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. Treatment begins with lifestyle modifications, and pharmacotherapy may be introduced when those changes are insufficient.
Treatment goals for metabolic syndrome are:
- Lowering the risk of heart disease
- Preventing the development of type 2 diabetes
(NHLBI, 2022b)
Treating metabolic syndrome requires a disciplinary team, including:
- Primary care practitioners, who screen and diagnose metabolic syndrome, treat different components of the syndrome, and make referrals to other professionals
- Endocrinologists, whose goal is to restore hormonal balance and restore metabolism
- Cardiologists, who play an advisory role or a coordinating role as specialists in the overall management of patients with increased cardiometabolic risks
- Nurses, who develop management strategies including education, planning and recommendations for physical exercise, dietary education and planning, medication management, and psychosocial support
- Occupational therapists, who provide knowledge and expertise in environmental supports, barriers, and modifications to support habit formation and change
- Physical therapists, who provide exercise training to improve factors underlying metabolic syndrome
- Dietitians and nutritionists, who counsel patients on nutrition issues and healthy eating habits
(Dobrowolski et al., 2022; Epley et al., 2021; Noghabi, 2021; Physiopedia, 2023)
Therapeutic Lifestyle Changes
Heart-healthy lifestyle changes, including smoking cessation, are the first line of treatment for metabolic syndrome. Weight loss and increased physical activity are aimed at reversing the direct causes of the condition, and nutrition management is focused on a diet of heart-healthy foods (NHLBI, 2022b).
PHYSICAL ACTIVITY AND EXERCISE
All aspects of metabolic syndrome benefit from increased physical activity. Physical exercise helps with losing weight and 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 (2021) recommends the following physical activity for adults for overall cardiovascular health:
- Getting at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity (or a combination of both), preferably spread through the week
- Moving more and sitting less throughout the day to offset the serious health risks of being sedentary
- Adding intensity, since moderate to vigorous aerobic exercise is best
- Adding muscle by including moderate-to-high-intensity muscle-strengthening activity
Patients may also benefit from partnering with others in activities such as swimming, biking, or walking groups to motivate and support one another to reach their goals.
DIETARY MODIFICATIONS
Exercise alone rarely leads to significant weight loss. A heart-healthy diet is usually also necessary, and nutrition planning is the second critical component of the initial treatment of metabolic syndrome.
FOODS TO AVOID
When recommending dietary changes, it is beneficial at the start to help the patient focus on foods to be phased out, including:
- Refined carbs:
- White flour
- Sugary snacks
- Beverages containing sugar
- Saturated fats (found in):
- Red meat
- Whole-milk dairy products
- Many baked goods
- Trans fats (found in):
- Fried foods
- Margarine
- Baked goods
- Snack foods
- Refrigerated doughs
- Coffee creamers
- Cured meats (which are high in sodium):
- Hot dogs
- Bacon
- Deli meats
- Sausages
- Processed foods, such as packaged foods and fast foods, which contain refined carbs, added sugar, high sodium content, hydrogenated oils, corn syrup, and saturated fats
HEART-HEALTHY FOODS
Once “unhealthy” foods are removed from the diet, meals can be built around heart-healthy alternatives, particularly whole, plant-based foods. A heart-healthy, balanced diet includes:
- Vegetables rich in complex carbohydrates that can help prevent blood sugar spikes, help in weight loss, and lower LDL cholesterol:
- Nonstarchy vegetables (e.g., salad greens, broccoli, peppers)
- Starchy vegetables that are higher in fiber (e.g., beans, lentils, chickpeas)
- Whole grains that reduce postprandial blood glucose and peripheral insulin resistance (e.g., barley; bulgur [cracked wheat]; farro; millet; quinoa; black, brown, and red rice; oats)
- Omega-3 fatty acids to help increase HDL, lower LDL cholesterol, and reduce triglycerides (e.g., nuts, seeds, and fatty fish such as salmon, mackerel, sardines, albacore tuna, anchovies)
(Cleveland Clinic, 2021)
Diet plans recommended for metabolic syndrome include:
- Mediterranean diet
- Low-carbohydrate diets
- Vegetarian diet
- Intermittent fasting
- DASH diet
(Cleveland Clinic, 2021)
SMOKING CESSATION
Smoking is a lifestyle factor that can increase the risk for metabolic syndrome since it exerts negative effects on abdominal obesity, blood pressure, blood glucose concentrations, and blood lipid profiles. Smoking may also negatively affect other factors that influence glucose and lipid metabolism. Metabolic syndrome risk may initially increase after smoking cessation possibly due to weight gain (Cleveland Clinic, 2023).
CASE
(Continued)
Treatment Planning
Today Sharon returns for a follow-up appointment. At her previous appointment, Sharon’s blood pressure was 187/93 mmHg. Today nurse Maria again obtains an elevated blood pressure reading of 189/94 mmHg.
Sharon’s blood test results are also in and show elevated levels of blood triglycerides (160 mg/dL), HDL cholesterol (43 mg/dL), total cholesterol (220 mg/dL), LDL cholesterol (148 mg/dL), and fasting blood glucose (142 mg/dL). Reviewing the laboratory results and the physical examination findings, the physician confirms the suspected diagnosis of metabolic syndrome.
Next, the physician and nurse discuss possible therapeutic recommendations with Sharon, including both lifestyle changes and medications to control her blood pressure. A treatment plan is outlined, with prescriptions for an antihypertensive, a cholesterol lowering medication. An appointment is made for a repeat fasting blood glucose test.
Maria then discusses dietary and physical activity measures to help Sharon lose weight and improve her diet. Maria describes the benefits of the Mediterranean diet for 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. Sharon 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. Maria also makes an appointment for Sharon to see a physical therapist to develop an exercise plan.
(continues)Pharmacologic Management
When lifestyle changes in diet and exercise are insufficient, medications may be introduced to manage the condition’s various components of hypertension, hyperglycemia, dyslipidemia, obesity, and prothrombotic state. Drugs prescribed for metabolic syndrome are listed in the table below.
| Drug class | Examples |
|---|---|
| (NHLBI, 2022b; Mayo Clinic, 2022a; Meigs, 2023) | |
| Antihypertensives |
|
| Dyslipidemia medications |
|
| Hyperglycemia medications |
|
| Anti-obesity medications |
|
| Prothrombin state medication |
|
Cognitive Behavioral Therapy
Changing one’s lifestyle requires guidance and determination. Losing weight and making other lifestyle changes is challenging. The therapeutic process often involves working with a practitioner, such as an occupational therapist, to identify and alter recurring negative patterns of thought and behavior.
Cognitive behavioral therapy (CBT) trains individuals to recognize automatic thoughts, assess them objectively, and develop alternative, more balanced, and rational thoughts. CBT concentrates on modifying problematic behaviors through:
- Setting mutually agreed-upon goals
- Eliminating maladaptive behaviors that prevent goal achievement
- Replacing maladaptive behaviors with constructive behaviors that meet the agreed-upon goals
Research has shown that CBT focused on changes in lifestyle are effective in the reduction of metabolic syndrome and cardiovascular risk factors (Nash, 2022).
CASE
(Continued)
Supporting Lifestyle Changes
Sharon returns to the clinic for repeat fasting blood sugar, which shows an elevated reading of 156 mg/dL, and meets with the nurse, Maria. Her blood pressure reading today was 134/82 mmHg, showing improvement with the antihypertensive medication. Maria discusses Sharon’s latest blood glucose reading with the physician, who provides Sharon with a prescription for Metformin. Maria discusses the side effects of this medication with Sharon.
Maria then asks Sharon how well she’s been managing her dietary and exercise regimen. Sharon states that she has not yet had a chance to try out the Mediterranean diet. She asks Maria to remind her about what strategies she should try at home, since she is “getting all confused about these new foods.” Maria asks Sharon if she would like to set up an appointment with a dietitian to help her develop a more specific dietary plan, and Sharon gives a sigh of relief, saying that she has always had “difficulty losing weight and exercising” on her own.
Maria asks Sharon about her upcoming appointment with the physical therapist to develop an exercise plan. Sharon suddenly bursts out in tears and reveals that she feels overwhelmed. She is afraid that she’ll never lose weight or get in shape and that she’s “going to get diabetes just like my mom” or “heart disease just like my dad.”
Assessing that Sharon may benefit from additional therapy to make such big lifestyle changes, Maria asks if she would be interested in meeting with an occupational therapist who can help her learn how to tackle the big challenges she is facing. Again, Sharon gives a sigh of relief and jokes that she “can use all the help I can get!”
Surgery
Bariatric surgery may be recommended when diet and exercise have failed to effectively reduce severe obesity and when the patient has serious health problems because of excessive weight. Some surgical procedures limit how much a person can eat, while others work by reducing the body’s ability to absorb nutrients. Some procedures do both. It is important that patients who undergo bariatric surgery receive life-long lifestyle support and medical monitoring.
TYPES OF BARIATRIC SURGERY
- Roux-en-Y gastric bypass (gastric bypass) is one of the most common bariatric surgical procedures. The surgeon creates a small pouch the size of a walnut at the top of the stomach and attaches a narrow portion of the small intestine directly to the pouch. Since the pouch can hold only about 1 ounce of food, this limits the amount of food a person can eat as well as the 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 about 80% 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.
(Mayo Clinic, 2022b)
POSTSURGICAL MANAGEMENT
Patients must be educated preoperatively so that they understand they will require lifelong follow-up by a multidisciplinary team to monitor body weight and compliance with the post-surgical regimen necessary for long-term success and micronutrient deficiency detection.
Post discharge, patient management includes assessment of hydration and micronutrient status, as well as assessment of medical comorbid conditions, such as hypertension, diabetes, and sleep apnea. Additional comorbid illness that may develop long-term include:
- Dumping syndrome
- Marginal or gastrojejunal ulcers
- Cholelithiasis
- Nephrolithiasis
- Depression
- Post sleeve gastrectomy stenosis
(Hamad, 2023)