METABOLIC SYNDROME

R BOWO PRAMONO
INTERNAL MEDICINE DEPARTEMENT
MF GMU/SARDJITO HOSPITAL
YOGYAKARTA
 Burden of Illness

• An epidemic disease
• High prevalence and increasing In developed and
also developing countries (inc. asian countries)

• Associated with a number of diseases and metabolic

abnormalities
• High morbidity and mortality
 Disorders associated Metabolic
Syndrome

● Insulin resistance/hyperinsulinemia ● Osteoarthritis

● Type 2 diabetes ● Stroke
● Hypertension ● Asthma
● Dyslipidemia ● Sleep apnea
● Coronary heart disease ● Breathing difficulties
● Gallbladder disease ● Complications of pregnancy
● Cancer (prostate,endometrial, uterine, cervical, ovarian, colon, kidney,
gallbladder, and postmenopausal breast)
● Menstrual irregularities
● Hirsutism ● Premature death
● Increases surgical risk ● Psychological distress

Must et al. 1999; Pi-Sunyer 1993; USDHHS 2001 (16–18)]

Metabolic Syndrome Related Diseases

• 80% of type 2 diabetes related to obesity

• 70% of Cardiovascular disease related to obesity
• 42% breast and colon cancer diagnosed among
obese individuals
• 30% of gall bladder surgery related to obesity
• 26% of obese people having high blood pressure
 Obesity, Insulin Resistance, Metabolic
Syndrome …..it’s a link (!)

• Metabolic syndrome is a clinically useful tool

to identify people at risk for diabetes and
cardiovascular disease
• It indicates cumulative cardio metabolic risk
exerted by abdominal obesity,
hyperglycemia, high triglyceride, low high
density lipoprotein cholesterol, and high
blood pressure
 Definition of Metabolic Syndrome

• Metabolic syndrome is a cluster of risk factors which

is responsible for excess of cardiovascular disease
morbidity among overweight and Obese patients and
those persons with type 2 diabetes mellitus.
• The National Cholesterol Education Program- Adult
Treatment Panel (NCEP-ATP III) identified metabolic
syndrome as an independent risk factor for
cardiovascular disease and considered it an indication
for intensive lifestyle modification.
 Definition of Metabolic Syndrome

2001 NCEP/ATP III

presence of any three of the following five traits:
– Abdominal obesity, defined as waist circumference in
> 40 inches and womenmen
> 35 inches
– Serum triglycerides ≥ 150 or drug treatment for elevated
triglycerides
– Serum HDL cholesterol < 40 mg/dl in men and < 50 mg/dl
in women or drug treatment for low HDL-C
– Blood pressure ≥ 130/85 mmHg or drug treatment for
elevated blood pressure
– Fasting plasma glucose ≥ 100 mg/dl or drug treatment
for
elevated blood glucose
 Criteria for diagnosis:

• World Health Organization

• International Diabetes Federation (IDF) -
European Association for the Study of
Diabetes (EASD)
• National Cholesterol Education Project, Adult
Treatment Panel (NCEP-ATP III)
• Others
 Hypertension:

• IDF:
– BP >130/85 or on Rx for previously Dxed
hypertension
• WHO:
– BP >140/90
• NCEP ATP III:
– BP >130/80
 Obesity:

• IDF:
– Central obesity - waist >94 cm for
circumference
Europid men, >80 Europid women with ethnicity
specific values for other groups
• WHO:
– Waist-hip ratio >0.9 - men or >0.85 - women
• ATP III:
– Waist circumference >40 in. - men, 35 in. - women
 Glucose Abnormalities:

• IDF:
– FPG >100 mg/dL (5.6 mmol.L) or previously
diagnosed type 2 diabetes
• WHO:
– Presence of diabetes, IGT, IFG, insulin
• resistance
ATP III:
– FBS >110 mg%, <126 mg% (ADA: FBS >100)
 Definition of Obesity

“EAT TO LIVE”
Intake = Expenditure
Weight Stable

“LIVE TO EAT”
Intake > Expenditure
Obese
 Definition of Obesity

A condition in which there is an excess of body fat

Based on BMI (which in closely related with body fat)

BMI Risk of
(Kg/m2) Co-morbidities

Underweight < 18.5 Low

Normal 18.5 – 22.9 Average
Overweight: > 23
At risk 23 – 24.9 Increased
Obese I 25 – 29.9 Moderate
Obese II > 30 Severe
The Asia Pacific Perspective: Redefining obesity & its treatment,
2000
 Patophysiology of Obesity

• Obesity is a chronic metabolic disease

• Caused by multiple and complex factors
• Main contribute factors :
- increased calorie intake
- decreased physical activity
- genetic influences
 Patophysiology of Obesity

Energy Balance Depend on:

• Energy intake calculated as calories ingested
as food
• Energy expenditure:
– Resting metabolic rate
– Exercise - induced thermogenesis
– Dietary - induced thermogenesis
The influence of Obesity(= excess fat)
in Metabolism Disorder
 Obesity as a risk factor

It is not the amount of fat but also its distribution that

determines the risk associated with obesity (WHO, 2000)

Waist circumference
WHO 2000
94 cm (Man)
80 cm (Woman)
Europe
102 cm (Man)
88 cm (Woman)
Asia Pasific
Android Gynoid
90 cm (Man)
Visceral/ Peripheral
80 cm (Woman)
Central Obesity
Obesity
 Obesity as a risk factor

• Visceral fat is specialized to provide short term

storage & rapid access to calories that can be
processed quickly by the liver
• Visceral fat cells have higher FA turnover & lipolysis
than subcutaneous fat cells

Large Insulin-Resistant Small Insulin-Sensitive

Adipocytes Adipocytes

Android Obesity Gynoid Obesity

 Insulin resistance

• Insulin resistance is a fundamental aspect of

the etiology of
- type 2 diabetes
- hypertension
- hyperlipidemia
-
atherosclerosis
• Condition where insulin becomes less effective at
lowering blood glucose
• The resulting increase in blood glucose may raise
levels outside the normal range and cause adverse
health effects
 Diagnosis of Insulin Resistance

• Gold Standart for investigating and quantifying insulin

resistance is the "hyperinsulinemic euglycemic clamp”
• The test is rarely performed in clinical care, but is used in
medical research
• In clinical setting ussualy use HOMA (Homeostasis Model
Assesment) technic

Glucose and Insulin are both during fasting

This model correlated well with estimates using the euglycemic clamp
(r = 0.88)
 Insulin resistance
(Basic mechanism and the defect)

insulin glucose

Insulin receptor
GLUT 4
tyrosine autophosphorylation
intracellular signaling

GLUT 4

transcription

mRNA
 The Role of Obesity on Insulin
Resistance

Leptin
(inflamator
Visvatin y) TNF-α
(Promotes
(inflamatory
adipogenesis)
)

IL-6,
VEGF, NGF
TGF β
Methalothionie
n

MCP-1, MIF,
Adiponectin
IL-8
Resistin
 Dyslipidemia:

• IDF:
– Triglycerides - >150mg/dL (1.7
mmol/L)
– HDL - <40 mg/dL (men), <50 mg/dL (women)
• WHO:
– Triglycerides - >150 mg/dL (1.7 mmol/L)
– HDL - <35 mg/dL (men), >39 mg/dL) women
• ATP III:
– Same as IDF
 Necessary Criteria to Make Diagnosis:

• IDF:
– Require central obesity plus two of the
other
abnormalities
•
WHO:
– Also requires microalbuminuria - Albumen/
creatinine ratio >30 mg/gm creatinine
•
ATP III:
– Require three or more of the five criteria
Linked Metabolic Abnormalities:

• Impaired glucose handling/insulin resistance

• Atherogenic dyslipidemia
• Endothelial dysfunction
• Prothrombotic state
• Hemodynamic changes
• Proinflammatory state
• Excess ovarian testosterone production
• Sleep-disordered breathing
 Obesity, Insulin Resistance, Metabolic
Syndrome …..it’s a link (!)

• Obesity is major cause of insulin resistance

• Insulin resistance is a fundamental aspect of the
etiology of metabolic syndrome
• Obesity is also cause of metabolic syndrome

What should we do ?
 Therapeutic Goals for Management of
Metabolic Syndrome

ATP III (2001) recommended two major therapeutic goals in patients with
syndrome
1. Treat underlying causes (overweight/obesity and
physical inactivity) by intensifying weight management
and increasing physical activity
2. Treat cardiovascular risk factors if they persist despite
lifestyle modification

There is no direct evidence that attempting to prevent type 2 diabetes and

CVD by treating metabolic syndrome is as effective as attaining the above
goals. It is possible to treat insulin resistance with drugs that enhance insulin
action.
 Therapeutic Goals for Management of
Metabolic Syndrome

Lifestyle Risk Factors

Year 1: Reduce body weight by 7-10%

Abdominal
Obesity Continue weight loss thereafter with
ultimate goal BMI < 25 kg/m2
At least 30 min (and preferably > 60 min)
Physical Inactivity continuous or intermittent moderate
intensity exercise 5X/wk but preferably daily
Reduced Intake of saturate fat, trans fat,
Atherogenic Diet cholesterol
 Therapeutic Goals for Management of
Metabolic Syndrome

Metabolic Risk Factors

High risk: <100 mg/dL (preferably <70 mg/dL)

Dyslipidemia
Moderate Risk: <130 mg/dL
Primary Target
Elevated LDL-C Low Risk: <160 mg/dL
Target HDL-C Raise to extent possible with weight reduction and exercise

Reduce to at least > 140/90 (<130/80 if diabetic)

Elevated BP
For IFG, encourage weight reduction and exercise
Elevated Glucose
For Type II DM, target A1C < 7 percent
Prothrombotic State Low dose aspirin for high risk patients
Proinflammatory Lifestyle therapies; no specific interventions
 Management of Obese-IR-MetS Link

Obesity management
Insulin resistance
Metabolic
syndrome
Step : 1. Prevention (obese in children)
2. Specific treatment to etiology:
Hypothyroidism, Hyperadrenocorticism, Male
hypogonadism, Hyperinsulinism, Hypopituitarism, Brain
3. tumor
4. Non specific treatment : weight loss programme
5. Exercise
6. Drug
Surgery
 Diet & Exercise Mets
• Obesity and physical inactivity are major
risk factors
• Diet and exercise may provide good
long-term glycaemic control in some
patients
• Improved cardiovascular status
• Cost-effective

Slide 37
 Guidelines for a healthy diet
PERKENI 2011

10/20/21 • Healthy balanced diet

composed of:
• 45-65% carbohydrate
• 20-25% fat
• 10–20% protein

10/20/21
10/20/21

Slide 38
 The Indonesian Food Pyramid

Slide 39
http://www.fagnutrition.com
Carbohydrate

East Less of These Eat More of These

White sugar, Brown sugar, White Fruit, Low fat Milk, Beans, Brown
bread, White rice, rice, Yoghurt, Whole wheat bread
Slide 40
Proteins

East Less of These Eat More of These

Sausages, processed meat, Chicken, Fish, Tofu

Shrimps and shell fish, Red
Meat Slide 41
Fat

East Less of These Eat More of These

Coconut, Margarine/butter, Avocado, Nuts, Olives, Oils rich in

Cheese, Oils/fats rich in poly and mono unsaturated fats
saturated fat Slide 42
 Slide 43

How you cook is important

Less Healthy More Healthy

 Understanding portion sizes is important
Recommendation to take smaller portion sizes of the less recommended food

Rice boiled – 200 g Rice boiled – 100 g

Calorie – 350 kcal Calorie – 175 kcal
Carbohydrates – 80gm Carbohydrates – 40gm

Noodles boiled – 200 gm

Calorie – 175 Kcal
Carbohydrates – 40 gm

Source: Daftar Bahan Makanan Penukar

Slide 44
 Practical Initiation of Diet Programs for diabetes patients
Food Mapping Systems

Food Mapping System can be used for patient education to increase patient compliance with diet
scheme

Steamed Brown
White Rice Fried Rice
Rice

Stir Fried Crispy Fried

Grilled Chicken
Chicken Chicken

Steamed / Grilled Deep Fried

Stir Fried Fish
Fish Shrimps

Steamed Steamed Dim Deep Fried Dim

Vegetables Sum Sum

Slide 45
 Practical Initiation of Diet Programs for diabetes patients
Healthy Plate Models

Portion Control Plate was effective in inducing weight loss and decreased use of hypoglycemic
medications in obese patients with type 2 diabetes mellitus

Protein
Carbo-
hydrate /
Starch
Vegetables
Carbo-
hydrate / Vegetables
Protein
Starch

T-shaped plate Y-shaped plate

model to loose model to maintain
weight weight
Slide 46
Pedersen DE et al. Arch Intern Med. 2007; 167
Slide 47
 Practical Initiation of Exercise Programs for diabetes patients
CRIPE Pricnciple

CRIPE: Continuous, Rhytmic, Interval, Progressive, Endurance

• Exercises should be done continuously without

Continuous
rest (e.g. 30 minutes of jogging without rest)
• Choose more rhythmical sports where regular
Rhythmic contraction and relaxation are possible (e.g.
walking, jogging, running and swimming)
• Exercises with both quick and slower actions (e.g.
Interval running followed by jogging)
• Increase intensity according to abilities (heart rate
Progressive
target: 75-85% from maximum heart rate)
• Exercise for endurance to improve
Endurance cardiorespiratory abilities (e.g. walking, jogging,
swimming, cycling)
Slide 48
 Slide 49

Exercise significantly reduces HbA1c

Pooled meta-analysis of 14 exercise trials

%
0.2
from baseline to post-intervention

0.08%
0.1
(weighted mean difference)

Exercise
0.0
Non-exercise control
Change in HbA1c

-0.1
-0.2
-0.3
p<0.001
-0.4
-0.5 Effect was
weight-independent
-0.6
-0.7 -0.66%

BouléSource:
NG, et Boule
al. JAMA
NG2001;286:1218-27.
et al. Effects of exercise on glycemic control and body mass in T2 Diabetes: JAMA2001; 286:1218-27
STOP SMOKING

Slide 50
 Summary

• Obesity has reached epidemic proportions

• Environmental, behavioral, and genetic factors have been shown
to
• contribute to the development of obesity.
Distribution of fat determines the risk associated with obesity
• especialy in central obesity
Abdominal or upper-body obesity, has been associated with a
number of diseases and metabolic abnormalities, especialy insulin
•
resistance
• Insulin resistance is the condition where insulin becomes
less
• effective at lowering blood glucose
Adipokines promotes impaired phosphorylation action, diminished
glucose transport, and abnormalities in glucose uptake
This underscores the importance of identifying people at risk for
obesity and its related disease states.
 Conclusions

• Metabolic Syndrome is becoming increasingly common in

our patient population
• It is not being adequately recognized and treated in our
outpatient clinics
• We recommend the following strategies to improve
diagnosis and treatment of metabolic syndrome:
1. Nursing staff measure waist circumference and calculate BMI
for
2.
every patient prior to MD evaluation
The “Therapeutic Goals for Management of Metabolic
3. Syndrome”
(as shown on slide 10) should be available to doctors for easy
reference
4. Examples of Lifestyle Modifications (slide 11) and Moderate
Physical
Activity (slide 12) should be provided to all patients keeping in
Thank You