She awakens tired and falls asleep too easily. Her husband has moved out of their bedroom because of her loud snoring. She has a family history of diabetes.
MG is 5 foot 3 and 170 pounds and has a BMI in the obesity range. Her waist is 36 inches. Her blood pressure has been 150/90 and on occasion higher. Laboratory studies revealed that her fasting blood sugar was 110 (normal is less than 100) and her hemoglobin A-1 C was 6.0 (falls into prediabetic). Her total cholesterol was 175 mg/dl, HDL-cholesterol 38 mg/dl (low), LDL 130 mg/dl (goal less than 100) and triglycerides were 300 mg/dl (high).
MG has metabolic syndrome. It does not get the notoriety of heart disease, stroke or diabetes, but if not aggressively treated can lead to those diseases along with higher risk for cognitive decline, certain cancers, and kidney and liver disease. In 2002, nearly 40 percent of adults in the U.S. had metabolic syndrome.
The central feature of metabolic syndrome is euphemistically called central obesity, which most of us call a potbelly. You can think of the abdominal fat as an endocrine gland that releases harmful fatty acids, a chemical called angiotensin II that raises your blood pressure and inflammatory markers. These substances are toxic to the pancreas and require the pancreas to make extra insulin. The fatty acids made by that “organ,” the potbelly, lead to increased levels of triglycerides and lower levels of HDL cholesterol, which have a deleterious effect on the arteries. Like most people, MG did not require medication for triglyceride levels.
Being Hispanic, MB has a higher risk for Type 2 diabetes. The disease has a definite genetic component, as it is two to six times more prevalent in African-Americans, Native Americans, Pima Indians and Hispanic Americans in the United States than in whites. Nearly 40 percent of diabetics have at least one parent with diabetes.
MG’s treatment plan requires lifestyle changes and medication. Taking medication is easy compared to losing weight. The diabetes prevention study that followed people like MG found a 50 percent reduction in the development of Type 2 diabetes with just a 10 percent weight loss.
In the September 2014 issue of JAMA, an analysis of 48 previous studies on brand-name diets such as Atkins (low carb), Ornish (low fat) and Weight Watchers (labeled a “moderate” approach) found similar weight loss of around 12 pounds more than for nondieters. The message: being on a diet causes you to lose weight regardless of which one it is.
To get a patient jump-started losing weight, I recommend a carbohydrate-restricted diet such as one sees with the Atkins or South Beach diets. A high quality but small study published last spring in the Annals of Internal Medicine compared a low-fat diet to a low-carb diet for weight loss. Nearly 150 obese subjects representing a diverse ethnic population were placed on one of the diets.
Those assigned to the low-fat diet were instructed to maintain less than 30 percent of their daily energy from total fat with less than 7 percent saturated and 55 percent from carbohydrates. The low-fat group was asked to limit saturated fat from meat, butter and milk. The low-carb group was told to cut back on white foods i.e. white bread, white pasta and sugary cereals and drinks.
After one year, the low-carb group lost far more weight: 12 pounds vs. 4 in the low-fat group. Low-carb diets are in fact low-calorie diets because increasing the amount of fiber and fat in your diet assuages your hunger. It is a good diet to jump-start a weight loss program, and I find it encourages patients to stick with it and also to begin an exercise program as they begin to feel better about themselves.
Importantly, the low-carb dieters were encouraged to avoid white carbs like sugar, white bread, potatoes and white rice and increase fish, nuts and legumes and use olive oil as their primary fat source. If that sounds familiar, you read my September column. The diet has many characteristics of the Mediterranean diet. It is a diet that has shown to reduce the risk of diabetes in people with metabolic syndrome.
Weight loss works. One study found that two-thirds of patients who lost 10 percent or more of their body weight over a two-year period no longer met the criteria for metabolic syndrome.
Exercise is the other key lifestyle feature for ridding yourself of metabolic syndrome. It is hard to lose weight without exercising, although few studies on the effects of exercise on the course of metabolic syndrome have been done. Many studies on diabetes show the profound effect of vigorous exercise causing a reduced risk for heart attack, stroke or cardiovascular and all-cause death rates. So I recommend 30 minutes of aerobic exercise on most days and some weight training.
MG was advised to have a coronary calcium score to help decide if she should be treated with a statin for her LDL cholesterol. This test determines the presence of calcified plaque in the coronary arteries, and I use it when there is a borderline indication for statin therapy to lower LDL cholesterol. Her score was 0 so we did not recommend statin medication like Lipitor or Crestor.
Her elevated triglycerides were not treated with medication as studies have found that even though medication lowers triglycerides it does not prevent cardiovascular disease.
Finally, the patient has symptoms of obstructive sleep apnea with morning fatigue and somnolence. She was sent for a sleep study and the findings and the role of sleep apnea in causing disease will be the subject of my next column.
Dr. Barry Ramo is a cardiologist with the New Mexico Heart Institute and medical editor for KOAT-TV.