As clinicians, we are all doing our best to obtain a full medical history, diagnose and the prognose the disease to the best of our knowledge and plan a treatment accordingly. Most of the time patients come to our outpatient clinics with a particular complaint and are treated for their symptoms. Patients improve with our treatment and are seen only at the next review. However, what we need to look into as family physicians, is the silent features of metabolic syndrome.

As the name indicates, metabolic syndrome is a constellation of signs rather than the patients’ symptoms and the earlier we diagnose metabolic syndrome, the earlier the patient can be educated about this asymptomatic medical condition.

This could be the best way to bring down the rising incidence of diabetes, hypertension, dyslipidaemia, cardiovascular disease, fatty liver disease and cerebrovascular accidents. Metabolic syndrome is a silent ailment, which needs to be addressed once the panel of signs show up.

Epidemiological studies have shown that in the past 30 years, there has been a high incidence of people falling into this category, with women exceeding men. Studies show that the adolescent age group is highly vulnerable to metabolic syndrome and can get lifestyle diseases much earlier in life. At our OPDs and regular health checks, we likely find that 50% of our patients on a daily basis fall into this metabolic syndrome. Most of the patients are asymptomatic and hence neglect their health at this stage.

It is a priority for the public health providers and the clinicians in our country, and worldwide, to make all efforts for the prevention and early detection of this condition and to continue research in this field.

In 1971, epidemiological studies done by Omran had put forward the theory of “Epidemiological Transition” which clearly said that the pattern of morbidity and mortality of a community is based on 3 stages:

1. The age of pestilence and famine
2. The age of receding pandemics
3. The age of degenerative and man-made disease.

In 2022, we can witness the validation of this hypothesis. The mortality and morbidity due to famine induced protein-energy malnutrition has definitely come down but it is still prevalent in underdeveloped parts of our country. The global COVID 19 pandemic, which we are still witnessing, has shown a high incidence of mortality in patients with metabolic syndrome. The third condition of man-made diseases can be discussed as being the diseases caused by untimely disability or death resulting from pollution of the environment. Whatever be the disease, its progression or prognosis or outcome is better in patients who do not fall into the metabolic syndrome criteria.

What is Metabolic syndrome:

Metabolic syndrome is the cluster of conditions given below:

1. Central obesity
2. Raised blood pressure
3. Impaired fasting glucose
4. Raised triglycerides
5. Low levels of HDL

When patients have any or all of the above, it is mandatory to inform them that they are having the signs of metabolic syndrome and they need to change their lifestyle.

Data:

A small data in a OPD in a day of 20 patients, we see almost 10 patients in various are groups are already falling into metabolic syndrome

Central Obesity:

The first and the foremost sign of the start of metabolic syndrome is central obesity – an increase in waist circumference leading to increased visceral fat. The main reason being unhealthy lifestyle .Obesity coupled with a sedentary lifestyle is a deadly combination as the two conditions are directly predispose to metabolic syndrome and are the leading causes of insulin resistance and increased body fat accumulation in the body. This insulin resistance further causes resultant hyperinsulinemia, which is high levels of unused insulin in the blood stream, which triggers the constellation of features that is metabolic syndrome.

To understand metabolic syndrome, we need to briefly go through the basic biochemistry of Insulin, carbohydrates, lipids and fat metabolism.

Basic biochemistry of Insulin:

Insulin is a 51 amino acid chain that is formed from a precursor polypeptide chain (Proinsulin) with 86 amino acids from which C – peptide and insulin are secreted in equimolar quantities. Elevated levels of glucose in the blood stream stimulates the release of insulin.

1. The beta cells in the pancreas have Glut2 receptors, which act as sensors of the blood sugar level, releasing insulin. The secretion is stopped when glucose levels in the blood are optimal.
2. The intake of food causes the secretion of pancreozymins and gastrin, which in turn, stimulates insulin production.

Hence, it is clearly understood that food intake stimulates insulin production and therefore a proper meal pattern is very essential.

Synthesis of Triglycerides:

Calories unused by the human body are ultimately converted into Triglycerides, during lipid metabolism.

Triglycerides are synthesized in the liver and adipose tissue. The triglycerides in adipose tissue are mainly for the storage of energy. The synthesis of triglycerides is mainly converted as VLDL as is transported. It needs to be understood that the glycerol which is converted into fatty acids in the synthesis of triglycerides is actually derived from the metabolism of glucose. Hence insulin resistance is a direct interface in the synthesis of triglycerides, leading to elevated triglyceride levels when there is a disruption in carbohydrate metabolism.

What is Insulin Resistance:

This is when adipose cells and liver are unable to respond to the release of insulin, due to the accumulation of visceral fat, leading to elevated  glucose in the blood, resulting in Hyperinsulinemia. One has to understand that the metabolism of glucose, lipids and proteins are interlinked and any disruption in this metabolic pathway leads to:

Insulin resistance leading to-> Hyperinsulinemia -> impaired glucose tolerance -> raised triglycerides -> raised BP.

The main reason behind being unhealthy lifestyle.

A sedentary lifestyle with unhealthy eating habits is the main etiology of metabolic syndrome.

Improper eating habits and sleep pattern being the main cause of derangement in metabolism to start.

The access to food at any time has made it even easier for obesity to develop. The constant food intake causes insulin release, but a sedentary lifestyle causes accumulation of visceral fat leading to central obesity. When central obesity occurs more of insulin is released due to the constant need for it, unfortunately, due to insulin resistance, it is not used up by the liver. The constant secretion of insulin means that the pancreas has been  constantly secreting insulin and  the blood level of insulin is high  causing  certain predisposing signs like hypoglycaemia/ anxiety/ extreme fatigue/ inability to concentrate, weight gain / hunger pangs and overeating, despite the person being non-diabetic, which is why this hyperinsulinemia goes unnoticed most of the time. The  pancreas become tired and finally, the pancreas is unable to secrete any more insulin and this leads to Type II Diabetes Mellitus.

Hyper Insulinemia:

We all know that insulin is secreted as a result of hyperglycaemia.

But when the insulin is not being used up due to the resistance offered by the liver due to the visceral fat around the organ (central obesity) there is a high level of insulin in the blood stream going unused by the body.

The insulin levels in the blood increased as a result of increased production of insulin from the pancreas leads to insulin resistance causing:

• Excess fatigue
• Sugar craving
• Weight gain
• Hunger pangs
• Low levels of concentrators (with sudden low sugars)
• Feelings of anxiety
• Sudden hypoglycaemic events which can either trigger seizures or myocardial infarction

This is a pre-diabetic condition and often hyper-insulinemia is overlooked.

But proper lifestyle changes need to be emphasised at this point to the patient, so that the required lifestyle changes may be made. Hyperinsulinemia can be explained as sudden hypoglycaemic events, irritability, anxiety, seizures and decreased concentration issues (children who are obese).

Complications of metabolic syndrome:

1. Raised Blood pressure – Hardening of the arteries – caused by the peripheral resistance offered by the reduced elasticity of the arteries due to atherosclerosis.
2. Diabetes Mellitus due to insulin resistance
3. Ischemic heart disease as a complication of above two
4. Medical renal disease
5. Peripheral arterial disease
6. Non- alcoholic fatty liver disease which can be lead to fibrosis and cirrhosis
7. Depression
8. Insomnia

Finally these lead to financial burdens and a poor quality of life.

Dietary Advice:

The best news is that metabolic syndrome can be reversed with a healthy diet and regular exercise. The primary reasons for metabolic syndrome are a sedentary lifestyle and poor unhealthy eating habits. Make sure your diet has whole grains. Consume wholesome portions of vegetables, healthy fats and lean meat and avoid foods high in sugar, simple carbohydrates and salted food and preserved food.

Also, avoid aerated beverages and fast food. Encourage patients to walk a minimum of half an hour daily.

Conclusion:

The number of patients falling into this syndrome has drastically increased in the past 3 decades; there is a high rise of more than 50 percent of the adult population in our country falling into these criteria. Women, armed forces personnel and adolescents are more prone to this condition and this issue needs to be addressed at the earliest. All efforts must be taken for the prevention, early detection and management of metabolic syndrome.

Dr. Kavitha Sundaravadanam
Senior Consultant Family Physician
Kauvery Hospital