METABOLIC SYNDROME Dr Gerhard Coetzer

Complaint Thirsty all the time Urinating more than usual Blurred vision Tiredness

Medical History No medical history 35 years old Smoking approximately 80 cigarettes per day No exercise history No surgical history More than 2 drinks more than twice a week

Clinical Examination Centrally obese- BMI 31 BP 130/85 Random glucose 17mmol/l Urine – Ketones 1+ – Glucose 1+

Special Examination HBA1C- 9.4 Fasting glucose 14mmol/l LDL- 5.1 HDL- 1.0 Trigliserides- 4.5 FBC- high Hb and Heamatocrit - smoking

3 Stage Summary Clinical- 35 Year old male patient with type 2 diabetes, hyper-cholestrolemia and central obesity. Personal- Patient has a young family as is shocked by the discovery that he is diabetic. His symptoms also interferes with his work. Contextual- 35 year old patient with metabolic syndrome, unsure of his future health wise and work wise.

Problem List Active problem list – High blood glucose – High cholesterol level Passive problem list Patient with metabolic syndrome that needs life style modification

Plan Started patient on blood glucose lowering medication Gave dietary advise Gave exercise program

Progression Patient stuck to exercise programme and eating plan Achieved weight loss Blood glucose is controlling- HBA1C Lipogram improved significantly Smokes +/- 15 cigarettes per day Looking forward to his 6 month follow up

DISCUSSION Definition – Metabolic syndrome is classified by a cluster of 5 cardio vascular disease risk factors of which 3 must be present(Sato et al, 2007). These 5 symptoms are: – Poor glucose control or diabetes – Low levels of HDL – High triglycerides and LDL – Central obesity – Hypertension

Metabolic syndrome is also referred to as the deadly quartet where lack of exercise leads to type 2 diabetes, hypertension, hyperlipidaemia and obesity. I like to call it the disease of the Sloth. When looking at the different risk factors we can start with the effect of exercise on type 2 diabetes.

Type 2 Diabetes Blood glucose is controlled by the release of insulin from the beta-cells in the pancreas, when the blood glucose levels are high, or release of glucagon by the liver to increase circulating plasma glucose. Blood glucose is tightly controlled by the body and is usually between 4mmol/L and 5mmol/L.

Glucagon and insulin regulate the pattern of glucose uptake and utilisation by peripheral tissues and uptake and release by the liver. The peripheral tissues involved is mostly muscle, which accounts for 80%, and adipose tissue, which accounts +- 3 – 4% (Björntorp et al, 1971). Because of the large effect of muscle it is cumulatively the most important in maintaining blood glucose homeostasis.

Type 2 diabetes is characterised by the bodies’ inability to maintain blood glucose levels. In most cases the muscle becomes desensitised to the circulating insulin which leads to episodes of hyperglycaemia (Bird and Hawley, 2012).

There are many publications that show that exercises increase muscle sensitivity to insulin (Bird and Hawley, 2012). The effect of exercise on the Hb1AC is similar to that of long term drug or insulin therapy (Bird and Hawley, 2012).

Current guidelines on the treatment of metabolic disorders from the American College of Sports Medicine recommend 150 minutes per week of moderate to vigorous exercise (Bird and Hawley, 2012). These guidelines are backed up by years of research.

The American Heart Foundation state that the daily recommended amount of exercise (30 minutes) can be accumulated over the course of the day by several exercise bouts where each bout lasts longer than ten minutes. (Bird and Hawley, 2012) it is however still unclear if this approach is as effective in decreasing the risk factors as a single 30minute bout of exercise.

New studies have also shown that short duration high intensity interval training produces a similar effect on insulin sensitivity than longer low intensity training (Bird and Hawley, 2012).

Therefore the new guidelines for exercise prescription is progressing away from moderate intensity for everyone, but rather to high intensity interval training for those who it will be safe for.

Obesity and Weight Risk Factor Excess weight is strongly associated with the development of metabolic syndrome and type 2 diabetes. As abdominal obesity is a risk factor for cardiac disease and forms part of metabolic syndrome it is also important to treat obesity.

It is well known that exercise improves health in patients of any weight. There is sufficient evidence to conclude that exercise alone only produces a moderate weight loss (Christa et al, 2004).

In studies comparing diet to exercise it is found that diet is more effective than exercise to lose weight (Christa et al, 2004). A number of large trials however, found that a combination of exercise and diet gives the best weight reduction (Church, 2011).

The American College of Sports Medicine position statement called: “Appropriate intervention strategies for weight loss and prevention of weight regain for adults” recommend combining exercise therapy and diet to promote weight loss

All individuals should strive for 150 moderate intensity exercises per week. With the aim at weight loss, patients should strive to combine weight training with high intensity aerobic training. Resistance training recommended twice a week with as little as 25 minutes high intensity training the other days of the week.

The effects of exercise on hypertension and hyperlipidaemia are well known and documented. You can turn around metabolic disease by decreasing your risk factors.