metabolic syndrome,plus obesity

1. Weight Control
Strategies in Metabolic
Syndrome
Dr Haider Ali
Final Year Trainee
Cardiology Unit LRH

2. WHAT IS METABOLIC SNYNDROME

3. • A constellation of interrelated risk factors of metabolic origin which
promote the development of ASCVD
• Patients with the metabolic syndrome also are at increased risk for
developing type 2 diabetes mellitus
WHAT IS METABOLIC SNYNDROME

4. Metabolic
Syndrome
Central
Obesity
High BP
High
FBS
High TG
Low
HDL
protein

5. HOW TO DIAGNOSE METABOLIC
SNYNDROME

6. Elevated waist
circumference
>102 cm (>40
inches) in men
>88 cm (>35 inches)
in women
Elevated
triglycerides
>150 mg/dL (1.7
mmol/L)
On drug treatment
for elevated
triglycerides
Reduced HDL-C <40 mg/dL (1.03
mmol/L) in men
<50 mg/dL (1.3
mmol/L) in women
On drug treatment
for reduced HDL
Elevated blood
pressure
>130 mm Hg
systolic blood
pressure
>85 mm Hg
diastolic blood
pressure
On antihypertensive
drug treatment in a
patient with a history
of hypertension
Elevated fasting
glucose
>100 mg/dL
On drug treatment
for elevated
glucose

7. Underlying Risk Factors
• The predominant underlying risk factors for the syndrome appear to
be abdominal obesity and insulin resistance
• Other associated conditions can be physical inactivity, aging,and
hormonal imbalance
• According to one theory insulin resistance is the essential cause of the
metabolic syndrome

8. Underlying Risk Factors
• Although some non obese people are insulin
resistant e.g., a person with diabetic parents or
south Asian ethnicity
• Insulin-resistant individuals commonly have an
abnormal fat distribution that is characterized by
predominant upper body fat
• Excess upper body fat can accumulate either
intraperitoneally (visceral fat) or subcutaneously

9. Underlying Risk Factors
• A pattern of upper abdominal obesity correlates more strongly with
insulin resistance and the metabolic syndrome than does lower-body
obesity
• Upper-body obesity is related with an unusually high release of NEFA
from adipose tissue
• Ectopic lipid accumulation in muscle and liver seemingly predisposes
to insulin resistance and dyslipidemia

11. Underlying Risk Factors
• The adipose tissue of obesity exhibits abnormalities in the production
of several adipokines that may separately affect insulin resistance
and/or modify risk for ASCVD
• These includes
• Inflammatory cytokines
• Plasminogen activator inhibitor-1 and
• Other bioactive products

12. Underlying Risk Factors
• At the same time the potentially protective adipokine, adiponectin, is
reduced
• These responses appear to heighten the connection between obesity
and inflammation
• Insulin-resistant people manifest evidence of low-grade inflammation
even without an increase of total body fat

13. Therapeutic Goals and Recommendations for
Clinical Management of Metabolic Syndrome
↓weight by 7-10% during year
1 of therapy. Continue weight
loss with goal to ultimately
achieve desirable weight
(BMI <25 kg/m2)
Reduced intake of
saturated fat, trans
fat, cholesterol
For IFG, delay
progression to type 2
DM. For
diabetes,HbA1C
<7.0%
Regular moderate-
intensity physical activity;
at least 30 min of
continuous or intermittent
(and preferably >60 min) 5
d/wk, but preferably daily
Reduce BP to at least
achieve BP of
<140/90 mm Hg (or
<130/80 mm Hg if
diabetes present
Reduce thrombotic
and fibrinolytic risk
factors, initiate low
dose aspirin and or
clopidogrel

14. Therapeutic Goals and Recommendations for
Clinical Management of Metabolic Syndrome
Control of
Lipid Profile
Life style
modification and
Drugs (Statins,
Fibrates, Niacin etc)

15. Weight Control Strategies in Metabolic Syndrome
Obesity (Class 1) 30–34.9 kg/m2 Obesity (Class 2) 35–39.9 kg/m2 Extreme obesity (Class 3) 40 kg/m2

16. What are the Long-Term Deleterious
Health Impacts of Severe Obesity

17. • Shorter life expectancy
• Lower QOL with fewer economic and
social opportunities
• Cardiovascular disease
• Type 2 diabetes mellitus
• Stroke
• High blood pressure/hypertension
• Kidney failure
• Dyslipidemia
• Obstructive sleep apnea
• GERD
• Cancer
• Depression
• Osteoarthritis
• Joint pain

18. Is the patient ready and motivated to lose weight?
Evaluation of readiness should include the following:
• Reasons and motivation for weight loss,
• Previous attempts at weight loss,
• Support expected from family, friends and foes
• Understanding of risks and benefits,
• Attitudes toward physical activity,
• Time availability
• Potential barriers to the patient’s adoption of change

19. Goals of therapy
• Reduce weight and maintain it for the long term
• The prevention of further weight gain should be the minimum goal
• An initial weight loss of 10 % of body weight achieved over 6 months
is a recommended target
• The rate of weight loss should be 1 to 2 pounds per week

20. Goals of therapy
• Greater rates of weight loss do not achieve better long-term results
• After the first 6 months of weight loss therapy, the priority should be
weight maintenance achieved through combined changes in diet,
physical activity, and behavior
• Further weight loss can be considered after a period of weight
maintenance

21. Dietary Therapy
• Caloric intake should be reduced by 500 - 1,000 calories/day from the
current level this will produce the recommended weight loss of 1-2
pounds per week
• The diet should be, but not too low in calories(less than 800 kcal/day)
• In general, diets containing 1,000 to 1,200 kcal/day should be
selected for most women
• A diet between 1,200 and 1,600 kcal/day should be chosen for men
or women whose wt > 165 pounds or more, or who exercise regularly

22. Dietary Therapy
• If the patient can stick with the 1,600 kcal/day diet but does not lose
weight then switch 1,200 kcal/day diet
• If a patient on either diet is hungry, you may want to increase the
calories by 100 to 200 per day
• Although dietary fat is a rich source of calories, reducing dietary fat
without reducing calories will not produce weight loss

25. Physical Activity
• The current recommendation is for patients to perform regular
moderate-intensity physical activity for at least 30 minutes
continuously at least 5 days per week (ideally, 7 days per week)
• Achieving moderate intensity activity for 120 to 150 minutes a week
may reduce the risk of developing metabolic syndrome
• Among patients who already have metabolic syndrome, physical
activity correlates with a much lower (about 50%) risk of developing
coronary heart disease

26. Pharmacologic Therapy
Correction of LDL-C and HDL-C levels
• Management of elevated LDL-C includes consideration of all statins at
all indicated ranges.
• The choice of drug and dose should be individualized to the patient
and titrated to achieve guideline-recommended goals
• Management of reduced HDL-C remains controversial, but starts with
diet/exercise modifications and may include niacin

27. Pharmacologic Therapy
Correction of LDL-C and HDL-C levels
• Fibrate therapy may be considered for elevated triglyceride and low
HDL-C levels
• Niacin raises low HDL-C levels and reduces cardiovascular events but
may exacerbate hyperglycemia, especially in high doses (>1500
mg/day)

28. Pharmacologic Therapy pills pic
• Drugs approved for reducing weight
• Orlistat
• Indications:
• BMI>30
• >27 if concomitant risk factors exist
• When life style changes of 6 months did not promote weight loss

29. Behavior Therapy
Strategies, that provide tools for overcoming barriers to compliance with
dietary therapy and/or increased physical activity are helpful in achieving
weight loss and weight maintenance
Specific strategies include
• self-monitoring of both eating habits and physical activity,
• stress management,
• stimulus control,
• problem solving,
• contingency management,
• cognitive restructuring, and
• social support

30. Surgery
• Weight loss surgery should be reserved for patients in whom efforts
at medical therapy have failed and who are suffering from the
complications of extreme obesity
• GI surgery (gastric restriction [vertical or gastric bypass) is an
intervention weight loss option for motivated subjects with
acceptable operative risks
• An integrated program must be in place to provide guidance on diet,
physical activity, and behavioral and social support both prior to and
after the surgery

31. Surgery
• Surgery is an option for the following patients:
• BMIs >= 40
• >= 35 with comorbid conditions

32. Types of Surgeries
Gastric banding
Purely Restrictive Procedures Hybrid Procedure
Roux-en-Y gastric bypass. ➀ indicates alimentary;
➁, biliopancreatic; and ➂, common

33. Types of Surgeries
A,Biliopancreatic diversion. B, Biliopancreatic diversion
duodenal switch. ➀ indicates alimentary; ➁, biliopancreatic;
and ➂, common.

34. Impact of the Type of Weight Loss Surgery on
Cardiometabolic profile and its Side Effects

35. Early Complications
The severely obese patient is at risk of developing several general
complications. They include
• thromboembolism (1%)
• pulmonary or respiratory insufficiency (<1%)
• hemorrhage(1%)
• peritonitis (1%)
• wound infection (2%)

36. Late Complications
• Gastric obstruction and band “slippage,” occurs in restrictive surgeries
• Gastric obstruction associated with gastric bypass or sleeve gastrectomy is due to
stenosis of the gastric outlet secondary to scar tissue and may be treated with
endoscopic dilation
• Marginal ulceration between the stomach pouch and the small intestine after gastric
bypass surgery is relatively rare but when present is a frequent source of abdominal pain
and anemia
• Incisional hernias
• Device-related complications with the gastric band include malfunction of the band,
tubing, or reservoir component
• Hypoglycemia has been reported after gastric bypass and can typically be managed
successfully with diet modulations
• Steatorrhea, diarrhea, and bacterial overgrowth are more common with malabsorptive
procedures than gastric banding

37. Effects of Bariatric Surgery on Metabolic Syndrome
• Bariatric surgery provides the greatest sustainable weight loss
• An average weight loss of 50% of excess weight at 5 years may be
considered a success
• An average percent excess body weight loss of 61% is accompanied by
improvements in type 2 diabetes mellitus, systemic hypertension,
obstructive sleep apnea, and dyslipidemia
• Bariatric surgical procedures have also been shown to be effective in
reversing the prevalence of the metabolic syndrome or the insulin
resistance syndrome

38. Effects of Bariatric Surgery on Metabolic Syndrome
• Surgery results in significant improvements in circulating lipid
concentrations and dyslipidemia
• TG levels are consistently reduced both immediately and after long-
term follow-up. Greater impacts are seen after RYGB, with reductions
of up to 50% to 60%, in contrast to gastric procedures, in which
triglyceride levels are reduced by only 16% to 25%
• Most studies have also shown a significant increase in HDL cholesterol
(13% to 47%) after weight loss surgery

39. • Moderate diet-induced weight loss (10% body weight) decreases liver fat
content and improves liver biochemistries
• Weight loss induced by bariatric surgery can decrease steatosis,
inflammation, and fibrosis and may reverse cirrhosis
• A meta analysis showed, obstructive sleep apnea improvement by 80%
• Results are most often reported as improvements in symptoms associated
with sleep apnea such as snoring and daytime sleepiness or with
polysomnogram reports at 6 to 18 months after a given surgical procedure
Effects of Bariatric Surgery on Metabolic Syndrome

40. • Weight loss has beneficial impacts on functional and structural
cardiac status. Indeed, weight loss as little as 8 kg can be associated
with a significant decrease in left ventricular mass
• In bariatric surgery, improvements in left ventricular systolic function
occur mainly in severely obese individuals whose systolic function
was significantly depressed preoperatively
• Bariatric surgery also has been associated with clinically significant
improvement in left ventricular systolic function in patients with
severe cardiomyopathy such as patients awaiting heart
transplantation
Effects of Bariatric Surgery on Metabolic Syndrome

41. Metabolic
Syndrom
Diet
Exercise
Drugs
Surgery

43. Thank You