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Metabolic Syndrome

Metabolic syndrome = Syndrome X = Insulin Resistance Syndrome = Dyslipidemia Syndrome

Metabolic Syndrome Criteria (2005 ATP III Criteria)

- Central or abdominal obesity (measured by waist circumference)

  • Men > 40 in

  • Women >35 in

- Triglycerides >150 mg/dL

- HDL cholesterol

  • Men <40 mg/dL

  • Women < 50 =mg/dL

- Blood pressure ³ 130/85 mmHg

- Fasting glucose reading ³ 100 mg/dL

If you have 3 or more of these components, you have metabolic syndrome. Approximately 34% of Americans have metabolic syndrome. This parallels the estimated 39% of Americans that are obese. Patients with metabolic syndrome have an increased risk for all-cause mortality and cardiovascular disease. This increased risk is independent of obesity.

Consider data from the famous Framingham population:

1) Obese people without metabolic syndrome DID NOT have a significantly increased risk of diabetes or CVD*. Obese people with the metabolic syndrome had a 10-fold increased risk for diabetes and a twofold increased risk for CVD relative to normal-weight people without the metabolic syndrome.

2) Normal-weight people with metabolic syndrome had a 4x increased risk for diabetes and a 3x increased risk for CVD

This points out that not all of our patients with obesity have the same risk factors. Moreover, not all patients with metabolic syndrome are obese.

In a study of 211 moderately obese (BMI 30 to 35) men and women, insulin sensitivity varied sixfold, and those with the greatest degree of insulin resistance had the highest blood pressure, triglyceride concentrations, and fasting and two-hour post oral glucose blood sugar levels, and the lowest HDL concentrations, despite equal levels of obesity**.

Thus, not all obese individuals have the same risk for developing CVD or diabetes; risks differ as a function of insulin sensitivity, with insulin-resistant, obese individuals at highest risk.

Metabolic syndrome is a significant risk factor for CVD and all-cause mortality. CVD is the leading cause of death for women and men. Therefore, metabolic syndrome should be at the center of prevention in primary care. Metabolic syndrome is also closely tied to the following conditions:

  • Fatty liver with steatosis and fibrosis

  • Hepatocellular and intrahepatic cholangiocarcinoma

  • Chronic Kidney Disease (CKD)

  • Polycystic Ovarian Syndrome (PCOS)

  • Sleep-disordered breathing

  • Hyperuricemia and gout

  • Cognitive decline

How do we treat it?

The cornerstone of treatment of metabolic syndrome is lifestyle modification. This term, lifestyle modification), gets thrown around a lot in medicine and normally is used interchangeably with “diet and exercise.” Lifestyle modification is defined as changing long-term habits over months to years. Treatment of metabolic syndrome doesn’t need a diet. It needs a lifestyle change that leads to weight loss and decrease of insulin. When you lower the insulin in the body, you will see lower blood sugars, blood pressure and improved lipid profile. The key to all these changes is insulin.

While you might lose some weight on the Mediterranean diet, DASH diet or low-glycemic diet, they don’t tackle the main problem of insulin resistance. For this reason, at Fulcrum family health, we advocate for a low carbohydrate diet. A low carb diet can be done in various ways as long as it lowers the carbohydrate/sugar intake as to lower the insulin that is secreted in the body. does an amazing job explaining the ins and outs of LCHF, explaining the physiology and posting great recipes. This website is written by physicians and trustworthy.

There are three main macronutrients; carbohydrates, proteins and fats. When we eat carbohydrates, we receive 4 kcal/gm of energy and we need insulin to utilize this energy. Proteins also give us 4 kcal/gm of energy but require much less insulin. When we consume fats, we receive 9 kcal/gm of energy and insulin is not necessary for this. Therefore, it stands to reason that, if we lower carbohydrates and instead focus on good fat and protein, we will decrease our need for insulin and our resistance to insulin. This is the low carbohydrate, high fat (LCHF) diet.

If carbohydrates are restricted to less than 20 grams/day and our body began using ketones (breakdown product of fat, alternative source of fuel in the body) we would consider it a “ketogenic diet.” Finally, if we add in time-restricted feeding (intermittent fasting) and exercise, we can improve insulin resistance and reverse metabolic syndrome. Voila! We save millions of lives and millions of health care dollars on a truly preventable disease.

We model our treatment on the work of VirtaHealth. Virtahealth is a company out of Indiana that was created in 2014 based off the work of Drs. Stephen Phinney and Jeff Volek. They joined with Dr. Sarah Hallberg and started the first ever, longterm study of ketogenic diets and diabetes. They implemented a LCHF diet and monitored ketone levels to ensure patients were in ketosis. Teams of physicians and coaches help the patients. Early research shows 55% of Type II diabetics reversed their diabetes and 74% continued diet at 2 years in. The biggest criticism to the LCHF diet is that it is not sustainable. VirtaHealth is proving that LCHF is sustainable as they continue into their 5th year. See their research at

Thin on the outside, Fat on the inside (TOFI)

Some people think they aren’t at risk because they aren’t obese. This is not true for everyone. Patients can have significant insulin resistance even if they do not have an elevated BMI. They are sometimes called TOFI (thin on the outside, fat on the inside). While this may feel like a crude term, it simply references the increased amount of abdominal fat that can not always be seen by the naked eye. TOFI patients are at high risk since visceral fat increases the risk of metabolic syndrome. Their risk can be determined by body composition analysis (BCA) and lab testing. Both of which, can be done at our office.

Metabolic syndrome risk factors can be determined with a good history, physical and lab testing. With our lab prices, we can screen for metabolic syndrome for $35. We offer additional, advanced lipid biomarker testing with Cleveland heart lab when indicated at discounted prices.

*Body mass index, metabolic syndrome, and risk of type 2 diabetes or cardiovascular disease. AU Meigs JB, Wilson PW, Fox CS, Vasan RS, Nathan DM, Sullivan LM, D'Agostino RB SO. J Clin Endocrinol Metab. 2006;91(8):2906.

**Heterogeneity in the prevalence of risk factors for cardiovascular disease and type 2 diabetes mellitus in obese individuals: effect of differences in insulin sensitivity. AU McLaughlin T, Abbasi F, Lamendola C, Reaven G SO. Arch Intern Med. 2007;167(7):642.

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