Some of your patients are trapped in the Metabolic Syndrome, but you can rescue them.
You are likely familiar with a certain type of patient: He or she is overweight or obese, with an apple-shaped figure caused by excess adipose tissue about the midsection.
Blood testing will generally reveal a poor lipid profile and high fasting blood sugar. And these symptoms will present in combination with hyper- tension marked by high blood pressure and psychological stress.
While researchers had been noticing these problems often occurring in concert, it wasn’t until a paper was presented to a European diabetes conference in 1965 that a name was given to the condition defined as a grouping of these risk factors: “Syndrome X.”
In 1989 it was renamed “The Deadly Quartet,” in 1992 called “The Insulin Resistance Syndrome,” and near the end of the 20th century Gerald Reaven described it as “Metabolic Syndrome (often abbreviated as “MetSyn” or “MetS”) in his landmark paper “Role of insulin resistance in human disease.”1
To date, researchers aren’t entirely sure about the etiology of this disorder, but it is alarmingly common. Some one-third of all US adults are affected, with some variation showing increased risk for older adults and certain ethnic groups.2 Because excess weight is a frequent culprit for back and joint pain, chances are you are already seeing a considerable number of these patients.
The bad news is that obesity and hyperglycemia are on the increase. The good news is that the ability to treat and potentially reverse MetS lies well within your power, and in many ways you are ideally suited to make a positive intervention in these patients’ lives.
A constellation of concerns
One doctor who sees this condition frequently is Julie Beck, DC, CSCS. “In conventional medicine, via observation, using the term syndrome is a diagnosis of a group of symptoms. MetS is the collection of high blood pressure, insulin resistance, and dyslipidemia.” She notes that once you become familiar with MetS, you can spot it visually or by symptoms, and you can run labs to confirm it (if allowed by your state’s scope of practice).
Another expert in this area is John Troup, PhD. He notes that MetS is defined by five criteria
developed through clinical research, consisting of the following:”
- Waist circumference more than 40 inches in men, 35 inches in women.
- Triglycerides above 150 mg/dL.
- High blood pressure more than 130/85 mmHg.
- Fasting plasma glucose equal to or greater than 110 mg/dL.
- High density lipoprotein (HDL) less than 40 mg/dL in men and less than 50 mg/dL in women, together with elevated low-density lipoprotein (LDL).3
According to Adam Killpartrick, DC, who also works with this type of patient, “These areas get out of balance. You have elevated cholesterol and blood sugar, and then belly fat and obesity, which raise the risk for heart disease and diabetes.” As a functional medicine practitioner, Killpartrick is less interested in diagnosis and more involved in addressing the root imbalances of MetS.
“Note that if you have only one of those symptoms, like elevated blood sugar, you don’t have MetS. If you do have one of the symptoms, though, your tendency to have the others increases.” If you have elevated cholesterol, he says, it can result in high blood pressure: “They’re intimately connected, and the web they weave raises risk.”
James Wilson, DC, ND, PhD, is an expert in treating MetS and related disorders. He views the syndrome as the product of a combination of excesses: “It’s not a disease as much as a condition that leads to disease. Excess stress, excess cortisol, excess insulin. Excess sedentary lifestyle. It’s really stress-driven, and of course stress elevates cortisol.”
If he suspects MetS is in the picture, he’ll proceed to testing: “We check blood pressure, and albumen in urine. With a dipstick you can perform the test right in your office,” Wilson says. He notes that fasting and post-prandial insulin testing can be done easily with a finger stick.
“Measuring fasting insulin just before eating breakfast and then again at 30, 60, 90, 120, and 150 minutes post-prandial is a much more accurate way to determine insulin resistance than only measuring fasting insulin. If any of the post-prandial readings are more than five times fasting insulin level, it shows insulin resistance.”
Wilson finds that cortisol levels are best checked with a saliva test. “When you look at it, cortisol is the driver behind a lot of the symptoms of the Metabolic Syndrome. Increased stress causes increased cortisol. Cortisol causes a rise in glucose by stimulating conversion of glycogen, fatty acids, peptides, and proteins to glucose to meet the increased need for cellular ATP during times of stress.”
All of the experts consulted agreed that once you have some experience in treating this patient base, you become adept at identifying those patients at risk. Spotting the problem is fairly straightforward, but are some patients more likely than others to manifest MetS?
According to Beck, the standard American lifestyle and diet are key culprits. “Drinking coffee to wake up, drinking wine or taking Ambien to sleep—it’s a lifestyle-associated illness, but it’s not a genetic time bomb,” she says.
On the other hand, MetS may be a result of epigenetic expression, the interface between genetics, physiology, and lifestyle. That’s why one person might succumb to the syndrome and not another, even if both follow a similar diet. “It’s not the genetics doing something wrong,” Beck says. “It’s the expression of genes via lifestyle behaviors.”
Wilson starts by observing the patient: “Does his stomach precede him? A pot belly, a personal spare tire? Does he have fatigue, brain fog, or an inability to focus? It’s not unlike adrenal fatigue, as many of the symptoms are the same.”
Other symptoms Wilson looks for are: sleepiness after a large meal, unspecified depression, erectile dysfunction, and intestinal bloating. Each of these factor into the etiology of MetS. And if the patient just looks rundown, out of shape, and overweight, you have good reasons to check for further evidence of the syndrome.
In Killpartrick’s experience, there are few patients he sees who are not potentially at risk, because poor quality food, a sedentary lifestyle, and a lack of daily attention to wellness are fairly ubiquitous to the American lifestyle. “Lately, I’m seeing more and more kids—children—having symptoms that used to be seen in adults exclusively. I think you’re going to be increasingly seeing MetS in younger people,” he says.
Another doctor who sees this syndrome frequently is Todd Singleton, DC: “Over half of the patients I see are MetS—they’re pre-diabetic. So, one of the first ways to diagnose it is to perform a visual inspection. Then check for blood pressure that’s greater than 140 over 90. These are just physical things you can get in the office.”
If Singleton can order or obtain a blood test, he’ll look for elevated triglycerides of 150 mg/dL or more, reduced HDL, and fasting glucose greater than 100 mg/dL. Because inflammation is so strongly associated with MetS, patients will generally have higher-than-normal
C-reactive protein.4 Not all patients are equally at risk, however. Troup notes that African Americans and Latinos tend to be at highest risk, and women are at a higher risk than men. “Anybody with one of the five criteria is at higher risk of the syndrome,” he says. If a patient present with a BMI of 30 or higher, then they’re definitely candidates who should be screened for the other four criteria. Taking a family history is strongly advised.
“They should be checked for blood pressure, blood glucose, and a cholesterol panel,” Troup says, adding the caveat that it differs by state whether DCs are in their scope of practice when looking to order certain tests.
Business as usual?
Given that addressing MetS in your practice involves a lot more than giving an adjustment, you may be tempted to overlook the symptoms. Again, it will vary by state, but some third-party payers allow DCs to bill for nutritional counseling, and some may allow you to obtain non-RD licensure. Otherwise, you might offer this on a cash basis, or bring an RD on board to assist you.
Consider the possible outcomes for your patients if their MetS is left untreated, given that each of the factors is a strong health risk individually. Combined, these risks become potentially devastating. Troup observes that MetS can lead to cardiovascular disease, atherosclerosis, hypertension, and diabetes, which are comorbidities. MetS is thus a precursor to these chronic disease states. “It can lead to very serious events,” he says, “and increased mortality has already been established.”
When Singleton’s patients are showing signs of MetS and are coming in specifically because they’re sick and want to lose weight, he puts them on a diet and exercise program. “I warn them that [otherwise] they’ll wind up in an assisted living facility—which is expensive.”
The direct risks patients face are considerable, but the indirect risks can be equally if not more alarming. For example, “MetS is connected in the literature to Alzheimer’s and dementia, and it causes your blood sugar to be dysregulated. When blood sugar is spiking all the time, it causes dAGEs— an acronym for dietary advanced glycation end products—which are like bruising as they are highly radical.”
This clarifies the picture. Oxidative stress and free radicals are damaging to all kinds of tissues, which is why diabetes and neurological problems are associated with dAGEs, and with an aging population this is a daunting proposition. MetS often progresses to non- insulin-dependent diabetes. “Now the patient needs external hormonal supplementation, while suffering from circulation problems, peripheral neuropathies, and vascular destruction,” Beck says. These are results of excess dAGEs, which finally lead to tissue necrosis.
And it gets worse: When you see raised insulin you tend to see excess cortisol. “This can be damaging to neural tissue and a lot of tissue in the body, Killpartrick says. He warns that if you don’t address these issues, if you let insulin get out of control, you get diabetes and then you get morbidity. “Increased estrogen and the lack of ability to deplete it from the system is a risk for cancer.”
There is a general progression these patients will experience, which Wilson describes as follows: “They go from insulin resistance to mild dyslipidemia, to hypertension, to diabetes, and finally to heart disease or cancer.” The MetS patient may find it difficult to lose weight because he or she will have increased estrogen and lowered testosterone, and dysglycemia, all of which depress thyroid function, slowing metabolism further.
Turning things around
MetS doesn’t occur overnight. The components of the syndrome reinforce one another so that patients may well succumb to a downward spiral in health, but the onset can be insidious and take years to manifest. In a similar manner, bringing the patient’s metabolic systems back into balance will take time and commitment. The good news is that plenty of DCs have established that you can indeed lead a patient back to recovery.
“MetS is a metabolism problem,” Beck says. “If the hormonal system is like an orchestra working in harmony, then if one player is off, others will be off, too.” She notes that if there’s an imbalance, there will be an inflammation problem. And when a person is nutrient deficient, the mitochondrial membrane can get “leaky” and struggle to contain glucose.
There may be more than one approach to resolving MetS, but the general solution will be something like this:
- Reduce inflammation
- Reduce weight
- Restore lipid balance
- Address hormonal imbalance
- Increase physical activity
Only addressing one component is akin to treating a symptom. What you’re looking for is a multipronged approach that gets the above targets working toward supporting one another and creating a virtuous cycle.
“A lot of approaches are natural ones,” Killpartrick says. “Like, if you have elevated cholesterol, instead of taking cholesterol medication try red yeast rice. You can supplement with magnesium.” But, he says, that’s not dealing with the underlying issue. First, you want to identify the primary cause that led to the original imbalance.
For example: Take cholesterol—ask why it’s being elevated. Is it hormonal? Is it due to cellular damage? Stress can even cause cholesterol to elevate. Blood pressure is another factor. Why is it so high? Is it due to a vertebral misalignment? Is it caused by obesity and stress on the blood vessels?
“The underlying cause is the key,” Killpartrick says. “And if you don’t address that, and are just using natural medicine in the place of regular medicine, any positive gains will be short-lived.”
In Wilson’s approach, he first looks to minimize stress. There are relaxation techniques he uses to help patients get into parasympathetic balance. “We teach them to breathe slowly, alternating breaths through one nostril at a time.” He recommends yoga as well.
“I have them take a sheet of paper, and write good for me on one side, and bad for me on the other,” Wilson says. He has patients list items on each side, then prioritize them into the top three, and finally isolate the most important. Then they make a written plan for maximizing the positive element and minimizing the negative one.
“After three weeks, they move to the next item. After implementing changes needed for the top three on each side, they usually start feeling better,” he says.
For his part, Troup finds DCs to be uniquely positioned and qualified to take care of MetS patients with nutrition support, therapy, and counseling. “A 12-week program with diet and activity can help transport the patient back to a health point.”
Inflammation has two phases: The initiation phase (after a long history of following a bad diet the patient is hyper- inflamed), which increases risk. The second phase is called the resolution phase, which allows tissues to heal.5 When these phases are in balance, a person is able to experience cellular health. But if the resolution pathway is overwhelmed, inflammation becomes chronic.
“There are pathway modulators in medical foods that help reduce inflammation. Those, in combination with diet, constitute a nutrition therapy that’s beneficial to patient outcomes,” Troup says. Troup recommends moving patients to a 40-30-30 diet plan, which is 40-percent carbohydrates, 30-percent protein, and 30-percent fat (commonly known as the Zone diet).
In a similar vein, Wilson suggests patients should follow a Mediterranean diet, which is low in sodium, high in vegetables, and favors low-glycemic-index foods. This is typical of the kind of low-calorie, high-nutrient diet MetS patients need.
“The biggest thing,” Wilson says, “is to cut out white foods—white flour, white sugar, and they need to look at labels. They may not realize how much sugar their food contains. Barley malt, fructose, dextrose, pasteurized honey—any sweet foods that immediately go to fat. And they want to avoid caffeine as it stimulates cortisol.”
As most people with MetS are magnesium deficient, Wilson finds they need about 500 mg of magnesium citrate. He also recommends supplemental trivalent chromium, manganese, vanadium, and zinc gluconate. In addition, Wilson finds these work well with several herbs such as bilberry (Vaccinium myrtillus), bitter melon (Momordica charantia), cinnamon, fenugreek, Indian kino tree bark (Pterocarpus marsupium), gymnema sylvestre, and jambolan (Syzygium cumini).
“It’s the combination of the nutrients and herbs that makes a difference. Almost all of these reduce and prevent hyperglycemia, and mainly work to normalize blood sugar,” Wilson says.Singleton’s clinic has health and dietary coaches who assist with lifestyle counseling. “Within three to six months of educating patients and creating new dietary habits, we can reverse the majority of the symptoms of MetS. Their blood pressure comes down, their weight comes down, and their glucose improves. That’s our window of opportunity.”
In Singleton’s experience, when patients start to see positive changes, they’re more inclined to stay on the path to recovery. “After six months of the program, then they’re autonomous. But if they regress to their old habits, there’s not much we can do.”
Expectations and outcomes
Killpartrick stresses that a MetS program will normally be tailored to each patient. And in the spirit of functional medicine, he points out that if you and your patient aren’t obtaining expected results, you should investigate further and make adjustments.
“One of the first things that will be observed in the initial 12-week period,” Troup says, “is a major reduction in weight.” Concomitantly, expect a decrease in BMI and waist circumference. “Triglycerides and lipids will be reduced and blood pressure will be controlled again.” He also cites outcome studies that demonstrate reduction of three of the five MetS components in three- to four-month timeframes.
Beck adds that, “Physiology-wise, looking at recycling cells, we’re talking maybe six to eight weeks. But patients should start feeling better in about two weeks.”
It would be best if your MetS patients never developed the condition in the first place. Those who would like to avoid it entirely (which should be everyone who doesn’t have it) should do the same things MetS patients in a recovery program do: reduce weight and maintain it at a healthy baseline, adopt a healthy diet, avoid stress and causes of inflammation, and engage in regular physical activity.
Trends in the U.S. population suggest that Metabolic Syndrome will be with us for a long time to come. You are exceedingly well-positioned to assist those afflicted onto the road to recovery. As our experts in this article will tell you, the patients you help will become your staunchest supporters and a reliable source of referrals.