News & Events: Member Articles
By Dr. Tom Welch, MD
Patient R.S. is a 54-year-old female who came in for a routine exam without any particular complaints. She doesn't smoke, eats the usual western diet and doesn't really do much in the way of exercise. She does have a family history of heart problems, however.
On physical exam, R.S.'s blood pressure was elevated at 135/88, she was 5'2" and 150 pounds with a waist circumference of 36 inches. Her cholesterol was elevated at 236; LDL or bad cholesterol was 152 and the HDL or good cholesterol was on the low side at 38. In addition, the triglycerides were elevated at 232. Her fasting blood sugar level was mildly elevated at 125 - not enough to be considered diabetic at this point but probably referred to as "pre-diabetic".
This represents the new syndrome of factors that cause coronary artery disease and hardening of the arteries. It's referred to as the metabolic syndrome. The metabolic syndrome itself is defined as the following:
- Abdominal obesity with a waist size greater than 40 inches in men and greater than 35 inches in women.
- Elevated triglycerides greater than 150.
- Reduced good cholesterol (HDL); less than 40 in men and less than 50 in women.
- Elevated blood pressure greater than 130/85.
- Elevated fasting sugar greater than 110 (pre-diabetes).
The consequence of the metabolic syndrome is that there is often progression to hardening of the arteries, especially in the cardiac area, as well as progression to full diabetes. The causes of the metabolic syndrome are many but the most important are:
- Insulin resistance
- Independent factors
Obesity itself is one of the main causes of insulin resistance and therefore in the eventual development of diabetes. Some of the independent factors would include advancing age, physical inactivity and the use of antidepressants, antihistamines and Cortisone. This is a very prevalent syndrome; up to 40-45% of those in their 60's have this condition, and if you look at the people around you, you'll see many who fit this category!
By modifying these factors, however, it is possible to improve the situation. For abdominal obesity, life style changes, including exercise and diet therapy, would be the treatment of choice. If the sugar is elevated and there is insulin resistance, again weight control and exercise are the easiest solutions, as well as modifying the diet and perhaps reducing carbohydrate intake. Whether one should add anti-diabetic drugs at this stage of the game in order to prevent the future development of diabetes is controversial and uncertain. Improving the cholesterol profile is usually accomplished not only with diet but also with medications called statins which lower the cholesterol very effectively. Blood pressure elevation generally requires treatment with antihypertensive drugs.
Unfortunately, all drugs can have side effects; therefore, a natural approach including exercise, weight loss and dietary modifications is the safest. However, it's often difficult to correct all of these abnormalities by natural means so medications often become necessary. Because the metabolic syndrome is also associated with some thickening of the blood, there are some who would propose that a small amount of aspirin be taken either on a daily basis or even 3 times per week. It would be generally recommended that this be only 81 mg which is a baby aspirin. This, however, is still controversial.
It's important that doctors screen for this metabolic syndrome as part of a routine clinical encounter because of the significant augmentation of the risk associated with hardening of the arteries and type-2 diabetes. Life style changes and treatment are necessary if the process is to be reversed and the problems with heart attack and stroke avoided. Fortunately, patient R.S, was able to reverse this process by losing weight, walking for 30 minutes 4 times a week and starting on a cholesterol-lowering medication.