Metabolic Syndrome

dr. Yunus Tanggo Sp.PD. PhDDepartment of Internal Medicine,

Universitas Kristen Indonesia General Hospital, Jakarta, Indonesia

Definition

The metabolic syndrome consists of a constellation of metabolic abnormalities that confer increased risk of cardiovascular disease (CVD) and diabetes mellitus (DM).

Metabolic Syndrome (History)• HTN-Hyperglycemia-Gout - Kylin 1923• Insulin Insensitivity - Himsworth 1936• “Diabetogenic Obesity” - Vague 1947• “Syndrome X” – Reaven 1988• WHO - Metabolic Syndrome 1998• NCEP - Metabolic Syndrome 2001• Dysmetabolic Syndrome (277.7) 2003

Other Names Used:• Syndrome X• Cardiometabolic Syndrome• Cardiovascular Dysmetabolic Syndrome• Insulin-Resistance Syndrome• Metabolic Syndrome• Beer Belly Syndrome• Reaven’s Syndrome• etc.

Risk Factors

• Overweight / obesity• Sedentary lifestyle• Aging• Diabetes mellitus• Coronary heart disease• Lypodystrophy

Pathophysiology of the Metabolic Syndrome

InsulinResistance

HypertensionType 2 Diabetes

DisorderedFibrinolysis

ComplexDyslipidemia

TG, LDLHDL

EndothelialDysfunction

SystemicInflammation

Athero-sclerosis

VisceralObesity

Adapted from the ADA. Diabetes Care. 1998;21:310-314;Pradhan AD et al. JAMA. 2001;286:327-334.

Insulin resistance is a precursor to a variety of metabolic abnormalities, including systemic inflammation, visceral obesity, and type 2 diabetes. Insulin resistance is also a risk factor for cardiovascular abnormalities, including hypertension, dyslipidemia (increased triglycerides and LDL and decreased HDL), disordered fibrinolysis, and endothelial dysfunction.All of these aberrations contribute to the atherosclerotic process.

To measure waist circumference, 1) locate the upper hip bone and the top of the right iliac crest, 2) place the measuring tape in a horizontal plane around the abdomen at the iliac crest, 3) ensure that the tape is snug but does not compress the skin, 4) the tape should be parallel to floor, and 5) record the measurement at the end of a normal expiration.Men are at increased relative risk if they have a waist circumference greater than 40 inches (102 cm); women are at an increased relative risk if they have a waist circumference greater than 35 inches (88 cm).There are ethnic- and age-related differences in body fat distribution that may affect the predictive validity of waist circumference as a surrogate for abdominal fat.Heterogeneity of composition of abdominal tissues, in particular adipose tissue and skeletal muscle, and their location-specific and changing relations with metabolic factors and CV risk factors in different ethnic groups do not allow a simple definition of abdominal obesity that could be applied uniformly. In particular, Asians appear to have higher morbidity at lower cutoff points for waist circumference than do white Caucasians.

Prevention and Treatment of Metabolic Syndrome

Lifestyle management – a program of weight loss and exercise

Tobacco cessation

Limiting alcohol consumption

Changes in dietary habits, including eating a heart-healthy diet

Medication to help lower blood pressure, improve insulin metabolism, improve cholesterol and increase weight loss

Weight-loss surgery (bariatric surgery) to treat morbid obesity in individuals for whom conservative measures have failed.

ABC’s of Metabolic Syndrome ManagementIntervention Goals / Treatment

A Antiplatelet agent Treat all high-risk patients with low-dose aspirin (or clopidogrel in those with CVD if aspirin is contraindicated) and consider low-dose aspirin in moderately high-risk patients.

B BP Control Aim for BP <130/85 mm Hg, or <130/80 mm Hg for type 2 diabetes. Consider ACE-I or ARBs and low dose diuretics in combination rx.

Intervention Goals

C Cholesterol Management

LDL-C targets, ATP III guidelines–High Risk: CHD, CHD risk equivalents (incl. >20% 10-year risk): <100 mg/dL (option <70 mg/dl if CVD present)– Moderately High Risk (10-20% risk or subclinical disease) 2 RF: <130 mg/dL, option <100 mg/dL– Moderate Risk (2+ RF, <10%) <130 mg/dL-- Low Risk: 0-1 RF: <160 mg/dL

Non-HDL-C targets 30 mg/dL higherHDL-C: >40 mg/dL (men)

>50 mg/dL (women)TG: <150 mg/dL

Cigarette Smoking

Long term smoking cessation

ABC’s of Metabolic Syndrome Management

Thank you