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METABOLIC SYNDROME

THE METABOLIC SYNDROME
Recent research has shown that the above cluster of abnormalities is strongly predictive of risk for diabetes, cardiovascular disease and stroke. This clustering is called The Metabolic Syndrome (also called Dysmetabolic Syndrome, Cardiovascular Dysmetabolic Syndrome, or Syndrome X). More than 30% of the US population likely has Metabolic Syndrome, increasing with age from 6.7% of 20-29 year olds to 43.5% in those aged 60 to 69.

This abnormal metabolic state is due to "insulin resistance," ineffective communication between insulin and its target cells. Insulin resistance not only effects the processing of sugar and fat, but it also:

• alters kidney function, which affects blood pressure
• increases inflammation, which damages blood vessels
• stimulates coagulation, which enhances clotting
• can affect fertility by impairing release of an egg from the ovary (as seen in polycystic ovarian syndrome) and may be at play causing diabetes and high blood pressure in pregnancy (gestational diabetes and pre-eclampsia).

Traditional medical strategies try to bring each "part" of the Syndrome into normal range-such as, lowering blood pressure, lipids or sugar levels-but fail to address the underlying insulin resistance.

Metabolic Syndrome Development: All Five Factors or Less?
Although the full syndrome includes all 5 factors, the presence of any one factor indicates increased risk. The more factors present, the more powerful is the prediction. After the full 5 factors that define metabolic syndrome, the next most powerful cluster is that of large waist size, high triglycerides and low HDL cholesterol. Next is hypertension (BP higher than 130/85). In fact, half of all people with hypertension are likely to have insulin resistance and are at highest risk for cardiovascular disease. The Metabolic Syndrome evolves slowly over time. The San Antonio Heart Study followed 2000 people over 8 years. At the start, some had none of these factors, some only one. Having a large waist circumference (abdominal obesity) at the start of the study was 3-times more likely to predict developing the full metabolic syndrome in men and 8-times more likely in women.

Sex Differences in Predicting Disease
These clusters are more potent predictors in women than in men. In the Framingham Heart Study men with 3 or more of these factors had over twice the risk of coronary-artery disease, women's risk increased 6-times. Nearly half of coronary events in women and one-fifth in men can be attributed to these clusters. A study of survival of over 6000 patients who underwent bypass grafting showed that 90% of those who died had at least one factor. Of those who had all 5 factors, men had a 2-3-fold higher risk of dying and women had a 10-fold higher risk.

In addition, some conditions in reproductive age women are also associated with insulin resistance, including: polycystic ovarian syndrome, which causes irregular menstrual cycles; and some complications of pregnancy, like gestational diabetes or pre-eclampsia. While these conditions are treated for their reproductive aspects, physicians often fail to address the larger implications for the long-term health of these women.

TREATING METABOLIC SYNDROME
After a review of the literature and a clinical trial among her own patients (see below), Dr. Hoffman has adapted a regimen for prevention and treatment:

• Macro-Nutrition: "low glycemic index" diet, including a medical food to decrease insulin levels and lose weight
• Micro-Nutrition: micronutrients to enhance insulin action at the cellular level (nutraceuticals)
• Exercise: regular exercise also reduces "insulin resistance"
• Pharmaceuticals (if necessary): medications to reduce insulin resistance

Sedentary lifestyle and excess food can worsen insulin resistance, even in the absence of obesity. The body has limited capacity to store sugar, its main fuel, in the liver and in muscles. It has unlimited capacity for fat storage. If excess sugar is taken in when the body's sugar stores are full, the excess sugar is converted into fat. When stored sugar (glycogen) is depleted by exercise, however, the liver and muscles have more room to take in new supplies of sugar and are more sensitive to insulin's action. This process is also affected, in a more complex biochemical way, by the quality and quantity of nutrients eaten.

Both weight loss and exercise reduce insulin resistance and the indicators of The Metabolic Syndrome. Unfortunately, the typical heart-healthy, low-fat diet is high in carbohydrates and may fail to produce weight loss in those who are insulin resistant. The good news is that there are nutritional approaches that specifically target insulin resistance, going beyond weight loss to improved body composition. Life style changes, including weight loss (likely an indicator for changes in the underlying Metabolic Syndrome), led to an 88% reduction in the chance of developing diabetes in Nurses Health Study.

DR. HOFFMAN'S PATIENT STUDY
A group of patients were invited to try this nutritional approach to altering body composition, meaning both losing weight and altering metabolic abnormalities. After a check-up, routine blood testing and a 2-hour glucose tolerance test that measures insulin levels, a body compartment measurement was done to assess how much tissue was fat and how much was muscle. Some patients in the study had just one of the factors, like large waist circumference or elevated blood pressure. Some had all of the factors. One had the fully evolved state of diabetes, hypertension, coronary artery disease and stroke. Several had polycystic ovarian syndrome and a history of having had gestational diabetes.

In this initial study, patient treatment included diet and nutritional supplements, as well as maintaining usual levels of physical activity. The diet was a low glycemic index diet -- high in complex carbohydrates (whole grains, legumes, fruits and vegetables) and restricted in refined carbohydrates (sweets, refined flour, potatoes, white rice) and unhealthy fats; these healthy foods enter the blood stream slowly and do not provoke a spike in insulin levels. This low glycemic index diet also included a medical food (powdered drink) that could be used as a meal replacement. The medical food also had a low glycemic index as well as nutrients to enhance insulin action. Other insulin enhancing nutritional supplements were prescribed, such as high doses of omega-3-fatty acids and conjugated linoleic acid (the "good" fats). These supplements improve communication between insulin and its target cells.

The Results
Patients were seen monthly for body measurements and counseling. After 6 months blood and body compartment testing was repeated. Numerous patients showed positive results:

• Those who demonstrated insulin resistance on the 2-hour glucose tolerance test lost significant amounts of weight.
• Those who actually normalized their insulin levels lost the most weight, in one case 60 pounds and in another 40 pounds.
• Those who were not insulin resistant lost some weight depending on how much they adhered to the calorie count, as with any diet.
• Some had significant declines in blood pressure, lipids or sugar levels, enough to begin weaning off prescription medication.
• No one lost lean muscle tissue. Losing lean tissue worsens insulin resistance and lowers metabolic rate so that you become resistant to further weight loss and have a rebound gain in weight after dieting. Sound familiar?

SUMMARY
"Whole Person" Care provides a uniquely effective approach to disease treatment and prevention. By addressing the "whole" rather than just the "parts," "Whole Person" Care is more tailored to each person's underlying physiology, less dependent on costly medications and more empowering for patients' ability to manage their long-term health.

If you are interested in this program, first schedule a complete check-up if you have not had one recently, then arrange for a two hour glucose tolerance test followed by a body compartment measurement.

For more reading about the metabolic syndrome, see:

• Eat, Drink and Be Healthy by Walter C. Willet, MD
• The Glucose Revolution by Jennie Brand-Miller, PhD
  

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