Syndrome X & Cardiac EffectsDo You Know Everything You Should?Syndrome X & Cardiac Effects

Do You Know Everything You Should?

Julia Garrison RN, MSN, CCRN, PCCNJulia Garrison RN, MSN, CCRN, PCCN

Code 266Proceedings Book pg. 641

StatisticsStatistics

24% of the adult population have Metabolic Syndrome X (Met Syn X) and the prevalence reaches 50-60% over age 50 years.

24% of the adult population have Metabolic Syndrome X (Met Syn X) and the prevalence reaches 50-60% over age 50 years.

StatisticsStatistics

Soon metabolic syndrome will overtake cigarette smoking as the number one risk

factor for heart disease among the US population.

Soon metabolic syndrome will overtake cigarette smoking as the number one risk

factor for heart disease among the US population.

JAMA 287:356, 2002

StatisticsStatistics

50% of hypertensive pts and 10% of those with normal blood pressure having evidence of

hyperinsulinemia.

50% of hypertensive pts and 10% of those with normal blood pressure having evidence of

hyperinsulinemia.

StatisticsStatistics

In Framingham, the metabolic syndrome alone predicted approximately 25% of all

new onset CVD.

In Framingham, the metabolic syndrome alone predicted approximately 25% of all

new onset CVD.

PredictionPrediction

The epidemic of insulin resistance syndrome will prevent our ability to improve rates of CVD, which currently accounts for half of deaths among men and one-third of deaths

among women.

The epidemic of insulin resistance syndrome will prevent our ability to improve rates of CVD, which currently accounts for half of deaths among men and one-third of deaths

among women.

Risk FactorsRisk Factors• For Women

– Android Appearance Alopecia

Hirsutism

Central obesity

– History Amenorrhea

Infertility

Gestational diabetes

Birth of baby > 9 lbs

• For Men & Women– Physical Assessment Acanthosis Nigricans

Skin Tags

• For Women– Android Appearance Alopecia

Hirsutism

Central obesity

– History Amenorrhea

Infertility

Gestational diabetes

Birth of baby > 9 lbs

• For Men & Women– Physical Assessment Acanthosis Nigricans

Skin Tags

Are you one of the “Lucky” ones?Are you one of the “Lucky” ones?

•PCOS (Polycystic Ovary Syndrome)

The most common endocrinopathy of women,

present in 4-7% of women

•Younger persons with CHD

Metabolic syndrome is particularly likely

to be present•Not Diabetic? Approximately one in five nondiabetic persons will develop the metabolic syndrome over the next 5 years

Why Do We Care? Why Do We Care?

Insulin resistance will lead to type 2 diabetes and subsequent CHD

Insulin resistance will lead to type 2 diabetes and subsequent CHD

Does This Person Sound Familiar?

Does This Person Sound Familiar?

E.C. - a 53 year old postmenopausal female -referred for tx of hypertension, with a family hx of T2D, hypertension, and CHD. She has felt well, postmenopausal symptoms had responded to hormone replacemnt tx. BP was “too high” during routine physical exam. BMI 23.7kg/m2, BP145/95. Lab results revealed a normal blood count and urinalysis, with glucose 102, triglycerides 238, LDL 147, HDL 40

E.C. - a 53 year old postmenopausal female -referred for tx of hypertension, with a family hx of T2D, hypertension, and CHD. She has felt well, postmenopausal symptoms had responded to hormone replacemnt tx. BP was “too high” during routine physical exam. BMI 23.7kg/m2, BP145/95. Lab results revealed a normal blood count and urinalysis, with glucose 102, triglycerides 238, LDL 147, HDL 40

How do we define it?How do we define it?

• The syndrome was first identified in 1988

• ICD –9 diagnostic code 277.7

• The syndrome was first identified in 1988

• ICD –9 diagnostic code 277.7

Major Characteristics of Met Syn XMajor Characteristics of Met Syn X

• insulin resistance/ glucose intolerance

• abdominal obesity

• elevated blood pressure

• lipid abnormalities (elevated levels of triglycerides and low levels of high density lipoprotein HDL)

• Proinflammatory state

• prothrombotic state  

• insulin resistance/ glucose intolerance

• abdominal obesity

• elevated blood pressure

• lipid abnormalities (elevated levels of triglycerides and low levels of high density lipoprotein HDL)

• Proinflammatory state

• prothrombotic state  

Metabolic Syndrome Effects of Insulin Resistance

Cardio protection

Pro-apoptotic state

Atherosclerosis

Anti-fibrinolytic state

Pro-thrombotic State

Chronic Pro-Inflammatory State

ROS generationOxidative stress

Platelet Hyperaggregability

Tonic vasoconstrictionAbnormal vascular reactivityVascular flow reserve

HyperinsulinemiaSodium retention

Diagnostic CriteriaDiagnostic Criteria

ATP III Clinical ManifestationsATP III Clinical Manifestations- Abdominal Obesity

Men >102 cm (>40in)

Women >88 cm (>35in)

- Triglycerides > 150 mg/dl

- HDL Cholesterol

Men < 40 mg/dl

Women < 50 mg/dl

- Blood Pressure >130/>85 mmHg

- Fasting Glucose >110 mg/dl

- Abdominal Obesity

Men >102 cm (>40in)

Women >88 cm (>35in)

- Triglycerides > 150 mg/dl

- HDL Cholesterol

Men < 40 mg/dl

Women < 50 mg/dl

- Blood Pressure >130/>85 mmHg

- Fasting Glucose >110 mg/dl

JAMA 285:2486, 2001.

WHO Clinical CriteriaWHO Clinical CriteriaInsulin Resistance, identified by 1 of the following:• Type II diabetes• Impaired fasting glucose• Impaired glucose tolerance• Or for those with normal fasting glucose levels(<110mg/dl),

glucose uptake below the lowest quartile for background population under investigation under hyperinsulinemic, euglycemic conditions

Plus any 2 of the following:• Antihypertensive medication &/or high blood pressure (>140

mmHg systolic or >90 mmHg diastolic)• Plasma triglycerides >150 mg/dl • HDL cholesterol <35 mg/dl in men or <39 mg/dl in women• BMI >30kg/m2 &/or waist:hip ratio>0.9 in men,>0.85 in women• Urinary albumin excretion rate >20mcg/min or

albumin:creatinine ratio >30mg/g

Insulin Resistance, identified by 1 of the following:• Type II diabetes• Impaired fasting glucose• Impaired glucose tolerance• Or for those with normal fasting glucose levels(<110mg/dl),

glucose uptake below the lowest quartile for background population under investigation under hyperinsulinemic, euglycemic conditions

Plus any 2 of the following:• Antihypertensive medication &/or high blood pressure (>140

mmHg systolic or >90 mmHg diastolic)• Plasma triglycerides >150 mg/dl • HDL cholesterol <35 mg/dl in men or <39 mg/dl in women• BMI >30kg/m2 &/or waist:hip ratio>0.9 in men,>0.85 in women• Urinary albumin excretion rate >20mcg/min or

albumin:creatinine ratio >30mg/g

AACE Clinical CriteriaAACE Clinical Criteria- Overweight/obesity BMI >25kg/m2- Elevated Triglycerides >150 mg/dl (1.69mmol/L)- Low HDL Cholesterol

Men < 40 mg/dl (1.04 mmol/L)Women < 50 mg/dl (1.29 mmol/L)

- Elevated Blood Pressure > 130/85 mmHg- 2 hr post glucose challenge > 140 mg/dl- Fasting Glucose Between 110 and 126 mg/dl- Other risk factors - Family history of type 2 diabetes,

hypertension, or CVD - Polycystic ovary syndrome - Sedentary lifestyle - Advancing age - Ethic groups having high risk for

type 2 diabetes or CVD

- Overweight/obesity BMI >25kg/m2- Elevated Triglycerides >150 mg/dl (1.69mmol/L)- Low HDL Cholesterol

Men < 40 mg/dl (1.04 mmol/L)Women < 50 mg/dl (1.29 mmol/L)

- Elevated Blood Pressure > 130/85 mmHg- 2 hr post glucose challenge > 140 mg/dl- Fasting Glucose Between 110 and 126 mg/dl- Other risk factors - Family history of type 2 diabetes,

hypertension, or CVD - Polycystic ovary syndrome - Sedentary lifestyle - Advancing age - Ethic groups having high risk for

type 2 diabetes or CVD

Other Useful MeasuresOther Useful Measures

• Triglyceride-to-HDL Cholesterol Ratio

• Small LDL particles

• Impaired glucose tolerance (IGT)

• Variation in coagulation factors – plasminogen activator inhibitor (PAI-1) – fibrinogen

• Triglyceride-to-HDL Cholesterol Ratio

• Small LDL particles

• Impaired glucose tolerance (IGT)

• Variation in coagulation factors – plasminogen activator inhibitor (PAI-1) – fibrinogen

CRPCRP

• There is a correlation between C-reactive protein (CRP) level and the number of syndrome components.

• CVD and CRP

• Waist circumference and CRP

• There is a correlation between C-reactive protein (CRP) level and the number of syndrome components.

• CVD and CRP

• Waist circumference and CRP

Circulation 107:391, 2003

Additional Tools to Help Make the Diagnosis

Additional Tools to Help Make the Diagnosis

• Insulin resistance score (HOMA-IR) – fasting plasma glucoses (mmol/L) X fasting serum

insulin (mIU/ml) / 22.5.

• Obtain lipid levels when most appropriate

• Insulin resistance score (HOMA-IR) – fasting plasma glucoses (mmol/L) X fasting serum

insulin (mIU/ml) / 22.5.

• Obtain lipid levels when most appropriate

Screening QuestionsScreening Questions1. Do you have difficulty losing weight despite exercising

regularly?2. Do you have a close relative who has had heart disease,

high blood pressure, T2D, polycystic ovarian syndrome, infertility problems, or obesity?

3. Do you experience frequent cravings for sugars or other high carbohydrate foods?4. Do you often feel tired after a meal?5. Do you eat meals that consist of pasta, rice, potatoes,

and corn more than 2-3 times per week?6. Do you awaken at night 2 or more times to urinate?7. Have you either gained or lost more than 5 lbs in the last 3 months?8. For women: Do you feel that you have more facial hair than other women in your family, racial, and/or ethnic

group?

The Metabolic Syndrome and Its Relationship to Type 2 Diabetes and Cardiovascular Disease

Excess Energy IntakeOver Expenditure

Genetic Predispostion Truncal Obesity Muscular Inactivity

Acquired or GeneticInsulin Resistance Metabolic Syndrome Unbalanced Diet

Hypertension Acquired or Genetic Beta Cell Defect

Cardiovascular Disease Type 2 Diabetes

Pathophysiology Pathophysiology

3 potential etiologic categories:

1-obesity and disorders of adipose tissue

2-insulin resistance

3-constellation of independent factors the mediate specific components of the syndrome.

3 potential etiologic categories:

1-obesity and disorders of adipose tissue

2-insulin resistance

3-constellation of independent factors the mediate specific components of the syndrome.

InsulinInsulin

Properties:• Vasodilation

• Anti-inflammatory

• Sodium retention

Properties:• Vasodilation

• Anti-inflammatory

• Sodium retention

Insulin ResistanceInsulin Resistance

Aging is the most important environmental factor in causing insulin resistance.

Physical fitness is as powerful as obesity in predicting insulin sensitivity 

Aging is the most important environmental factor in causing insulin resistance.

Physical fitness is as powerful as obesity in predicting insulin sensitivity 

HyperinsulinemiaHyperinsulinemia

Results in:• Increased CHD risk• Reactive hypoglycemia• High triglycerides• Low HDL• Hypercholesteremia• Hypertension• Hypofibrinolysis• Polycystic ovaries

Results in:• Increased CHD risk• Reactive hypoglycemia• High triglycerides• Low HDL• Hypercholesteremia• Hypertension• Hypofibrinolysis• Polycystic ovaries

PCOSPCOS

• The most common endocrinopathy among young women

• Affects 6-10% of women of childbearing age

• Accounts for 50-60% of female infertility • 82% of women with T2D have polycystic

ovaries.

• The most common endocrinopathy among young women

• Affects 6-10% of women of childbearing age

• Accounts for 50-60% of female infertility • 82% of women with T2D have polycystic

ovaries.

Why fat?Why fat?

• The Real Question Is:

Where Are The Famines?

• The Real Question Is:

Where Are The Famines?

Adipose TissueAdipose Tissue

• An important source of hormones, the best known of which is Leptin.

• Decrease in Insulin Sensitivity

• Increased hepatic triglyceride production and higher free fatty acid FFA level.

• Elevated Angiotensin II levels

• An important source of hormones, the best known of which is Leptin.

• Decrease in Insulin Sensitivity

• Increased hepatic triglyceride production and higher free fatty acid FFA level.

• Elevated Angiotensin II levels

Adipose TissueAdipose Tissue• Adipose tissue also plays a central role in insulin

resistance because it synthesizes and secretes: • Adipose tissue also plays a central role in insulin

resistance because it synthesizes and secretes:

- Cortisol

- Adiponectin

- nonesterified fatty acids (NEFA)

- interleukin-6

- plasminogen activator inhibitor-1 (PAI-1)

- tumor necrosis factor

- proinflammatory cytokines (C-reactive protein)

LeptinLeptin

• Leptin increases sympathetic activity and may increase sodium reabsorption and heart rate.

• When insufficient levels, there is a marked increase in tissue fat, increased triglycerides,

• Insulin increases Leptin production

• Leptin increases sympathetic activity and may increase sodium reabsorption and heart rate.

• When insufficient levels, there is a marked increase in tissue fat, increased triglycerides,

• Insulin increases Leptin production

InflammationInflammation

• Result of excessive caloric intake• Result of excessive caloric intake

Organ Involvement - RenalOrgan Involvement - Renal

• Uric acid clearance is also correlated with insulin sensitivity.

• RAS – cross talk between angiotensin II and insulin signaling contributes to the pathophysiology

• Uric acid clearance is also correlated with insulin sensitivity.

• RAS – cross talk between angiotensin II and insulin signaling contributes to the pathophysiology

Organ Involvement - LungOrgan Involvement - Lung

• Abnormal lung function and sleep apnea may be related to diabetes

• 2hr insulin levels show a progressive rise with increased frequency of sleep apnea.

• Abnormal lung function and sleep apnea may be related to diabetes

• 2hr insulin levels show a progressive rise with increased frequency of sleep apnea.

Organ Involvement - Liver

Organ Involvement - Liver

• The liver is the major organ involved in lipid and glucose homeostasis.

• Similar to alcoholic liver disease, there is a spectrum of abnormalities, progressing to nonalcoholic steatohepatits (NASH)

• The liver is the major organ involved in lipid and glucose homeostasis.

• Similar to alcoholic liver disease, there is a spectrum of abnormalities, progressing to nonalcoholic steatohepatits (NASH)

DyslipidemiasDyslipidemias

HDL

LDL

Triglycerides

HDL & LDL VLDL

Cardiovascular SystemCardiovascular System

• Hypertension– Somatostatin – Sodium retention and angiotensin II

• Hypertension and lipid metabolism

• Increased vascular resistance

• abnormal vascular smooth muscle function

• Hypertension– Somatostatin – Sodium retention and angiotensin II

• Hypertension and lipid metabolism

• Increased vascular resistance

• abnormal vascular smooth muscle function

Other Important ModifiersOther Important Modifiers

• Physical inactivity promotes the development of obesity and modifies muscle insulin sensitivity.

• Aging is commonly accompanied by a loss of muscle mass and by an increase in body fat particularly accumulation of fat in the abdomen, both changes can increase insulin resistance.

• Physical inactivity promotes the development of obesity and modifies muscle insulin sensitivity.

• Aging is commonly accompanied by a loss of muscle mass and by an increase in body fat particularly accumulation of fat in the abdomen, both changes can increase insulin resistance.

Management of the Metabolic SyndromeManagement of the Metabolic Syndrome

• Consists primarily of 2 strategies: – modification or reversal of the root causes, including

weight reduction and increased physical activity– direct treatment of the metabolic risk factors,

including atherogenic dyslipidemia, elevated blood pressure, the prothrombotic state, and underlying insulin resistance.

• Consists primarily of 2 strategies: – modification or reversal of the root causes, including

weight reduction and increased physical activity– direct treatment of the metabolic risk factors,

including atherogenic dyslipidemia, elevated blood pressure, the prothrombotic state, and underlying insulin resistance.

InterventionIntervention

• Opportunity for early intervention is present when insulin levels are elevated in association with the other components of the metabolic syndrome

• Optimal to screen for all components of metabolic syndrome when obtaining a fasting insulin level.

• Opportunity for early intervention is present when insulin levels are elevated in association with the other components of the metabolic syndrome

• Optimal to screen for all components of metabolic syndrome when obtaining a fasting insulin level.

Two Main Treatment GoalsTwo Main Treatment Goals

1 – reduce the contribution of underlying

causes such as obesity and physical

inactivity.

2 – treat the patient for lipid and nonlipid

risk factors.

1 – reduce the contribution of underlying

causes such as obesity and physical

inactivity.

2 – treat the patient for lipid and nonlipid

risk factors.

The ABCDE’s for Treatment for Metabolic Syndrome X

The ABCDE’s for Treatment for Metabolic Syndrome X

1. Antiplatelet

2. BP (Hypertension) Control – Which are best?

3. Cholesterol Control

4. Diet

5. Exercise

1. Antiplatelet

2. BP (Hypertension) Control – Which are best?

3. Cholesterol Control

4. Diet

5. Exercise

Tx of Pro-Inflammatory StateTx of Pro-Inflammatory State

• Growing interest in development of drugs to dampen the pro-inflammatory state.

• Several lipid - lowering drugs will reduce CRP levels, which could reflect an anti-inflammatory action.

• Growing interest in development of drugs to dampen the pro-inflammatory state.

• Several lipid - lowering drugs will reduce CRP levels, which could reflect an anti-inflammatory action.

Tx of Pro-Thrombotic stateTx of Pro-Thrombotic state

• No drugs are available that target PAI-I and fibrinogen.

• An alternative approach to the pro-thrombotic state is antiplatelet therapy.

• ACE inhibitors have been found to improve the fibrinolytic profile of the MSX by reducing plasma PAI-1 levels.

• No drugs are available that target PAI-I and fibrinogen.

• An alternative approach to the pro-thrombotic state is antiplatelet therapy.

• ACE inhibitors have been found to improve the fibrinolytic profile of the MSX by reducing plasma PAI-1 levels.

BP (Hypertension) Control – Which are Best?

BP (Hypertension) Control – Which are Best?

• Blood pressure lowering agents do not necessarily affect comorbidities

• Vasoactive qualities need to be considered

• Blood pressure lowering agents do not necessarily affect comorbidities

• Vasoactive qualities need to be considered

RAS and Intervention with ARBs and ACE Inhibitors

Angiotensinogen Renin

Angiotensin I ACE Angiotensin Converting Inhibitors Enzyme (ACE)

Angiotensin II Angiotensin Receptor Blockers AT1 Receptor AT2 Receptor Vasoconstriction Vasodilation Sympathetic Activation Inhibition of Cell Growth Cell Proliferation Apoptosis Aldosterone Release Renal Sodium Resorption

Atherosclerosis, hypertension

ARB ARB

• Are they better than ACE?

• What unique effects do they have?– Slows progression of renal disease

– Prevents new onset diabetes

– Cardiovascular effects

– Decreases inflammation

– tolerability

• Are they better than ACE?

• What unique effects do they have?– Slows progression of renal disease

– Prevents new onset diabetes

– Cardiovascular effects

– Decreases inflammation

– tolerability

Other CategoriesOther Categories

• Beta Blockers

• Diuretics

• Beta Blockers

• Diuretics

Cholesterol TreatmentCholesterol Treatment

•Candidates by current guidelines

•Poor compliance

•Failure to reach LDL goals in large measure are due to inadequate treatment by physician.

•True target for treatment in diabetes should be the apoB rather than LDL cholesterol.

Cholesterol Treatment GuidelinesCholesterol Treatment Guidelines

Once LDL goal has been reached ,

the next focus is to lower triglycerides

and then raise HDL.

Once LDL goal has been reached ,

the next focus is to lower triglycerides

and then raise HDL.

StatinsStatins

• Because statins are the most effective drug in lowering LDL, they are usually considered first line therapies.

• Reduce cholesterol, are atheroprotective, and improve endothelial function

• Statins reduce risk of CVD events in X. • When used, 80% of patients receiving a

statin reached their cholesterol goal  

• Because statins are the most effective drug in lowering LDL, they are usually considered first line therapies.

• Reduce cholesterol, are atheroprotective, and improve endothelial function

• Statins reduce risk of CVD events in X. • When used, 80% of patients receiving a

statin reached their cholesterol goal  

HypertriglyceridemiaHypertriglyceridemia

• Can cause pancreatitis– Dietary changes

– Avoidance of medications

– Improving glycemia

– Triglyceride lowering drugs

• Can cause pancreatitis– Dietary changes

– Avoidance of medications

– Improving glycemia

– Triglyceride lowering drugs

Nicotinic AcidsNicotinic Acids

• Isn’t statins enough?

• Niacin increases LDL size while statins lower LDL mass

• Give ASA ½ hr before to minimize flushing 

• Isn’t statins enough?

• Niacin increases LDL size while statins lower LDL mass

• Give ASA ½ hr before to minimize flushing 

FibratesFibrates

• Reduction of the inflammation process at the level of the vascular wall

• Reduce CVD end points in patients with dyslipidemia

• Have insulin sensitizing effects

• Reduction of the inflammation process at the level of the vascular wall

• Reduce CVD end points in patients with dyslipidemia

• Have insulin sensitizing effects

Combination TherapyCombination Therapy

• Most effective at decreasing LDL levels but also provide some improvements in HDL cholesterol values.

• Statin with antihypertensive therapy

• Simvastatin plus niacin

• Fenofibrate-statin

• Most effective at decreasing LDL levels but also provide some improvements in HDL cholesterol values.

• Statin with antihypertensive therapy

• Simvastatin plus niacin

• Fenofibrate-statin

HMG-CoA-ReductaseLiver

HMG-CoA

Statins

Mevalonate Cholesterol

HypercholesterolemiaAngiotensin II

AT1 Receptor

Vasoconstriction

Hypertension

Reactive Oxygen species

Endothelial Dysfunction

Proliferation

Atherosclerosis

+ +

+

+

+

SummarySummary

• Gains in life expectancy with strict control of cholesterol concentrations are similar to those achieved with smoking cessation, control of diastolic blood pressure, or weight.

• Currently available drugs do not robustly raise HDL cholesterol.

• Gains in life expectancy with strict control of cholesterol concentrations are similar to those achieved with smoking cessation, control of diastolic blood pressure, or weight.

• Currently available drugs do not robustly raise HDL cholesterol.

Diet Diet

• Why?

• Realistic goals are a 5-10% weight loss

• ATP III recommendations for diet composition

• Why?

• Realistic goals are a 5-10% weight loss

• ATP III recommendations for diet composition

Dietary RecommendationsDietary Recommendations

• Glycemic Index

• Recommend very high intakes of grain products

• No single diet is currently recommended for patients with metabolic syndrome.

• Is Atkins the best way? If not, what is?

• CHANGE BEHAVIOR!

• Glycemic Index

• Recommend very high intakes of grain products

• No single diet is currently recommended for patients with metabolic syndrome.

• Is Atkins the best way? If not, what is?

• CHANGE BEHAVIOR!

Specific PracticesSpecific Practices

• 1 - Reduce saturated fat intake to <7% of calories • 2 - Reduce dietary cholesterol intake to

<200mg/day – Every ounce of beef, lamb, pork, poultry, and fish contains

approximately 25mg of dietary cholesterol– 1 cup of milk contains 4-33mg of dietary cholesterol  

• 3 - Trim excess calories  • 4 - Add water soluble fiber• 5 - Add stanol or sterol ester margarines • 6 - Trim excess alcohol intake to <3% of calories• 7 - Use of omega 3 fatty acids

• 1 - Reduce saturated fat intake to <7% of calories • 2 - Reduce dietary cholesterol intake to

<200mg/day – Every ounce of beef, lamb, pork, poultry, and fish contains

approximately 25mg of dietary cholesterol– 1 cup of milk contains 4-33mg of dietary cholesterol  

• 3 - Trim excess calories  • 4 - Add water soluble fiber• 5 - Add stanol or sterol ester margarines • 6 - Trim excess alcohol intake to <3% of calories• 7 - Use of omega 3 fatty acids

Diet MedicationsDiet Medications

1. Appetite suppressants

2. Inhibitors of nutrient absorption

3. Dietary polyunsaturated fatty acid (PUFA) supplementation

1. Appetite suppressants

2. Inhibitors of nutrient absorption

3. Dietary polyunsaturated fatty acid (PUFA) supplementation

Exercise Exercise

• Why is exercise so important?

• Will it help?

• How often?

• Is it really going to make a difference?

• What is the best way to maintain to efforts?

• Why is exercise so important?

• Will it help?

• How often?

• Is it really going to make a difference?

• What is the best way to maintain to efforts?

Treatment OptionsTreatment Options• ATPIII had identified metabolic syndrome as an

indication for vigorous lifestyle intervention.

– Weight loss significantly improves all aspects of metabolic syndrome.

– Increasing physical activity and decreasing caloric intake by reducing portion sizes will improve metabolic syndrome abnormalities, even in the absence of weight loss.

–  Need for modification of dyslipidemia, blood pressure, and prothrombotic state in persons undergoing LDL lowering therapy.

• ATPIII had identified metabolic syndrome as an indication for vigorous lifestyle intervention.

– Weight loss significantly improves all aspects of metabolic syndrome.

– Increasing physical activity and decreasing caloric intake by reducing portion sizes will improve metabolic syndrome abnormalities, even in the absence of weight loss.

–  Need for modification of dyslipidemia, blood pressure, and prothrombotic state in persons undergoing LDL lowering therapy.

Pharmacological Recommendations for Insulin Resistance

Pharmacological Recommendations for Insulin Resistance

1. Metformin

2. Thiazolidinediones

3. Sulfomylureas

4. Other potential treatment

1. Metformin

2. Thiazolidinediones

3. Sulfomylureas

4. Other potential treatment

PCOSPCOS

• Treatment may be aimed at inducing fertility

• Weight loss through diet and exercise or use of insulin-sensitizing agents

• In addition to reducing androgens and improving reproductive function, improvement in CVD risk should be a goal of tx.

• Treatment to improve insulin sensitivity should be useful in the disease

• Treatment may be aimed at inducing fertility

• Weight loss through diet and exercise or use of insulin-sensitizing agents

• In addition to reducing androgens and improving reproductive function, improvement in CVD risk should be a goal of tx.

• Treatment to improve insulin sensitivity should be useful in the disease

Tx of NASHTx of NASH• Insulin sensitizing agents

• Vitamin E

• Insulin sensitizing agents

• Vitamin E

In SummaryIn Summary• Aging is the most important environmental

factor in causing insulin resistance• Weight reduction and increased physical

activity in persons with the metabolic syndrome

• Lifestyle and/or drug therapies to lower LDL to less than 100 mg/dL.

• Institution of treatment of other lipid or nonlipid risk factors, consider use of nicontinic acid or fibric acid for elevated triglycerides or low high density lipoprotein HDL cholesterol

• Aging is the most important environmental factor in causing insulin resistance

• Weight reduction and increased physical activity in persons with the metabolic syndrome

• Lifestyle and/or drug therapies to lower LDL to less than 100 mg/dL.

• Institution of treatment of other lipid or nonlipid risk factors, consider use of nicontinic acid or fibric acid for elevated triglycerides or low high density lipoprotein HDL cholesterol

•  Weight reduction from obesity guidelines at

http://www.nhlbi.nih.gov and http://www.americanheart.org.

• •www.aace.com/pub/irscc/findings.php

• full text guidelines – www.acc.org, www.americanheart.org

•  Weight reduction from obesity guidelines at

http://www.nhlbi.nih.gov and http://www.americanheart.org.

• •www.aace.com/pub/irscc/findings.php

• full text guidelines – www.acc.org, www.americanheart.org