Managing and Treating Metabolic Syndrome

I'm at lunch with a group of friends. We're raving about the joys of retirement (no alarm clocks! no commutes! no bosses!) until, inevitably, the conversation turns to our assorted ailments: aching knees, bladders that seem to have a mind of their own, dental woes and new medications adding to the line-up in our daily pill boxes.

Luckily, we're a blessedly healthy group, considering our ages (58-82, with most of us somewhere in our early seventies), but there's still much to discuss. Then, as we contemplate the dessert menu, my plump and pretty friend, who swears she was born in a chocolate factory, says, "No dessert for me from now on. I've got metabolic syndrome."

The six of us – who peruse medical websites the way we devoured Danielle Steele novels in our twenties, who've been medical show junkies from Ben Casey's days straight through
"Grey's Anatomy" and "The Good Doctor" – look at her in puzzlement. "Metabolic syndrome? What's that?" I ask, trying to decide between gelato and a strawberry tart (hey, it's got fruit in it).

None of us know. Although scarcely talked about, it's ubiquitous. According to the National Heart, Lung and Blood Institute, about 1 in 3 Americans has metabolic syndrome. The number of people living with metabolic syndrome increases with age, affecting between 40 % and 50% of people above 50.

It's been referred to in many polysyllabic ways — insulin-resistance syndrome, hypertriglyceridemic waist, dysmetabolic syndrome, syndrome X, the deadly quartet — but it's most commonly called metabolic syndrome.

In 2005, the American Heart Association and National Heart, Lung and Blood Institute issued a definitive statement listing diagnostic criteria defining it as "a constellation of interrelated risk factors of metabolic origin that appear to directly promote the development of atherosclerotic cardiovascular disease. (ASCVD)." 

Patients with the syndrome are also at increased risk for developing type 2 diabetes mellitus. As reported by current standards, some of the cluster of metabolic factors involved includes:

• Abdominal obesity – a waist circumference of more than 35 inches for women and more than 40 inches for men
• Hypertension - high blood pressure of 130/80 mm Hg or higher
• Impaired fasting blood glucose – a level equal to or greater than 100 mg/dl
• High triglyceride levels of more than 150 mg/dl
• A low HDL (good) cholesterol level – less than 40 mg/dL for men and lower than 50 mg/dL for women

To be diagnosed with metabolic syndrome, an individual must have at least three of the above five factors. 

While the condition is often referred to as a discrete entity with a single cause, Ian J. Neeland MD, Associate Professor of Medicine at Case Western Reserve University School of Medicine and Director of Cardiovascular Prevention at The University Hospitals Harrington Heart and Vascular Institute in Cleveland, Ohio, says, "It is important to understand that metabolic syndrome is more than the sum of its parts. The constellation of symptoms makes the risk of cardiovascular disease and type 2 diabetes so universal."

Risk factors include:

• Older age
• Ethnicity: African Americans, Hispanics and South Asians are at higher risk
• Obesity, especially excess abdominal fat
• A body mass index (BMI) above 25
• Insulin resistance
• Family or personal history of type 2 diabetes or a personal history of gestational diabetes (diabetes when pregnant)
• Sleep apnea
• Sedentary lifestyle, poor dietary choices
• Family predisposition

Metabolic syndrome is a complex risk factor for cardiovascular heart disease and type 2 diabetes. People with the disorder are prone to developing inflammatory conditions and are more likely to develop blood clotting disorders.

Most people with metabolic syndrome have insulin resistance when cells cannot use insulin efficiently. If the body cannot produce enough insulin to compensate for this, the blood sugar level increases, causing pre-diabetes or type 2 diabetes. 

A 2021 journal study reported that as many as 68.1% of patients with type 2 diabetes have metabolic syndrome. For people with diabetes or pre-diabetes, maintaining good blood glucose control is critical in preventing the development of metabolic syndrome and lessening the severity of its effects if it is present.

Researchers at Johns Hopkins found that metabolic syndrome also doubles the risk of congestive heart failure when the heart's ability to pump blood and oxygen around the body is severely impaired.

According to Neeland, abdominal obesity, also called visceral adiposity, is the primary driver of the consequences of metabolic syndrome. Unlike subcutaneous fat, just below your skin, visceral fat is belly fat that lies deep within the abdominal walls and surrounds your stomach, liver, intestines and other organs. 

People with potbellies that are more "apple-shaped" than "pear-shaped" tend to have more visceral fat, which is the most dangerous to your health. Body fat can be assessed by measuring the waist, looking at the waist-to-hip ratio, and calculating the body mass index (BMI), which measures body fat based on height and weight. 

Even though it persists as one of the criteria, a high BMI may not reflect the actual metabolic and cardiovascular disease risk, says Neeland. MRIs are the most precise way of measuring body fat distribution, although this is only sometimes done in clinical practice.

Body fat distribution and the fat-to-muscle ratio are essential rather than the BMI alone. Ectopic fat – which collects in places where it doesn't belong – is a risk factor for metabolic syndrome, non-alcoholic fatty liver disease (NAFLD), insulin resistance and other related disorders. This "bad" fat can lead to tissue and organ damage, including fat around the pericardium. 

Sarcopenia – the loss of skeletal muscle mass and decreased muscle quality as we age – can also contribute to metabolic syndrome, particularly when paired with excess adipose tissue. This is known as sarcopenic obesity.

As with many things, preventing metabolic syndrome is a better strategy than treating it once it has occurred. As expected, prevention involves controlling risk factors such as glucose levels, blood pressure, high lipid levels and excess abdominal fat. 

Weight loss is usually helpful.

While no specific treatments for the syndrome exist, medications, diet and exercise can treat the individual components. This might mean drugs to normalize blood pressure, fibrates, extended-release niacin (nicotinic acid), or omega-three fatty acids to lower triglycerides and statins to lower LDL ("bad") cholesterol and raise HDL ("good" cholesterol levels.) 

If diabetes or pre-diabetes cannot be controlled with diet or exercise alone, oral hypoglycemic agents may be added. Metformin, in particular, is effective for people with metabolic syndrome.

A healthy diet should contain unsaturated fats and avoid trans or saturated fats. Heart-healthy fats such as olive oil and foods high in soluble fiber should be part of the diet. Refined carbohydrates and sugar-sweetened beverages should be avoided. 

After checking with your doctor, exercise plans should include aerobic and resistance training to strengthen muscles and prevent sarcopenic obesity. "In treating metabolic syndrome, we need to treat the underlying core symptoms. With lifestyle changes such as diet and exercise, cardiometabolic factors are very modifiable targets," says Neeland.

Barbra Williams Cosentino RN, LCSW, is a psychotherapist in Queens, N.Y., and a freelance writer whose essays and articles on health, parenting and mental health have appeared in the New York Times, Medscape, BabyCenter and many other national and online publications. Read More