Transcript Metabolic Syndrome - RCRMC Family Medicine Residency

Metabolic Syndrome
Yusra Mir, MD
Zunairah Syed, MD
Harjagjit Maan, MD
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
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:





Abdominal obesity, defined as waist circumference in men > 40
inches and women > 35 inches
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
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
Background
According to the 3rd 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)
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)
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
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
Inclusion Criteria
Inclusion Criteria


All the patients who come to family care clinic
Age >= 18
Results & Analysis
Detailed Study data
Patients
Categories
Patients %
Not
Educated Educated
Not
Total
Educated
Educated
Total
Metabolic Syndrome (Diagnosed)
13
75
88
14.8
85.2
45.1
DM
4
11
15
26.7
73.3
7.7
HTN
12
22
34
35.3
64.7
17.4
Obesity (BMI)
3
15
18
16.7
83.3
9.2
DM & HTN
8
14
22
36.4
63.6
11.3
HTN & Hyperlipidemia
6
12
18
33.3
66.7
9.2
Metabolic Syndrome (Projected)
27
101
128
21.1
78.9
65.6
Total Patients
46
149
195
23.6
76.4
100.0
Metabolic Syndrome (Projected) row also includes the patients with
DM & HTN
HTN & Hyperlipidemia
# of Patients by Disease &
Education
Patients by Disease & Education
140
Number of Patients
120
100
Patients Educated
80
Patients Not Educated
60
Patients Total
40
20
0
M
ab
et
ic
ol
Sy
r
nd
om
e
(D
o
gn
a
i
d
se
)
M
D
TN
H
I)
TN
H
ia
d)
m
e
e
t
d
c
ty
pi
je
M
si
rli
D
ro
e
e
b
(P
yp
O
e
H
m
&
ro
N
d
n
T
H
Sy
il c
o
ab
et
M
M
(B
&
Dusease Category
% of Patients by Disease &
Education
Patients by Disease & Education
100.0
% of Patients
80.0
Patients % Educated
60.0
Patients % Not Educated
40.0
Patients % Total
20.0
0.0
M
lic
bo
a
et
S
e
m
ro
d
yn
)
ed
s
no
ag
i
(D
DM
N
HT
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)
ia
m
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e
c
&
d
y
je
pi
sit
rli
ro
DM
e
e
P
b
(
p
O
e
Hy
m
&
ro
N
nd
T
y
H
S
lic
o
ab
et
M
M
(B
H
Disease Category
Patients & Education
All Patients & Education
24%
Educated
Not Educated
76%
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.
Therapeutic Goals for Management
of Metabolic Syndrome
Lifestyle Risk Factors
Year 1: Reduce body weight by 7-10%
Abdominal Obesity
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
Therapeutic Goals for Management
of Metabolic Syndrome
Metabolic Risk Factors
Dyslipidemia
High risk: <100 mg/dL (preferably <70
mg/dL)
Primary Target Elevated LDL-C
Moderate Risk: <130 mg/dL
Low Risk: <160 mg/dL
Target HDL-C
Elevated BP
Elevated Glucose
Raise to extent possible with weight
reduction and exercise
Reduce to at least > 140/90 (<130/80 if
diabetic)
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
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)
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)
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
Bibliography
Up-To-Date
E-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.