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METABOLIC SYNDROME
Nature, Nurture, Nutrition
Genomics, Proteomics,
Metabolomics
Janice Werbinski, M.D., FACOG
Gynecologist -Borgess Women’s Health
Former Medical Director -BMH Women’s Center
Associate Clinical Professor - MSU / CHM
Author, Curriculum, Women’s Health Track,
Internal Medicine Residency, MSU/KCMS
Founding President, ACWHP
Consultant/Metabolic Syndrome Program –
Borgess Integrative Medicine
CLASSIC DEFINITION
Syndrome X (Dr. G. Reaven)
High Blood Pressure (>130/85)
High Blood Fats (Triglyceride) (>150)
Low HDL (Good) Cholesterol (<50 mg/dl)
Borderline Diabetes (FBS>110 mg/dl)
Increased Waist to Hip Ratio (>35” waist)
Central Obesity-Inability to Lose Weight
Family History of DM, HTN, CVD,Obesity
FUNCTIONAL MEDICINE
DEFINITION
Metabolic Syndrome
“An age-related functional disorder of
glucose metabolism, mediated by
altered genetic expression at the cell
membrane level, and manifested under
particular environmental conditions.”
-Dan Lukaczer, ND
Institute for Functional Medicine
Alternative Labels
Syndrome “X”
Metabolic Syndrome
Insulin Resistance
Pre-Diabetes
Glucose Intolerance
INCIDENCE
Up to 25% of Americans (47,000,000 in US)
50% May not be Obese
Increasing in Children and Adolescents
Increasing in Industrialized Nations
Very Close Association with:
-Diabetes
-Cardiovascular Disease
-PCOS
-Preeclampsia / Eclampsia
LABORATORY
PARAMETERS
Fasting Glucose & Insulin
2 hour Glucose & Insulin after 75gm glucola
Lipid panel
Homocysteine
Thyroid panel
CRP
Euglycemic Clamp Studies (Research)
CAUSES
1. GENETIC PREDISPOSITION (Genomics)
2. STANDARD AMERICAN DIET (SAD)
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Processed Foods, Preservatives, Additives
Low-and No-Fat Foods (High Carb)
The Food Pyramid (High Carb)
Trans- and Saturated Fats
Low in Essential Nutrients and Fiber
High Fructose Corn Syrup and Soda
3. SEDENTARY LIFESTYLE
4. GLUTEN AND DAIRY INTOLERANCE common
Does Nutrigenomics Play a Role?
RESULTING SYNDROMES
Classic presentation
CAD
CVA
Hyperlipidemia
Hypertension
DM
Obesity
Cancer
PCOS
CLASSIC APPROACH
(KNEE-JERK)
Missing the Forest for the
Trees
Traditional Allopathic Approach
Abnormal Parameter, Symptom, or Laboratory
Blood Values:
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GTT, or 2 hr Postprandial Glucose
LDL Cholesterol
Blood Pressure
High BMI
Mood Disorders
GERD
Fibromyalgia/ Chronic Fatigue Syndrome
Signs of PCOS
IBS
Knee-Jerk Reaction
Diabetic Meds
Antihypertensives
Statins
Analgesics
OC’s/Progestins
Antidepressants
Proton pump inhibitors
Anorexics
Bariatric Surgery
WHY TRADITIONAL
APPROACH FAILS
Patient has intense CHO cravings – diet &
medications alone do not lessen the cravings
Patients worry about the multiple symptoms, thinking
their body is becoming alien - need emotional support
& education of this multidimensional condition
Medications are prescribed to treat a prevalent
symptom or disease, not the global assimilation of
symptoms
Poly-pharmacy increases drug interaction, cost, side
effects, & non-compliance
Patients ask for a holistic model due to multiple
symptoms
Patients want to be FUNCTIONAL again
NUTRITIONAL APPROACH
Kalamazoo Heart Center of
Excellence:
Metabolic Syndrome
Program
THE CASE FOR NUTRITIONAL
THERAPIES
This disorder does not result from a lack of
prescription drugs
There is no “magic bullet”
Many end up taking 4 or more drugs then
dealing with an array of side effects
Drugs merely treat a symptom or lab value
while allowing the underlying disease
process to continue
TREATMENT PLAN
Once diagnosis is made:
Assess any medical problems
Psychophysiological assessment: meet the patient in
their moment with all of their symptoms
Set up Primary and Secondary goals together with
the patient
Nutritional Supplement Recommendations
40-30-30 Macronutrient Plan
Lifestyle Modification Discussion
F/U at 3 wks, 8 wks, 3 mos, 6 mos, 9 mos, 12 mos
Group Classes for Health Education
PROGRAM GOALS
Appropriate Calories to Ideal Weight
Increase Omega-3 Oils
Increase MonoUnsaturated (Mediterranean) Fat
Low Saturated and Trans Fatty Acids
Low Glycemic Index Foods
High Fiber
Low simple CHO (increase complex CHO)
Moderate Protein
NUTRICEUTICAL
TREATMENT
DIET IN GENERAL:
“Mediterranean”
30% Protein
30% Good Fats (monounsaturated)
40% Low Glycemic Index Carbs
Soy
High in Soluble Fiber
Micronutrients
NUTRICEUTICAL
MODE OF ACTION
OMEGA - 3 FATS (EPA/DHA)-Cell Wall and
Receptor Function
a LIPOIC ACID -Mimics Insulin
MG -Needed for release of Insulin
CHROMIUM -Increases function of insulin
VANADIUM -Mimics insulin (>100mg toxic)
gamma LINOLEIC ACID-Restores insulin
function. Restores nerve function
FIBER -Slows Glu absorption in GI Tract
MODE OF ACTION
Pharmaceutical vs. Nutriceutical
ENHANCED
INSULIN
SECRETION
Sulfonylurea
(Micronase)
PHARMA
CEUTICAL
NUTRI
CEUTICAL
Meglitinides
(Prandin)
Magnesium
Vanadium
SLOWED
GLUCOSE
ABSORPTION
AlphaGlycosidase
Inhibitors
(Acarbose)
SolubleFiber
Complex
Carbs
Protein
REDUCED
GLUCOSE
PRODUCTION
PERIPHERAL
GLUCOSE
DISPOSAL
IMPROVED
RECEPTOR
FUNCTION
Biguanides
(Metformin)
Thiazolidinediones
(Actos)
Complex
Carbs
Protein
Fiber
Thiazolidinediones
(Actos)
PUFA
Lipoic Acid
Linoleic Acid
PUFA
Omega-3
Vanadium
Recommended Nutrients
EPA
DHA
Mg
Cr
Vd
CLA
Vit E
Vit C
aLA
Arg
1500-4000 MG
1000-2000MG
200-400 mg
400-1000 ug
15-50 mg
1000-3000 mg
400-800 U
2-6 gm
50-200 mg
2 gm
GOOD CARBS
GLYCEMIC INDEX
Volunteers’ blood sugar response to a test food
containing 50 gm carbohydrate, as compared to
50 gm pure glucose (3 Tbs)
HIGH
MODERATE
LOW
VERY LOW
>70%
55-66%
40-54%
<39%
Glycemic Load of Various
Foods
White bread
Potato
Carrots
Rice
Oat Grain Bread
Pasta
All-Bran
Corn Flakes
Corn Chips
Pretzels
Peanuts
70
85
71
88
47
45
42
84
73
80
14
Foods that Lower I.R.
Rice (esp. high amylose starch)
Soluble Fiber (slows glucose absorption)
Vegetable Protein (modulate GLUT-4
transport)
Complex CHO (slowly digested, prevents
rapid change in glucose and insulin)
Foods to Avoid
Refined CHO (Glycemic Index)
Simple Sugars -High Fructose Corn Syrup
White bread and flour
Juices
Sugar-containing Soda
Processed Foods
Trans Fats
Saturated Fats
GOOD FATS
Monounsaturated, “Mediterranean” (olive)
Omega-3 Fatty Acids (Fish Oils, Flaxseed)
Conjugated Linoleic Acid (PPAR agonist,
acts like TZD’s)
Alpha Lipoic Acid (Antioxidant)
FATS AND HEART DISEASE
Saturated Fat Diet
– Finland
– US
Monounsaturated Fat
– Italy
– Greece
Low Total Fat
– Japan
Shopping Tips
AVOID THE CENTER AISLES AT THE
SUPERMARKET
SHOP MAINLY IN THE PERIMETER
AREAS:
– Fresh Produce
– Fruits and Vegetables
– Meats and Eggs
– +/- Frozen Foods
UNHEALTHY DIET
Refined CHO is absorbed rapidly and
triggers release of excess insulin
Diminished insulin signal impedes fusion of
transport channel vesicles with cell
membrane
Insulin signal is diminished by
Phosphotyrosine, TNF alpha, cytokines,
NF-kappa, inflammatory substances
HEALTHY DIET AND
MICRONUTRIENTS
Complex CHO more slowly absorbed in
intestine – appropriate insulin released
(Soy, Amylose Starch, fiber)
Insulin signal supported by: Vn, Cr, CLA,
Lipoate, Inositol, Mg, Vit E
Strong insulin signal directs sugar transport
vesicle to fuse with cell wall
CLA binds to nucleus to support gene
expression
GOALS
Work closely with PCP
Approach chronic“diseases” by addressing
underlying functional problems
Formulate a viable program for the
prevention of disease
CONCLUSION
Correction of lab values does not
constitute wellness
Lifestyle intervention REQUIRES
immediate positive effects & education
for optimal change and management.
The healing process needs: support,
love, hope & humor
END
CASE PRESENTATIONS
Metabolic Syndrome
Insulin Resistance
Syndrome X
Case Study - PCOS
(Rebecca)
31 y.o. Woman with:
Anxiety
PMS and Moodiness
Fatigue
Amenorrhea
Sleep Disorder
PCOS (Rebecca)
October 31
Glucose
– FBS
– 2 hr
Insulin
– Fasting
– 2 hr
Cholesterol
HDL
LDL
Triglyceride
Weight
Menses
93
112
12
108
271
39
178
269
165
absent
December 21
Glucose
– FBS
– 2 hr
Insulin
– Fasting
– 2 hr
Cholesterol
HDL
LDL
Triglyceride
Weight
Menses
91
83
9
17
200
45
141
71
153
regular
Case Study – PMS, Fatigue
(Martha)
54 y.o. Woman with:
Anxiety
Irritable Bowel Symptoms
Adrenal Fatigue
Fibromyalgia
No weight loss with low fat diet, exercise
Fatigue, FMA (Martha)
November 8
Glucose
– FBS
– 2 hr
Insulin
– Fasting
– 2 hr
Cholesterol
HDL
LDL
Triglyceride
Weight
TSH
February 21
114
209
9
87
204
77
111
78
189
3.94 (2/13/02)
Glucose
– FBS
– 2 hr
Insulin
– Fasting
– 2 hr
Cholesterol
HDL
LDL
Triglyceride
Weight
104
92
7
25
70
97
84
169
PHARMACEUTICAL
SIDE EFFECTS
SU - hypoglycemia, weight gain,
hyperinsulinemia
Non-SU Secretagogues - same, plus
3/day dosing
Biguanides - GI upset, lactic acidosis
a-Glucosidase Inhib - GI upset, 3/day
dose
Thiazolidinediones - LFT, weight gain,
edema, slow onset of action
METABOLIC SYMPTOMS
AND SYNDROMES
Symptoms:
Weakness/Fatigue
Muscle Pain
Diarrhea/Constipation
Stomach Irritation
Sleep Problems
Allergy Symptoms
Inability to Lose Wt
Immune Problems
Hypoglycemia
Syndromes:
Chronic Fatigue
Fibromyalgia
Irritable Bowel
Syndrome
Somatization
PMS/PCOS
Mood Disorders
Chronic Yeast