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Chapter 5

Chapter 5. Insulin Resistance and the Metabolic Syndrome. Insulin resistance syndrome : term used to distinguish Syndrome X from other diagnoses that are also called Syndrome X

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Chapter 5

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  1. Chapter 5 Insulin Resistance and the Metabolic Syndrome

  2. Insulin resistance syndrome: term used to distinguish Syndrome X from other diagnoses that are also called Syndrome X Metabolic syndrome: a recent term used by the National Cholesterol Education Program with the Therapeutic Lifestyle Changes (TLC) diet Known by Many Names

  3. The Common Gene Insulin resistance is common—1 in 4 Americans have insulin resistance; incidence is as high as 60% in some populations Common cause of a variety of health conditions A genetic predisposition realized because of the environment (diet issues and inadequate physical activity)

  4. The Thrifty Gene Insulin resistance is believed to be the physiologic mechanism that allowed populations in the past to survive repeated bouts of famine (a survivor gene) Persons with insulin resistance tend to gain weight easily in times of “plenty” and have difficulty losing weight in times of “famine” (or periods of dieting) Historically high levels of physical activity (foraging for food) with low intake of kilocalories (low food availability) favored individuals who could maintain their weight without a high kilocalorie intake U.S. adolescents’ rate of metabolic syndrome increases proportionally to use of television, computer, and video games(Mark and Janssen, 2008)

  5. The Genetics and Physiology Insulin resistance is common in persons whose ancestors lived near the equator—Spanish/Latino, Native American, African, Asian, and Pacific Islanders—but the condition is found around the world The body cells “resist” the action of insulin; the usual consequence is an increased production of insulin to override the resistance at the cell level Hyperinsulinemia (excess insulin in the blood) is felt to play a large part in the health issues of insulin resistance

  6. A Diagnosis Based on Health Correlates/Conditions Definition of the American Association of Clinical Endocrinologists Central obesity: waist >40 inches for men and >35 inches for women; or waist-to-hip measurement >1.0 for men and >0.8 for women; overweight also considered with body mass index >25 Hypertension (HTN) (BP ≥140/90: insulin resistance is the cause of HTN in 50% to 80% of cases Dyslipidemia: triglycerides >150 with HDL cholesterol <40 mg/dL; <50 mg/dL for women Hyperinsulinemia causes an enzyme, lipoprotein lipase, to be impaired, resulting in elevated triglyceride levels (1) Prediabetes: FBG 110-126 mg/dL or 2-hr OGTT >140-199 mg/dL (once diabetes has developed it is argued that the term metabolic syndrome may not apply)

  7. 2005 International Diabetes Federation (IDF) Definition of Metabolic Syndrome Central obesity Dyslipidemia Hypertension Glucose intolerance (FBG >100 mg/dL)* *IDF uses more liberal criteria of FBG versus other standards using >110 mg/dL

  8. Other Risk Factors Found with the Metabolic Syndrome Hyperinsulinemia*: elevated C-peptide (indirect marker of excess insulin production) or ratio of FBG: insulin <7 Other risk factors: family hx of diabetes, HTN, CVD, high-risk ethnicity, sedentary lifestyle, and advancing age Polycystic ovary syndrome (PCOS): ovarian cysts with male-pattern hair growth or loss and irregular menstrual cycles caused by elevated androgen levels; a common cause of infertility Gout: high levels of uric acid in the blood; may collect as crystals in joints (e.g., feet and/or hands) *Hyperinsulinemia also found with some cancers

  9. Gout Painful condition related to high levels of uric acid crystals that build up in joints (commonly feet and hands) Associated with the metabolic syndrome and historically believed to have been helpful in maintaining adequate blood pressure when salt availability was low May be treated with low purine diet with low intake of meats, especially organ meats, and/or fish and legumes Also treated with avoidance of alcohol, slow weight loss, and good fluid intake Milk and yogurt intake associated with lower levels of uric acid crystals

  10. Recent Associations with the Metabolic Syndrome Nonalcoholic fatty liver Screening advised for adolescents with evidence of the metabolic syndrome (Fraser et al., 2007) Hypothyroidism Elevated CRP (C-reactive protein, a marker of inflammation) Elevated ferritin levels Acanthosis nigricans (“dirty neck syndrome” as often found in the neck area) and cutaneous papillomas (“skin tags”)

  11. Acanthosis Nigricans and Cutaneous Papillomas: “Skin Tags” Acanthosis nigricans causes dark patches to occur on the skin, often in the underarm area as shown, or on the neck; cutaneous papillomas or “skin tags” are also commonly found with insulin resistance and diabetes.

  12. Nerve disease has been linked to low HDL cholesterol levels (Pittenger et al., 2005) Chronic renal insufficiency linked with the metabolic syndrome (Zoccali et al., 2007) Depression linked with inflammation; appears due to altered enzyme function. The result is that the amino acid tryptophan, normally metabolized to serotonin, is metabolized into a different pathway (Maes et al., 2007) Ménière's disease linked with hyperinsulinemia (D’Avila and Lavinsky, 2005) Risk of insulin resistance may be set in utero with mother’s high kilocalorie intake or gestational diabetes (Boney et al., 2005; Armitage et al., 2005) FYI

  13. Reactive Hypoglycemia Controversial diagnosis Signs and symptoms related to counterregulatory hormones Glucagon leading to nausea Adrenalin or epinephrine leading to physical tremors or “shakes” Cortisol leading to warm, sweaty feeling Can cause feelings of weakness and decreased cognitive ability with mild hypoglycemia Reported to induce migraines Prevent symptoms with small, frequent meals (low-glycemic load) for control of hyperinsulinemia and stable blood glucose

  14. Prevention of the Metabolic Syndrome Emphasize regular physical activity Include high-fiber foods Avoid excess refined carbohydrates found in beverages and processed foods Emphasize unsaturated fats; avoid excess saturated fat and trans fats Maintain ideal body weight—work to prevent excess weight gain Include adequate sleep of about 8 hours to help manage weight and reduce cortisol levels(Chaput et al., 2007; Gonzalez-Ortiz and Martinez-Abundis, 2005)

  15. Magnesium deficiency linked with inflammation; increased intake controls inflammation (Rayssiguier and Mazur, 2005); food is preferable source to control blood pressure (Champagne, 2008) Altered copper levels noted among persons with diabetes (Aguilar et al., 2007) Potassium and magnesium (with calcium and avoidance of excess sodium) reduce blood pressure, as found with metabolic syndrome Vitamins and minerals with antioxidant role help maintain health of mitochondria One Role of High-Fiber Foods Related to Mineral Content

  16. Management of the Metabolic Syndrome Fat intake as high as 35% of daily kilocalories, with emphasis on monounsaturated fats Inclusion of omega-3 fatty acids from cold-water fish (reduce triglycerides, HTN, and hyperinsulinemia) Carbohydrate intake 45% to 50% of daily kilocalories, with emphasis on high-fiber sources (>20 g fiber) in several small meals (low–glycemic-load meals) Increased exercise and low kilocalorie intake to promote weight loss Decrease inflammation with omega-3 fats, high-magnesium foods, and increased antioxidant vitamins (vitamin C, beta carotene) Moderate alcohol intake for individuals who already drink

  17. Medication Concerns in Managing Insulin Resistance Clinicians advised to monitor clients at risk for insulin resistance who are using certain medications for treatment of schizophrenia Antipsychotics associated with weight gain should be avoided in persons with risk for insulin resistance

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