Overview: Insulin Resistance and the Metabolic Syndrome

• The syndrome of insulin resistance (IR) and the metabolic syndrome were coined in the 1980s by Gerald Reaven, MD, an endocrinologist at Stanford Medical School in California. Other names used to describe the condition include syn-drome X, prediabetes, dysmetabolic syndrome, and cardio-metabolic syndrome.

• Metabolic syndrome is associated with a constellation of risk factors for atherosclerosis and type 2 diabetes mellitus (DM), including:

• Elevated fasting glucose

• Elevated triglycerides

• Reduced high-density lipoprotein (HDL) cholesterol

• Hypertension

• Central obesity

• When three or more of these risk factors are present, a per-son qualifies for metabolic syndrome. Following a joint scientific statement by several major organizations, a set of defined cutoff values were determined for all components, with the exception of waist circumference (Table 31-1).

• According to the National Cholesterol Education Program Adult Treatment Panel III, a waist circumference of more than 40 inches (101 cm) in men and more than 35 inches (89 cm) in women is one of the defining criteria for metabolic syndrome.

• These values apply to Western cultures only. For information on other ethnic groups, refer to the 2010 article by Lear et al that outlines existing and proposed waist circumference and waist-to-hip ratios. Additional abnormalities include endothelial dysfunction, a procoagulant state, and a proinflammatory state. Table 31-2 provides a list of abnormalities associated with IR.

Important points to consider

• Lifestyle intervention offers the greatest promise for prevention and management of metabolic syndrome.

• The Mediterranean and low glycemic index/load diets are considered the most effective nutritional regimens for metabolic syndrome and insulin resistance.

• Stress management and exercise are key therapeutic components.

Prevention Prescription

• Maintain a healthy body weight. People with an increase in visceral (truncal) fat are at higher risk.

• Exercise 30 minutes/day most days of the week for patients with appropriate weight and 60 minutes/day most days of the week for those needing to lose weight.

• Manage stress and increase the relaxation (parasympathetic) response.

• Follow a low-glycemic load, Mediterranean-type diet.

• Take a high-quality multivitamin that includes minerals and B-group vitamins.

Integrative therapeutics review

Laboratory Evaluation

• 2-Hour glucose and insulin tolerance test to measure glucose and insulin levels after fasting and 2 hours after a glucose load

• Serum lipid measurements (looking for increased triglyceride level, decrease in high-density lipoprotein cholesterol level, and normal or slightly increased low-density lipoprotein cholesterol level)

• Fasting glucose higher than 100 mg/dl.

• High-sensitivity C-reactive protein, a marker for inflammation, and gamma-glutamyltranspeptidase, a marker of liver toxicity

Lifestyle

• Encourage an exercise routine that consists of moderate intensity workouts and resistance training.

• Encourage goals to achieve appropriate weight.

• Encourage the patient to stop using nicotine-containing products.

Nutrition

• Low-carbohydrate, Mediterranean-type diet with a focus on low-glycemic index foods

• High-fiber diet including soluble fiber such as psyllium, oats, and barley

• Decreased consumption of red meat and fried foods

Mind-Body Therapy

• Encourage lifestyle choices to reduce stress and anxiety. Recommend a relaxation technique fitted. for the individual.

• Note: The preceding recommendations highly outweigh those that follow for the treatment of insulin resistance and metabolic syndrome.

Supplements

• High-quality multivitamin with minerals and B-group vitamins

• Omega-3 fatty acids (eicosatetraenoic acid and docosahexaenoic acid): 1 to 4 g per day to reduce inflammation, blood pressure, and triglyceride levels

• Chromium picolinate: 200 to 1000 mcg/day

• Vitamin C: 1000 to 2000 mg/day

• Vitamin D: 300 to 2000 units/day

• Alpha-lipoic acid: 100 to 300 mg/day

• Coenzyme Q10: 60 to 120 mg/day High-risk individuals may need to consider additional supplementation as outlined in the body of the text.

Botanicals

• American ginseng: 100 to 200 mg/day

• Milk thistle: 420 to 600 mg/day

Pharmaceuticals

• Metformin: 500 to 2500 mg each morning or twice daily

• Pioglitazone: 15 to 45 mg/day

Key Web Sources

• http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance

• http://www.myhealthywaist.org

• http://www.lipidsonline.org

• http://www.mayoclinic.com/health/calorie-calculator/NU00598

• http://www.fitday.com