1. Metabolic Syndrome Yusra Mir, MD Zunairah Syed, MD Harjagjit Maan, MD

2. Introduction Metabolic syndrome is a clinically useful tool to identify people at risk for diabetes and cardiovascular disease It indicates cumulative cardio metabolic risk exerted by abdominal obesity, hyperglycemia, high triglyceride, low high density lipoprotein cholesterol, and high blood pressure

3. Definition of Metabolic Syndrome According 2001 NCEP/ATP III, the criteria to define metabolic syndrome are presence of any three of the following five traits: According 2001 NCEP/ATP III, the criteria to define metabolic syndrome are presence of any three of the following five traits: Abdominal obesity, defined as waist circumference in men > 40 inches and women > 35 inches Abdominal obesity, defined as waist circumference in men > 40 inches and women > 35 inches Serum triglycerides ≥ 150 or drug treatment for elevated triglycerides Serum triglycerides ≥ 150 or drug treatment for elevated triglycerides Serum HDL cholesterol < 40 mg/dl in men and < 50 mg/dl in women or drug treatment for low HDL-C Serum HDL cholesterol < 40 mg/dl in men and < 50 mg/dl in women or drug treatment for low HDL-C Blood pressure ≥ 130/85 mmHg or drug treatment for elevated blood pressure Blood pressure ≥ 130/85 mmHg or drug treatment for elevated blood pressure Fasting plasma glucose ≥ 100 mg/dl or drug treatment for elevated blood glucose Fasting plasma glucose ≥ 100 mg/dl or drug treatment for elevated blood glucose

4. Background According to the 3 rd National Health and Nutrition Examination Survey (NHANES III, 1988 to 1994): Overall prevalence was 22%, with an age-dependent increase (6.7, 43.5, and 42.0 % for ages 20 to 29, 60 to 69, and > 70 years, respectively) Overall prevalence was 22%, with an age-dependent increase (6.7, 43.5, and 42.0 % for ages 20 to 29, 60 to 69, and > 70 years, respectively) Mexican-Americans had the highest age-adjusted prevalence (31.9%) Mexican-Americans had the highest age-adjusted prevalence (31.9%) Among Mexican-Americans and African-Americans, the prevalence was higher in women than in men (57 and 26 % higher, respectively) Among Mexican-Americans and African-Americans, the prevalence was higher in women than in men (57 and 26 % higher, respectively) Incidence of metabolic syndrome has increased The NHANES 1999-2002 database shows 34.5% of participants met ATP III criteria as compared to 22% in 1988 to 1994 The NHANES 1999-2002 database shows 34.5% of participants met ATP III criteria as compared to 22% in 1988 to 1994

5. Materials & Method In order to know the performance of the Family Care Clinic in screening and treatment of Metabolic Syndrome, we reviewed a total of 195 charts using ATP III 2001 criteria

6. Inclusion Criteria All the patients who come to family care clinic All the patients who come to family care clinic Age >= 18 Age >= 18

7. Results & Analysis

8. Detailed Study data  Metabolic Syndrome (Projected) row also includes the patients with  DM & HTN  HTN & Hyperlipidemia

9. # of Patients by Disease & Education

10. % of Patients by Disease & Education

11. Patients & Education

12. Discussion In 2001, ATP III recommended two major therapeutic goals in patients with syndrome (goals reinforced by a report from the American Heart Association and National Institutes of Health) 1.Treat underlying causes (overweight/obesity and physical inactivity) by intensifying weight management and increasing physical activity 2.Treat cardiovascular risk factors if they persist despite lifestyle modification There is no direct evidence that attempting to prevent type 2 diabetes and CVD by treating metabolic syndrome is as effective as attaining the above goals. It is possible to treat insulin resistance with drugs that enhance insulin action. However, the ability of such an approach to improve outcomes compared to weight reduction and exercise alone is not yet well supported by clinical trials.

13. Therapeutic Goals for Management of Metabolic Syndrome Abdominal Obesity Year 1: Reduce body weight by 7-10% Continue weight loss thereafter with ultimate goal BMI < 25 kg/m2 Physical Inactivity At least 30 min (and preferably > 60 min) continuous or intermittent moderate intensity exercise 5X/wk but preferably daily Atherogenic Diet Reduced Intake of saturate fat, trans fat, cholesterol Lifestyle Risk Factors

14. Therapeutic Goals for Management of Metabolic Syndrome Dyslipidemia Primary Target Elevated LDL-C Primary Target Elevated LDL-C High risk: <100 mg/dL (preferably <70 mg/dL) Moderate Risk: <130 mg/dL Low Risk: <160 mg/dL Target HDL-C Target HDL-C Raise to extent possible with weight reduction and exercise Elevated BP Reduce to at least > 140/90 ( 140/90 (<130/80 if diabetic) Elevated Glucose For IFG, encourage weight reduction and exercise For Type II DM, target A1C < 7 percent Prothrombotic State Low dose aspirin for high risk patients Proinflammatory State Lifestyle therapies; no specific interventions Metabolic Risk Factors

15. Examples of Lifestyle Modifications Low glycemic index foods (vegetables, broccoli, cabbage, cauliflower, cucumber) Higher fish intake Higher consumption of vegetables Mediterranean-style diet (increased consumption of who grains, fruits, vegetables, nuts, and olive oil) A lifestyle of 10% fat whole foods vegetarian diet, aerobic exercise, stress management, training, smoking cessation, group psychosocial support The DASH (Dietary Approaches to Stop Hypertension) eating plan (reduced calories and increased consumption of fruit, vegetables, low-fat dairy, and whole grains and lower in saturated fat, total fat, and cholesterol intake restricted to 2,400 mg NA) Low fat intake and increased physical activity Aerobic exercise Source: Geriatric Aging 2007 referenced in “Preventing Diabetes and Cardiovascular Disease in Older Adults” (medscape.com)

16. Examples of Moderate Physical Activity Gardening for 30-45 minutes Raking leaves for 30 minutes Walking 3 kms in 30 minutes Stair walking for 15 minutes Wheeling self in wheelchair for 30-40 minutes Bicycling8 kms in 30 minutes Water Aerobics for 30 minutes Source: Adapted from National Heart, Lung, and Blood Institute. Geriatric Aging 2007 referenced in “Preventing Diabetes and Cardiovascular Disease in Older Adults” (medscape.com)

17. Conclusions Metabolic Syndrome is becoming increasingly common in our patient population It is not being adequately recognized and treated in our outpatient clinics We recommend the following strategies to improve diagnosis and treatment of metabolic syndrome: 1.Nursing staff measure waist circumference and calculate BMI for every patient prior to MD evaluation 2.The “Therapeutic Goals for Management of Metabolic Syndrome” (as shown on slide 10) should be available to doctors for easy reference 3.Examples of Lifestyle Modifications (slide 11) and Moderate Physical Activity (slide 12) should be provided to all patients keeping in mind the high prevalence of metabolic syndrome in our patient population 4.Metabolic syndrome to be added to ICD code 9 in the yellow billing form

18. Bibliography Up-To-DateE-Medicine Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285:2486-97. The Diabetes Prevention Program Research Group. Diabetes Care 2000; 23:1619-29. Intensive Lifestyle Changes for Reversal of Coronary Heart Disease. JAMA 1998;280:2001-7.