Insulin resistance is a BIG problem

Metabolic syndrome is a BIG problem and growing. It affects over 25% of adults and 4% of adolescents. It's also called "insulin resistance syndrome" or "syndrome X" or "dysmetabolic syndrome" and even has its own ICD-9 code "see table 1". New treatment guidelines will focus even more attention on it...

• This syndrome is a combination of any 3 of the following: abdominal obesity, high triglycerides, low HDL, hypertension or hyperglycemia. Patients with 4 or 5 of these factors have a 3-fold higher risk of heart disease and a 24-fold higher risk of diabetes.

Obesity and physical inactivity are the main culprits. Exercise and weight loss are the key to improving metabolic syndrome and reducing the risk of heart disease and diabetes. FOR EXAMPLE, reduction in calories by approximately 500 kcal/day is often an acceptable strategy to achieve the goal of an ideal weight. Take the example of a sedentary woman, 50 years of age, height 66 inches, weight 190 pounds (86 kg), BMI 29 kg/m², and no reported exercise. By the Harris-Benedict equation, the usual caloric intake would be estimated at 1556 kcal/day. Dietary consumption of 1050 kcal/day, a 500 kcal/day lower intake, with no change in exercise would be expected to lead to a weight loss of approximately one pound a week. Obesity experts have recommended an initial goal of weight loss as approximately 10% of baseline and a reasonable time to achieve this goal as 6 months.

NPS-adv

Table (1). Diagnostic Criteria for the Metabolic Syndrome
Factor	Criteria
1	Abdominal girth, >35 inches (88 cm) in women, >40 inches (102 cm) in men
2	HDL-C, <40 mg/dL in men, <50 mg/dL in women
3	Triglycerides, fasting, >150 mg/dL (1.69 mmol/L)
4	Blood pressure, >130/85 mm Hg
5	Fasting glucose ≥110 mg/dL (>6.1 mmol/L)

High triglycerides and low HDL are often present. Use a statin if diet and exercise aren't enough. Add gemfibrozil (Lopid 600 mg BID), fenofibrate (Lipanthyl 160 mg once daily), or niacin if needed to further lower triglycerides or increase HDL. Combining a statin with one of these drugs can increase myopathy risk. Have patients report muscle pain or weakness.

Hypertension. Nearly 40% of patients with hypertension have metabolic syndrome. Consider using an ACE inhibitor or angiotensin receptor blocker. These drugs can reduce the risk of cardiovascular disease and might also reduce the risk of developing type 2 diabetes.

Hyperglycemia. Metformin (Glucophage) by dose 850 mg once daily for one month; if tolerating, increase to 850 mg twice daily, or acarbose (Glucobay) 25 mg 3 times daily can reduce the risk of diabetes in patients with impaired glucose tolerance. Metformin is often preferred because it lowers insulin resistance and triglycerides and helps with weight loss.

Rosiglitazone (Avandia) 4 mg once or twice daily or pioglitazone (Actos) 15 to 30 mg once daily, also lower insulin resistance and triglycerides, but can cause weight GAIN. Thiazolidinediones (Avandia, Actos) are limited by adverse effects like fluid retention, weight gain, heart failure, bone loss, possibly myocardial infarction for rosiglitazone, and possibly bladder cancer for pioglitazone. Recommend aspirin 81 mg/day for most metabolic syndrome patients due to their high cardiovascular risk.

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References

1. Meigs JB. Metabolic syndrome (insulin resistance syndrome or syndrome X), UpToDate. [online] Available at: https://www.uptodate.com/contents/metabolic-syndrome-insulin-resistance-syndrome-or-syndrome.
2. National Institute of Diabetes and Digestive and Kidney Diseases (2019). Insulin Resistance & Prediabetes. NIDDK. [online]. Available at: https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/prediabetes-insulin-resistance.
3. Wilson PW, Grundy SM. The metabolic syndrome: practical guide to origins and treatment: Part I. Circulation. 2003 Sep 23;108(12):1422-4.
4. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001 May 16;285(19):2486-97.
5. Weir E, Lipscombe L. Metabolic syndrome: Waist not want not. CMAJ. 2004;170(9):1390-1391.

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