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The Metabolic Syndrome Gil C. Grimes, MD September 2006.

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Presentation on theme: "The Metabolic Syndrome Gil C. Grimes, MD September 2006."— Presentation transcript:

1 The Metabolic Syndrome Gil C. Grimes, MD September 2006

2 Objectives Define Metabolic Syndrome Review the prevalence in our population Discuss the proposed pathophysiology Review associated morbidity and mortality Define treatment strategies

3 Definitions

4 World Health Organization Definition One of these Insulin resistance Impaired glucose regulation FPG 110 mg/dl and/or 2 hour PG 140 mg/dl Two of these Hypertension SBP 140 DBP 90 Elevated Triglycerides ( 150 mg/dl) and/or low HDL (35 mg/dl males and 39 mg/dl females) Central Obesity waist to hip ratio >0.90 males, >0.85 females, or BMI>33 kg/m 2 Microalbuminuria urinary albumin excretion rate 20 mg/min or albumin/creatinine ratio 30 mg/g Albert KGMM et al Diabetic Med 1998;15: [Level 5]

5 National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATPIII) Definition Three of the following Abdominal circumference Men > 40 inches Women >35 inches Triglycerides > 150 mg/dl HDL Cholesterol Men < 40 mg/dl Women <50 mg/dl Blood Pressure > 130/85 mm Hg Glycemia >110mg/dl Expert panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, JAMA 2001;285: [Level 5]

6 Prevalence

7 Obesity US 1991 [Level 2b]

8 Obesity US 1992 [Level 2b]

9 Obesity US 1993 [Level 2b]

10 Obesity US 1994 [Level 2b]

11 Obesity US 1995 [Level 2b]

12 Obesity US 1996 [Level 2b]

13 Obesity US 1997 [Level 2b]

14 Obesity US 1998 [Level 2b]

15 Obesity US 1999 [Level 2b]

16 Obesity US 2000 [Level 2b]

17 Obesity US 2001 [Level 2b]

18 Texas 2001 Behavioral Risk Factor Surveillance System, 2001 CDC [Level 2b]

19 Prevalence in FOS and SAHS populations Meigs J et al Diabetes 2003; 52: [Level 2c]

20 Prevalence Metabolic Syndrome in NHANES III Ford ES et al JAMA 2002;287: [Level 2 c]

21 Prevalence Metabolic Syndrome in NHANES III by Race Ford ES et al JAMA 2002;287: [Level 2 c]

22 Prevalence in Adolescents from NHANES III Cook S et al Arch Pediatric Adolec Med 2003;157: [Level 2c]

23 Pathophysiology

24 Proposed Pathophysiology Role of adipose tissue and inflammation IL-6 (pro-inflammatory compound) Produces 25% of IL-6 Stimulate acute phase hepatic protein production Obesity associated with increased C-reactive protein Represents chronic low level inflammation More related to Waist to hip ratio than BMI Visser M et al JAMA 1999;282: [Level 2b]

25 CRP and BMI Visser M et al JAMA 1999;282: [Level 2b]

26 CRP, IL-6, and subsequent DM Pradhan AD et al JAMA 2001;286: [Level 2b]

27 Cartoon of mechanism of disease

28 Associated Morbidity and Mortality

29 CHD Morbidity and Mortality Lakka H et al JAMA 2002; 288: [Level 1b]

30 Metabolic Syndrome as a Risk for CHD and Diabetes Sattar N et al Circulation 2003:108:414-9 [Level 2b]

31 Risks for CHD and CVA Morbidity Isomaa B et al Diabetes Care 2001;24: [Level 2b]

32 Risk for CHD Mortality Isomaa B et al Diabetes Care 2001;24: [Level 1a]

33 Risk for CHD and Diabetes Sattar N et al Circulation 2003:108:414-9 [Level 2b]

34 Risk for DM from Kuopio IHD Risk Factor Study Presence of Metabolic Syndrome Odds Ratio of developing DM 10 4 fold increased risk for DM WHO Definition with Waist Hip Ratio >0.90 Sensitivity 0.83 Specificity 0.78 NCEP Definition Sensitivity 0.57 Specificity 0.90 Laaksonen D et al Am J Epidemiol 2002;156: [Level 2b]

35 Treatment

36 Prevention is the Key Diminish the adipose poisoning Must extrapolate from other studies Diabetes Prevention Program Goal 150 minutes of exercise weekly Low fat diet Nutrition counseling every 90 days NNT 8 people for 3 years to prevent 1 new DM Absolute Risk Reduction 12.77% Tuomilheto J et al NEJM 2001;344: [Level 1a]

37 Treatment Lifestyle vs. Metformin Similar design NNT for 3 years to prevent on case of DM Lifestyle 6.9 Metformin 13.9 Diabetes Prevention Program Group NEJM 2002;346: [Level 1a]

38 Treatment Lifestyle vs. Xenical Subgroup analysis of Xenical trial 40% of patients positive for Metabolic syndrome Type II DM 13.9% lifestyle group Type II DM 9.8% Xenical group Industry sponsored study Torgerson J et al 12 th European Congress on Obesity 2003 [Level 2b ?]

39 Statins et al Presence of Metabolic Syndrome indicates at least 2 risk factors LDL goal <100 mg/dl Statins reduce LDL on average 18-55% Fenofibrate reduce Triglycerides 20-50% and raise HDL 10-35% Niacin reduce LDL 5-25% Triglycerides 20-50% and raise HDL 15-35% Combinations work well, caution for increased risk of adverse events OMara NB Prescribers Letter 2003;19:191001

40 Control the Pressure JNC 7 guidelines and ALLHAT tell us to lower the pressure Intensive lifestyle modification HOPE trial 32% reduction in new onset DM for ramipril LIFE trial Losartan 6% developed DM Atenolol 8% developed DM

41 Aspirin Therapy Routine recommendation for those at increased risk for cardiovascular disease Unclear if it decreases progression of Metabolic Syndrome Use based on High Risk status of these patients

42 Sample Patient 38 year old male Weight 250 lbs Height 72 inches BMI 34 BP 140/86 Screen Glucose? Screen Lipids? Therapy?

43 Take Home It is common in our patients The prevalence is expected to increase The process starts early The intervention needs to start early Get your patients up and moving


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