Supplement Article  |   March 2010
Spotlight on the metabolic syndrome Informing patients about recent research and how it might affect them
Article Information
Cardiovascular Disorders / Endocrinology / Obstetrics and Gynecology / Preventive Medicine / Diabetes
Supplement Article   |   March 2010
Spotlight on the metabolic syndrome Informing patients about recent research and how it might affect them
The Journal of the American Osteopathic Association, March 2010, Vol. 110, eS26-eS27. doi:
The Journal of the American Osteopathic Association, March 2010, Vol. 110, eS26-eS27. doi:
Although metabolic syndrome—sometimes called syndrome X—is not completely understood, we do know that fat stored in the abdominal region, called visceral fat, and insulin resistance are major contributing factors. Abdominal fat is considered “toxic” because it secretes hormones and other chemicals much in the same way as endocrine organs, in the process altering one's metabolism and contributing to insulin resistance. 
The National Heart Lung and Blood Institute estimates that in the United States, about 47 million, or 25% of adults, have the metabolic syndrome. It can affect anyone, but is most frequently seen in people who are significantly overweight (especially in the abdominal area) and who lead a sedentary lifestyle. People with the metabolic syndrome are three times more likely to have a heart attack or stroke. One in four is more likely to develop diabetes than a person who does not have the syndrome. 
The hip-to-waist ratio is a good indicator of disease risk. This measurement is obtained dividing the waist by the hip measurement. (Moderate Health Risk is indicated by a score of 0.96 to 1.0 in men and 0.81 to 0.85 in women. High Health Risk is seen as a score of 1.0 or more in men and 0.85 or more in women.) 
Talking points: Signs
Anyone who has at least three of the following signs may have the metabolic syndrome: 
  • Overweight or obesity (apple shaped)—most fat around the middle. In men, waist over 40 inches and in women, waist over 35 inches.
  • Hypertension—blood pressure higher than 130/85 mm Hg
  • Fasting blood sugar—greater than 110 mg/dL
  • Triglycerides—above 150 mg/dL
  • Low HDL cholesterol (the “good” cholesterol)—Men at risk = HDL below 40 mg/dL; Women at risk = HDL level below 50 mg/dL
Talking points: Recommendations
The journal Circulation summarizes recent American Heart Association recommendations emphasizing that cutting down on added sugar can address America's high obesity rates and its subsequent cardiovascular risk. 
The article, “Dietary sugars intake and cardiovascular health: A scientific statement from the American Heart Association,” by Rachel K. Johnson, PhD, MPH, RD, and colleagues at the University of Vermont, states that Americans should drastically reduce the amount of sugar in their diet—at the table, during cooking, and in food processing. 
The article concludes that added sweeteners should not account for more than 100 calories a day for women or 150 calories for men, or roughly five to nine teaspoons of sugar daily for the average adult. The current average sugar intake is 22 teaspoons, or 355 calories, a day, mostly from soft drinks and other sweetened beverages. 
Talk about sugar with your patients and give them ideal sugar limits as outlined above. Explain that added sugars can take many forms—from honey in tea to high-fructose corn syrup in soft drinks—and aren't specified on food nutrient labels. 
Talking points: Stress
Discuss the links between stress, abdominal fat and CV risk. A number of studies show a relationship between stress, abdominal fat and cardiovascular risk. People more responsive to psychological stress appear to be at an increased risk of developing obesity. 
The biological mechanisms underlying this phenomenon are poorly understood, but cytokines, including the “fat hormone” leptin and interleukin, play a key role in fat metabolism and have been reported in abnormal levels in obese people and those under stress. 
The article, “Stress-induced cytokine responses and central adiposity in young women,” by University College in London researchers Brydon L, Wright C E, O'Donnell K and colleagues, concludes that women who get “stressed out” tend to have more abdominal fat than those who don't. 
Women who respond to stress with an increase in blood pressure and release of cytokines, such as leptin into the blood, tend to have more abdominal fat than women who do not respond to stress with such increases. 
The study also found a positive correlation between waist circumference and stress-induced increases in plasma levels of both leptin and interleukin-1 receptor antagonist (IL-1Ra) responses. There was also a significant positive correlation between prolonged diastolic blood pressure responses to stress and measures of total and abdominal obesity. 
Since women who had larger cytokine responses to stress were more abdominally obese than women with smaller cytokine stress responses, increased cytokine production could be a mechanism linking stress and abdominal obesity. 
Lowering blood pressure during stress is particularly important for women who tend to get easily stressed. 
Talking points: Exercise
Periodic intense exercise is essential in such people because it is known to produce the exact opposite metabolic results as those found in this study. 
Yoga, for example, can positively impact blood pressure, and might otherwise help reduce stress. The same benefits might be true for men. Exercise is of even greater importance for women who have midsection fat and high stress. 
Talking points: Fat distribution
Discuss the links between stress, cortisol and fat distribution. A study in Obesity Research (1994 May;2(3):255-62) by Yale researchers found that cortisol secretion might also represent a mechanism for the association between stress and abdominal fat. 
The researchers measured waist-to-hip ratio (WHR) and salivary cortisol levels in response to laboratory stressors (eg, timed arithmetic) and also considered background life stress and psychological traits. Compared to low WHR subjects, high WHR subjects secreted significantly more cortisol during the stressful session. These findings support the hypothesis that cortisol secretion might represent a mechanism for the observed association between stress and abdominal fat distribution. 
Talking points: Diet
Discuss how important it is for people to reduce abdominal weight, particularly high-stress individuals. A well-chosen low-fat, low-sodium diet along with staying active and maintaining a regular exercise plan, are proven techniques. Good food choices include plenty of fresh fruits and vegetables and whole grains. 
Foods that are grilled, steamed, broiled or baked are preferred. Many studies show that a “Mediterranean-type” diet is heart-healthy and that the typical Western diet, rich in meat, refined grains and fried foods, increases the risk of developing metabolic syndrome. 
Talking points: Childbearing
Address connection between child-bearing and the metabolic syndrome. A Kaiser Permanente study in the August 2009 issue of the American Journal of Obstetrics & Gynecology reports that childbearing increased the likelihood of developing metabolic syndrome, regardless of whether she develops gestational diabetes mellitus. 
Researcher August Erica P. Gunderson, PhD, and colleagues studied 1,451 women (18 to 30 years old) who had never given birth, following them for 20 years, and identified 259 incident cases of metabolic syndrome. Results suggest that childbearing contributes to development of the metabolic syndrome and that the association is partially mediated through weight gain and lack of physical activity. 
Pregnancy is a good opportunity to warn about the dangers of metabolic syndrome and weight gain as an added risk. Encourage your pregnant patients to adhere to dietary recommendations and to keep as active as possible. 
 This “DO Touch” column is designed to provide physicians with information they can use and share with their patients.
 This continuing medical education publication is supported by an educational grant from Merck & Co, Inc.