Metabolic Syndrome. Shon Meek MD, PhD Mayo Clinic Florida Endocrinology

Transcription

1 Metabolic Syndrome Shon Meek MD, PhD Mayo Clinic Florida Endocrinology

2 Disclosure No conflict of interest No financial disclosure

3 Does This Patient Have Metabolic Syndrome? 1. Yes 2. No

4 Does This Patient Have Metabolic Syndrome? 1. Yes 2. No

5 Visceral Fat

6 National Cholesterol Education Program Adult Treatment Program III 3 of following: Abdominal Obesity men > 102 cm (40 in) women> 88 cm (35 in) Triglycerides >150 mg/dl, or drug Rx Low HDL or drug Rx < 40 mg/dl men < 50 mg/dl women Blood pressure >130/85 mmhg, or drug Rx Fasting plasma glucose >100 mg/dl or drug Rx

7 International Diabetes Association Increase waist circumference Men >94 cm, >90 cm Asians Women > 88 cm Plus any 2 of following: Triglycerides > 150 mg/dl, or drug Rx Low HDL or drug Rx < 40 mg/dl men < 50 mg/dl women Blood pressure > 130/85 mmhg, or drug Rx Fasting plasma glucose > 100 mg/dl

8 Metabolic Syndrome and Diabetes Mellitus Risk Diabetes Care :1898

9 Metabolic Syndrome and Cardiovascular Disease Risk Am J Med :812

10 Mortality after Myocardial Infarction with Pre-Diabetes 2841 patients in Denmark with MI complicated by heart failure A1C obtained at baseline Am Heart J :470

11 Metabolic Syndrome Association with Other Disorders Steatohepatitis/Cirrhosis Hepatocellular/Cholangiocarcinoma Chronic Kidney Disease Polycystic Ovarian Syndrome Sleep Disordered Breathing Gout

12 Prevalence of Metabolic Syndrome by Weight Arch Int Med 2003:427

13 Prevalence of Metabolic Syndrome by Age

14 Prevalence of Metabolic Syndrome by Ethnicity

15 Metabolic Syndrome Additional Risk Factors Family History Postmenopausal status Smoking Low income status High carbohydrate, sugar intake No alcohol Physical inactivity Poor cardiovascular fitness Atypical antipsychotic medicine

16 Case 1 70 year old woman feels well. Exam Lab Weight 100 kg Height 168 cm BMI 34.2 BP140/86 P 68 Waist circumference 90 cm Cholesterol 220 mg/dl HDL 45 mg/dl LDL 135 mg/dl Triglyceride 200 mg/dl Fasting Glucose 105 mg/dl TSH 15, free T4 normal

17 Case 1 1. Start a statin 2. Start a blood pressure medicine 3. Start a SGLT2 inhibitor 4. Start levothyroxine 5. Send to bariatric surgery

18 Metabolic Syndrome vs TSH Prospective study 1032 patients age developed metabolic syndrome, TSH increased OR 2.3 for metabolic syndrome Clin Endocrinol :911

19 Case 2 43 year old man presented with 60 lb weight gain PMH: Hypertension, Sleep Apnea, Hyperlipidemia Med: amlodipine, furosemide, KCl, omeprazole PE: BP 160/96, Weight 95 kg, Height 154 cm Waist circumference 106 cm Lab: glucose fasting124 mg/dl, A1C 6.4, Chol 240, Trig 250, HDL 35, LDL 155, TSH 1.5, Cr 1.5

20 Case 2 1. Add ACE inhibitor 2. Start metformin 3. Obtain aldosterone and renin 4. Obtain resting energy expenditure 5. Obtain urine free cortisol

21 Case 3 55 year old female Past History: sleep apnea, gestational diabetes Meds: omeprazole as needed Social: no tobacco or alcohol, IT specialist Family History: diabetes both parents PE BP 135/88, Weight 90 kg, Height 150 cm waist circumference 93 cm Lab: Fasting Glucose 120, A1C 6.4 Chol 267, HDL 45, Trig 160, LDL190 TSH 2.9

22 Case 3 1. Refer to nutritionist for weight loss 2. Start a statin 3. Start metformin 4. Advise her to sit less 5. Refer her for diabetes education

23 Metabolic Syndrome Hyperlipemia - Primary Prevention AHA/ACC Statin treatment age No diabetes Diabetes 10 year cardiovascular event risk >7.4%, moderate high dose 10 year cardiovascular event risk 5-7.5% consider moderate dose moderate dose 10 year cardiovascular event risk >7.4% high dose

24 Statin Daily Moderate Dose Primary Prevention 40 mg lovastatin 40 mg pravastatin 40 mg simvastatin 20 mg atorvastatin 10 mg rosuvastatin

25 Metabolic Syndrome Hypertension Unknown if ACE inhibitor or ARB beneficial in patients without diabetes, renal, or cardiovascular disease Consider ACE, ARB, calcium channel blockers since they lack adverse metabolic effects

26 Risk Factors for Hyperglycemia Family history Inactivity Diet Smoking Endogenous sex steroids testosterone associated in women testosterone inversely associated in men Irregular menses - diabetes associated with longer intermenstrual cycles Gestational Diabetes Breast feeding decreases risk

27 Risk Factors for Hyperglycemia Impaired fasting glucose/impaired glucose tolerance Obesity Fat distribution intra-abdominal fat Birth weight - U shaped distribution Ethnicity Indian, Asian, Hispanic, African American

28 Pre-Diabetes Impaired fasting glucose - IFG fasting glucose mg/dl (5.6-7 mmol/l) Impaired glucose tolerance - IGT glucose mg/dl (7.8-11mmol/L) 2 hours after 75 g glucose tolerance test and fasting glucose <126 mg/dl (7mmol/L) Diabetes Care (3):753

29 Impaired Fasting Glucose - IFG Impaired Glucose Tolerance - IGT 4 persons have IFG/IGT for every person with diabetes 25 % develop diabetes in 3-4 years >70% develop diabetes over long follow-up Diabetes Care : 61 Diabetes Care (3):753

30 Diabetes Prevention IGT Da Qing 530 Chinese with IGT Diet/exercise versus controls Average BMI 25.8 kg/m², average age had BMI < 25 kg/m² (39%) 322 BMI >25 kg/m² BMI target < 25 kg/m² lean: reduce simple sugars, increase vegetables obese: weight reduction, goal BMI <25 kg/m² Exercise daily 30 minutes mild 20 minutes moderate 10 minutes strenuous

31 Diabetes Prevention IGT Da Qing Mean rate of diabetes for each clinic at 6 years Relative decrease in diabetes similar when stratified for BMI Small changes in BMI among controls and intervention Diabetes Care (4):537

32 Da Qing Diabetes Prevention Trial 20 year incidence diabetes: 93% control, 80% intervention Intervention group had 3.6 fewer years of diabetes Lancet :1783

33 Diabetes Prevention IGT USA 3234 patient with IGT BMI 31 Age 55 Metformin 850 mg BID, vs lifestyle, vs placebo Lifestyle weight loss target>7%, walking 150 min/week

34 Diabetes Prevention IGT - USA lifestyle reduced diabetes by 58% metformin reduced diabetes by 31% NEJM (6):393

35 Metabolic Syndrome Association with Standing and Physical Activity Cross-sectional study 7075 patients, A men, B women Physical Activity guidelines >500 MET values/min/week Mayo Clin Proc 2015(11):1524

36 Mortality: Sitting, Fitness, Activity Mayo Clin Proc 2015:1537

37 Pre-Diabetes ADA Guidelines Weight loss counseling Exercise >150 min/week moderate activity Diet counseling trans fat minimized, emphasize omega 3, monounsaturated fat alcohol <1-2 drinks day monitor carbohydrate fiber 14g/1000 kcal, whole grains sugar substitutes acceptable Smoking cessation Diabetes Care :Supp 1

38 Pre-Diabetes ADA Guidelines Metformin if: Impaired fasting glucose Impaired glucose tolerance A1C Most effective with: age < 60 obese BMI 35 kg/m 2 gestational diabetes Metformin dose 850mg twice daily Monitor A1C twice yearly Diabetes Care :Supp 1

39 Metabolic Syndrome Summary Co-occurrence of metabolic risk factors for diabetes and cardiovascular disease Measurements include waist circumference, glucose, lipids and blood pressure Treatment of risk factors recommended to reduce cardiovascular disease Treatment with therapeutic lifestyle modification and/or metformin reduces risk of diabetes