What is metabolic syndrome, and how can it best be handled?
Metabolic Syndrome is not a disease in the usual sense but a cluster of conditions that occur together, increasing the risk of heart disease, cerebral-vascular accident and type 2 diabetes. These conditions include high blood pressure, high blood sugar, excess abdominal adipose tissue, and abnormal cholesterol or triglyceride levels.
Metabolic Syndrome has become increasingly common in the United States, and it is a major public health problem. It is estimated that one-third of U.S. adults are diagnosed with it. Aggressive life-style changes can delay or even prevent the onset of serious health problems.
The development of metabolic syndrome is related to three issues:
Weight: Approximately 22% of people who are overweight and 60% of those with obesity have metabolic syndrome. However, not everyone who is overweight or obese has metabolic syndrome, and those with normal weight can develop metabolic syndrome.
Lack of exercise: Inactivity has been linked to a variety of diseases, including heart disease, cancer, and diabetes. Furthermore, inactivity contributes to weight gain.
Genetics: Research suggests that a genetic link may predispose the development of metabolic syndrome among family members.
DIAGNOSIS OF METABOLIC SYNDROME
A diagnosis of metabolic syndrome is made if at least three of these conditions are present, according to guidelines from the Heart, Lung, and Blood Institute and the American Heart Association:
- High Blood Pressure: BP >130/85 mmHg or diagnosed with hypertension.
- High fasting glucose: Blood glucose >100 mg/
- Hypertriglyceridemia: Blood triglycerides>150 ml/dL (or on medication)
- Low high-density lipoprotein cholesterol: Blood HDL cholesterol< 40mg/dL in men, <50 mg/dL in women.
Additional risk factors identified include the following:
Diabetes: Gestational diabetes or a family history of diabetes increases the risk of developing metabolic syndrome.
Age: The risk of metabolic syndrome increases with age. Almost 35% of all adults and 50% of those who are 60 years of age or older are estimated to have metabolic syndrome. Research shoes that the risk of MS in women begins to increase around perimenopause, which appears to be related to increases in testosterone during that time period.
Insulin Resistance: Insulin resistance occurs when excess glucose in the blood reduces the ability of the cells to absorb and use blood sugar for energy. This increases the risk of developing prediabetes, and eventually Type 2 diabetes.
Ethnicity: In the United States, Hispanics, especially Hispanic women are at greatest risk for developing metabolic syndrome.
Non-genetic factors that contribute to weight gain: Maternal smoking during pregnancy, gestational weight gain, stress and anxiety which can lead to over-eating. Additionally, psychiatric drugs, steroids, antidiabetic drugs, antihistamines and beta-blockers increase the risk for metabolic syndrome.
Stress: Stress in childhood can increase cardiometabolic factors and increase adipokines predisposing individuals to metabolic syndrome later in life. Furthermore, high stress exacerbates the risk of developing metabolic syndrome among adults.
Other Diseases: Nonalcoholic fatty liver disease, polycystic ovary syndrome or sleep apnea are risk factors for metabolic syndrome.
Lower Socioeconomic Status: Lack of access to fresh fruits and vegetables, healthcare, and safe neighborhoods for walking are strongly associated with metabolic syndrome.
SOCIO-ECONOMIC FACTORS RELATED TO METABOLIC SYNDROME
A chronic disease such as diabetes, metabolic syndrome and cardiovascular disease predominately affects those in the lowest socio-economic class and rural communities. Women in the lowest income bracket have a 1.81 odds ratio of developing metabolic syndrome than the general population.
Recent studies indicate that persons with lower socio-economic status had a greater risk of developing depression compared to those with higher socio-economic status. Those with depression tended to have greater rates of smoking, alcohol consumption and physical inactivity, as well as less compliance with medication regimen. Findings to date suggest a strong association between depression and metabolic syndrome.
A study found that workers of lower socioeconomic status were at increased risk of becoming obese compared to workers of higher socioeconomic status with the same stress level. This suggest that health inequalities may be present on an individual’s perceived environmental control. This perceived control could directly regulate underlying physiologic responses and increase physical susceptibility to stress.
Neighborhood characteristics are a potential mechanism linking lower socio-economic status to metabolic syndrome. People with lower socio-economic status tend to live in neighborhoods with greater crime rates, fewer areas for recreational activities, a prevalence of liquor stores, billboard advertisements for cigarettes, fast food restaurants and an absence of grocery stores.
Availability and affordability of fresh fruits and vegetables is restricted in these neighborhoods. Foods which are low in nutritional value containing excess sugars, fats or refined grains are often more affordable resulting in greater caloric intake and risk for obesity.
A further potential mechanism is health care access. The US Census Bureau showed that the likelihood of being covered by health insurance increased as income rose. Furthermore, the quality of health care received in the United States is related to income. Consequently, variability in healthcare because of socio-economic status may contribute to differences in treatment for components of metabolic syndrome. Access to healthcare is also inadequate in rural areas, thereby limiting treatment for those at risk.
Interventions that target a change in lifestyle habits through dietary, lifestyle and behavior modifications as a means of reducing the risk factors associated with diabetes, obesity, hypertension and cardiovascular disease offer cost effective solutions which empower patients. The primary problem is addressing the discrepancy between existing knowledge and effectively applying that knowledge to lower the risk.
The Diabetes Prevention and Management program in West Virginia and City Health Works in Harlem, New York are evidence-based programs. The program in West Virginia consists of twenty-two sessions taught by trained health coaches and community experts. The City Health Works offers 1:1 coaching for three to five months and phone calls for another nine months.
Research has identified core features of these interventions which include:
Site Selection: Places of worship offer a safe environment in multiple diverse communities and conveniently located within the community. Attached kitchens for cooking demonstrations and space for physical activity demonstrations are critical factors for success. Prevention programs that educate in healthy food preparation and physical activity are more effective in changing lifestyle habits than programs without demonstrations. The availability of parking is important for consistent participation throughout the program, especially during inclement weather.
Coaching occurs in participants homes with the City Health Works program. Participants report feeling more comfortable in their natural environments and coaches can educate other family members in shopping and preparing more nutritious foods. Walking clubs are encouraged to increase physical activity and motivation among participants.
Health coaching is helpful when a patient’s condition can be improved through lifestyle changes or when it requires a patient to learn new approaches for monitoring and managing their day-to-day health. Coaching programs often target people with chronic but controllable conditions such as diabetes or prediabetes.
Health coaches trained in diabetes education have been shown to be effective in reducing A1C and LDL levels and weight loss. Important components include changes in mindset, physical activity, eating habits, stress management, medication adherence and follow-up on medical appointments. The City Health Works coaches address socioeconomic needs such as access to food pantries, vouchers for farmers markets and Section 8 housing.
Health coaches are viewed as peers instead of researchers, which facilitates increased trust during interactions. To facilitate healthy reminders, health coaches reach out to participants in between sessions via texts and emails to check-in and encourage adjustments in lifestyle habits. Coaches are recruited from the same neighborhood in the City Works program which enhances their understanding of the challenges the participants face in making lifestyle changes.
Participatory Feedback ensures the sustainability of the program. This is accomplished with focus groups, feedback from health coaches to improve the training, and community champions who provide support and motivation to participants. A system champion is responsible for ensuring that the program runs smoothly. Participatory research requires engagement from individuals to design pragmatic solutions that can reduce workplace stress and effectively change behaviors in that environment.
Community Engagement includes pre-screenings at local malls, restaurants and churches. The pre-screenings increase awareness about diabetes prevention and management, provide potential participants with important health information, and the posted fliers in clinics, hospitals, restaurants, grocery stores and churches provide a community-wide reminder about improving health. Screening is an example of community engagement especially when it addresses an area of health disparities on a larger scale.
Social Environment including culture, local values, peer-to-peer support, feeling comfortable, friendliness, trust and a proven track record are critical for retention. Evidence suggests that in communities valuing generosity and loyalty, peer-to-peer support is more readily received.
Metabolic Syndrome has become an epidemic in the United States impacting an estimated one-third of the population. Programs employing health coaches focusing on lifestyle changes have proven effective in creasing knowledge and practices that emphasize nutrition, physical activity, medication adherence and stress management. Participants report reduced A1C levels, reduced hospitalizations, weight loss and a sense of empowerment. Developing trusting relationships with health coaches in comfortable and accessible environments, respecting local culture, community engagement and participatory feedback are critical factors for ensuring success in prevention of metabolic syndrome.
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