TREATING METABOLIC SYNDROME

The individual components of metabolic syndrome—abdominal obesity, high triglycerides, low HDL cholesterol, high blood pressure, and high fasting glucose—would not always be treated if found in isolation. When found together, however, metabolic syndrome is typically diagnosed, indicating the need for treatment. That is, metabolic syndrome lowers the threshold for the treatment of its components.

Treatment goals for metabolic syndrome are:

  • Treat underlying causes
  • Prevent the development of type 2 diabetes
  • Treat cardiovascular risk factors (i.e., manage hypertension, lower LDL cholesterol and triglyceride levels)
    (NHLBI, 2019)

Treatment for metabolic syndrome consists of the following main therapeutic strategies:

  • Weight loss and increased physical activity focused on reversing the direct causes of the condition
  • Medications designed to treat the condition’s various components, such as dyslipidemia, hypertension, prothrombic conditions, and insulin resistance
  • Dietary management focused on lowering cholesterol and restricting calories from simple carbohydrates (i.e., emphasis on low-fat dairy, whole grains, and fresh fruits and vegetables)
    (NHLBI, 2019)

Treatment of the components of metabolic syndrome begins with lifestyle changes. Because lifestyle changes are easy to prescribe but difficult to carry out, often medications must be added to ensure that the treatment regimens succeed.

Therapeutic Lifestyle Changes

Lifestyle modification is the preferred treatment of metabolic syndrome. Therapeutic lifestyle changes—such as increased physical exercise, eating a heart-healthy diet, and weight management—are the cornerstones of the treatment of obesity, hypertension, insulin resistance, and most dyslipidemias. Reducing dietary calories and fats (especially saturated and trans fats) and increasing exercise can significantly reduce the risk of developing diabetes and atherosclerotic cardiovascular disease (NHLBI, 2019).

EXERCISE

All aspects of metabolic syndrome benefit from increased physical activity. Physical exercise helps in losing weight and in maintaining weight loss, and it has additional independent metabolic effects that directly reduce insulin resistance. Physical activity is usually a safe and beneficial treatment for people with metabolic syndrome and its associated consequences of atherosclerotic cardiovascular disease and type 2 diabetes.

The American Heart Association (2018) recommends the following physical activity for adults:

  • For overall cardiovascular health:
    • Get at least 30 minutes of moderate-intensity exercise at least 5 days per week for a total of 150 minutes.
    • Get at least 25 minutes of vigorous aerobic activity at least 3 days per week for a total of 75 minutes, or a combination of moderate-and vigorous-intensity aerobic activity.
    • Do moderate- to high-intensity muscle-strengthening activity at least 2 days per week for additional health benefits.
    • Spend less time sitting. Even light-intensity activity may balance some of the risks of being sedentary.
    • Get even more benefits by being active at least 300 minutes (5 hours) per week.
    • Start slowly and increase the amount and intensity of activity gradually over time.
  • For lowering blood pressure and cholesterol:
    • Get an average of 40 minutes of moderate- to vigorous-intensity aerobic activity 3 or 4 times per week.

For high-risk patients with comorbidities who are deconditioned or have had recent cardiac events, careful supervision of physical rehabilitation is recommended. Referral to a physical therapist or exercise physiologist to evaluate, plan, and monitor the patient’s progress with his or her exercise program is an important consideration (AHA, 2018).

Patients may also benefit from partnering with others in activities such as swimming, biking, or walking groups to motivate and support each other to reach their goals.

SUPERVISED EXERCISE

Patients with metabolic syndrome are at risk of developing neuropathy (i.e., peripheral pain, numbness) characterized by a loss of unmyelinated cutaneous axons. Unmyelinated axons are susceptible to both physical and metabolic injury. However, they are also capable of rapid regeneration. Supervised exercise has been found to improve cutaneous reinnervation capacity in patients with metabolic syndrome. In a study conducted by Singleton and colleagues (2015), a relatively brief but intensive exercise program designed to improve glucose, insulin, and lipid metabolism resulted in a clear increase in the ability of cutaneous axons to regenerate following controlled denervation.

DIETARY MODIFICATIONS

Exercise alone rarely leads to significant weight loss. A heart-healthy diet is usually necessary, and nutrition planning is the second critical component of the initial treatment of metabolic syndrome.

Even a modest weight loss makes a difference for an overweight or obese person, and losing 5% to 7% of the original weight and keeping the weight off is a realistic goal. The ADA (2020b) recommends that patients aim for a weight loss of 7% of body weight, noting that a small but consistent weight loss of 1/2 to 2 pounds per week is the safest way to accomplish this.

Simply reducing the overall calories in the diet will improve the lipid profile. Reducing the amount of unhealthy fats and sugars improves the lipid profile even further. It is especially important to remove foods that are high in simple carbohydrates, refined grains, and saturated or trans fats (ADA, 2020c). It may also be important to restrict sodium intake to <2,300 mg/day.

Following a Mediterranean diet rich in nutrient-dense foods such as whole grains, vegetables, fruits, legumes, low-fat dairy, lean meats, nuts, and seeds is recommended for body weight management (ADA, 2020b).

MEDITERRANEAN DIET

The Mediterranean diet food pyramid is recognized as the “gold standard” eating pattern that promotes good health and prevention of cardiovascular risks:

  • High consumption of monosaturated fatty acids (primarily from olives and olive oil)
  • Daily consumption of fruits, vegetables, whole grain cereals, and low-fat dairy products
  • Weekly consumption of fish, poultry, tree nuts, and legumes
  • A relatively low consumption of red meat (approximately twice per month)
  • Moderate daily consumption of alcohol (normally with meals)

Additionally, studies suggest that adherence to the Mediterranean diet can positively affect individual components of metabolic syndrome such as waist circumference, dyslipidemia, hypertension, and hyperglycemia.

(Foodpyramid.com, 2015; Mayo Clinic, 2019b)

Some research shows that insulin resistance can be reduced by following low-carbohydrate and ketogenic diets (Diabetes.co.uk, 2019). Ketogenic diets are high-fat, adequate protein, and low-carbohydrate. This type of diet alters the way energy is used in the body. Fat is converted into fatty acids and ketone bodies. This helps to lower glucose levels and reduces insulin resistance. Others caution the use of a ketogenic diet due to the high fat content (especially unsaturated fats), combined with eating fewer nutrient-rich fruits and vegetables for long-term cardiovascular health (Abbasi, 2018).

CASE

Angela, Age 52

The nurse, Lashay, enters the examination room to check the blood pressure and take a blood sample from the patient, Angela, who is a 52-year-old female recently diagnosed with metabolic syndrome. After removing the blood pressure cuff from Angela’s arm, Lashay asks how well she has been managing her weight, and the patient replies that she has been having “difficulty losing weight” on her own and asks for more information about what strategies she should try at home. A discussion of diet and exercise ensues, during which Angela reveals that she has continued to struggle with healthy food choices and regular exercise.

Lashay discusses the benefits of the Mediterranean diet in managing the various components of metabolic syndrome. While reviewing the components of the diet, they look together at an educational booklet that outlines how to follow the Mediterranean diet model, with practical menu suggestions and a baseline assessment about knowledge of the healthy food choices included in the model. Angela mentions that the diet seems easier than she imagined to follow and states that she will start to shop and plan her meals better with this information.

Lashay helps the patient make an appointment with a registered dietitian with the aim of establishing an individualized diet and exercise plan based on Angela’s needs. Lashay also helps facilitate a referral to a physical therapist for an evaluation and treatment plan to address Angela’s strength and endurance. They plan to have a follow-up visit in six weeks to monitor Angela’s progress.

SMOKING CESSATION

When associated with metabolic syndrome, smoking increases the chance of developing insulin resistance, type 2 diabetes, and dyslipidemias. In addition, smoking contributes to the development of a variety of cancers, atherosclerotic cardiovascular diseases, lung diseases, gastrointestinal diseases, reproductive problems, osteoporosis, cataracts, age-related macular degeneration, and hypothyroidism.

Medications

HYPERTENSION MEDICATIONS

When lifestyle changes in diet and exercise are insufficient, persistent hypertension requires medication. For metabolic syndrome, antihypertensive drug therapy usually begins with an angiotensin-converting-enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB). Beta-blockers are avoided in metabolic syndrome because they tend to cause weight gain, increased triglyceride levels, and reduced HDL cholesterol levels (ADA, 2020c).

HYPERGLYCEMIA MEDICATIONS

Antidiabetic drug therapy may be considered for high-risk patients with metabolic syndrome or prediabetes who are unable to control their blood sugar with weight loss and exercise. Research shows that drugs such as metformin (Glucophage) or acarbose (Precose) can delay the onset of type 2 diabetes in people with prediabetes, but not nearly as effectively as lifestyle changes (ADA, 2020b).

DYSLIPIDEMIA MEDICATIONS

The dyslipidemias of metabolic syndrome have two characteristics: high blood levels of triglycerides and low blood levels of HDL cholesterol. Both of these problems can lead to atherosclerotic cardiovascular disease. Metabolic syndrome is often worsened by the presence of another dyslipidemia, hypercholesterolemia (high blood levels of LDL cholesterol), which by itself is a major contributor to the development of coronary (atherosclerotic) heart disease.

When a three- to six-month trial of therapeutic lifestyle changes does not sufficiently improve these heart-threatening features of a patient’s lipid profile, medications such as statins may be added.

OBESITY MEDICATIONS

Lifestyle changes and counseling are the first steps in treating patients with obesity and metabolic syndrome. When these steps do not lead to sufficient weight loss, antiobesity medications can be tried. Pharmacotherapy for the treatment of obesity may be combined with lifestyle changes and can result in loss of 5% to 10% of body weight. Each medication has risks and benefits and should be used under close medical supervision (ADA, 2020b).

PROTHROMBOTIC STATE THERAPY

Metabolic syndrome may be accompanied by a prothrombotic state, an increased tendency of the blood to form clots. Some clinicians prescribe daily low-dose aspirin as part of the therapy for metabolic syndrome for those patients who are at high risk or who have a history of heart disease or stroke (AHA, 2019).

Cognitive Behavioral Therapy

Changing one’s lifestyle requires guidance and determination. Losing weight and making other lifestyle changes, for example, takes encouragement, self-monitoring, and practical advice. Cognitive behavioral therapy (CBT) focuses on helping a person understand how their actions and behaviors, including how someone thinks about an action or behavior change, can have a direct impact to the body.

People who engage in CBT often are guided by a trained psychologist or professional health coach who helps them understand their readiness and motivation to make a change by:

  • Setting specific goals
  • Outlining strategies for positive self-talk and self-monitoring
  • Providing regular feedback and reinforcement
  • Understanding the positive impact of the behavior change
  • Outlining incentives and strategies for motivation

Research has shown that CBT can have a positive effect for patients with metabolic syndrome, including reducing waist circumference, fasting triglyceride levels, and hypertension. Participants have also reported an improved quality of life as a result of CBT (Zhang et al., 2016).

Surgery

Therapeutic lifestyle changes and medications work least often in severely obese patients. For these patients, bariatric surgery is an option. Surgery is considered if the patient has tried monitored dieting, exercise regimens, and medications.

It is important that persons who undergo bariatric surgery receive life-long lifestyle support and medical monitoring.

BARIATRIC SURGERY ACCREDITATION

The best hospitals for bariatric surgery are those that perform a significant number of the surgeries and that use a team (physician, psychologist, physical and occupational therapists, and dietitian) to treat patients. Patients making the decision to have surgery should be aware of quality and standards for centers that perform bariatric surgery.

The American College of Surgeons and the American Society for Metabolic and Bariatric Surgery combined their respective national bariatric surgery accreditation programs into a single, unified program to achieve one national accreditation standard for bariatric surgery centers: the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). MBSAQIP accreditation is important because it provides an objective and measurable way by which a center demonstrates that it offers high-quality care to patients in the setting of a multidisciplinary team approach (MBSAQIP, 2020).

TYPES OF BARIATRIC SURGERY

Bariatric surgery assists with weight loss in two ways: restriction of the amount of space in the stomach (limiting intake of food) and malabsorption by shortening or bypassing the small intestine (reducing absorption). Examples of bariatric surgery are listed below (Merck Manual, 2019):

  • Roux-en-Y gastric bypass (gastric bypass) is one of the most common bariatric surgical procedures, in which the surgeon creates a small pouch at the top of the stomach and attaches a narrow portion of the small intestine directly to the pouch, limiting the amount of food a person can eat as well as the amount of calories and nutrients absorbed.
  • Laparoscopic adjustable gastric banding (lap banding) is a procedure that involves placing a band with an inflatable balloon around the upper part of the stomach. The band restricts the size of the stomach as well as narrows the opening to the rest of the stomach. A port placed under the skin in the abdominal area is connected and used to inflate or deflate the band to adjust the size. This procedure restricts the amount of food intake, with an early feeling of fullness.
  • Sleeve gastrectomy (gastric sleeve) is a procedure involving the surgical removal of a section of the stomach. The remaining part of the stomach is formed into a smaller tube-like structure. The smaller stomach restricts the amount of food intake and decreases the production of ghrelin (a hormone that regulates the appetite).
  • Duodenal switch with biliopancreatic diversion begins with the removal of a large part of the stomach, leaving the connection to the first part of the small intestine (duodenum). The middle section of the small intestine is closed off and reattached to the end of the intestine, allowing the bile and pancreatic juices to flow normally. As a result, the patient has a smaller stomach, restricting food intake as well as limiting absorption because food bypasses most of the small intestine.

POSTSURGICAL CARE

Clinical guidelines have been developed for nutrition care after bariatric surgery, with an emphasis on detection and management of complications such as vitamin and mineral deficiencies, osteoporosis, and hypoglycemia. The goals of nutrition care after surgery are to provide adequate energy and nutrition to support lean body mass during extreme weight loss, support tissue healing, and encourage foods and liquids that maximize weight loss and promote weight maintenance while minimizing side effects of reflux, dumping syndrome, and early satiety (Franz & Evert, 2017).

After surgery, life-long lifestyle support and medical monitoring is necessary. Physical therapists and occupational therapists are an integral part of the rehabilitation team supporting patients in the postoperative and recovery period. Early mobilization, with assistance from occupational therapists who teach activities of daily living and physical therapists who create and monitor a regular exercise and strengthening program, is an important part of long-term recovery (ADA, 2020d).