with a
previous diagnosis of diabetes mellitus will have normal fasting glucose
levels without insulin or other kind of pharmacological therapy for diabetes.
Conclusions
MetSx is a common and deadly disease whose prevalence has increased in
recent years. Despite the lack of a unified definition, there is global
consensus on the importance and consequences of this condition. The
cornerstone in the management of MetSx is lifestyle change. Patients may
need professional support to achieve their individualized goals of regular
exercise and diet. Other modes of treatment are also helpful, but should be
considered auxiliary methods and should be attempted only when lifestyle
changes have not yielded the expected results.
