METABOLIC SYNDROME
in
LOW BMI
BILL ROMERO, MD, MS, CNS
Body Mass Index (BMI)
 BMI is a weight to height ratio.
 The heavier the weight, relative to the same
height, the higher the BMI.
 Estimates the fat percentage
 Same weight and height will have the same
BMI, regardless of body fat percentage.
 May have normal BMI even if Body Fat %
is in Obese Range (>25%).
BMI Table
 BMI = [( lbs/inches² ) (weight in pounds X 703 )] / height in inches²
BMI vs. Fat Percentage
 Same weight and height but varying fat
percentages.
Fat Percentage
 Most commonly measured by bio-
impedance
 Small amount of electricity is passed
through body and resistance is measured
 The more fat, the more resistance.
Normal Weight Obesity
 It is possible that one can weigh “normal’ and be
medically obese
 Normal Weight Obesity
 Same risk factors as “overweight” obesity
 Classifications:
– Normal: 25% and below
– Overweight: Above 25 to 29%
– Obese: 30 to 40%
– Morbidly Obese: Above 40%
Carbohydrate Metabolism
An unhealthy diet, high in refined carbohydrates, causes rapid
elevation of blood sugar. The pancreas responds by
increasing insulin output.
Keith Vosseller, Lance Wells, M. Daniel Lane, and Gerald W. Hart
Elevated nucleocytoplasmic glycosylation by O-GlcNAc results in insulin resistance associated
with defects in Akt activation in 3T3-L1 adipocytes PNAS 2002; 99: 5313-5318.
Insulin Resistance
If the capacity of the insulin receptors is compromised due to
nutrient insufficiencies and excess in sugar consumption
the internal message to the cells is reduced and the
efficiency of the cell is compromised.
Premise
 Obesity causes a biochemical change:
insulin resistance
 Insulin resistance leads to progressive
weight gain (vicious cycle)
 Insulin resistance must be recognized and
treated
 Proper nutrition, exercise and medications
can reduce insulin resistance and reverse
obesity.
Metabolic Syndrome
 Obesity
 Insulin Resistance
 Hypertension
 Hyperlipidemia
 Prothrombotic State
 Proinflammatory State
DIAGNOSIS
 Insulin Resistance
– Fasting Glucose to Fasting Insulin (G:I Ratio) <
4.5 (Legro, et al)
– 2-Hr Insulin 5X greater than Fasting Insulin
– Fasting Insulin >20
– Elevated insulin levels in OGTT with Insulin
Test
– Waist to Hip Ratio
Glycemic Index
 Ranks carbohydrates on
how fast their sugar can
raise glucose compared to
equivalent amount of
sugar.
 Practical Use: allows us to
choose “slow-release”
carbohydrates
 Included in Nutritional
Data of food in Europe;
proposed to be included in
the US
FOOD
KCal
GI
Table Sugar
100
100
White Bread
100
70
Pumpernick
el Bread
100
51
Fruit
Pear
GI
33
Apple
Pineapple
45
63
Glycemic Load
 Compares carbohydrates on volume needed
to raise blood sugar. For example,
watermelon has a high glycemic index but
because it is mostly water, you can eat more
of it than table sugar to raise your blood
sugar
 A GL of 20 or more is high, a GL of 11 to
19 inclusive is medium, and a GL of 10 or
less is low
Pharmacologic Intervention
 Morbid obesity with laboratory verified
insulin resistance
 Not compliant with diet or exercise
 Metformin 500 mg BID or 1000 mg XR OD
with meals
MANAGEMENT: Dietary
Three Fundamental Principles
1. Timing: Eat small meals every three hours
Levels of Satisfaction
>140 Stuffed
120-140 Full
90-120 Satisfaction
70-90 Hungry
<70 Starving
Adrenaline - shaky, irritable, hungry
Cortisol – store sugar from already depleted supply
Glucagon – release sugar from liver
MANAGEMENT: Dietary
1. Timing: Eat every three hours regardless of
hunger.
Many of us do not eat enough during the day.
Inadequate caloric intake during the
day leads to:
a. Reactive Hypoglycemia
b. Nocturnal Eating Syndrome
c. Central Adiposity
It is self-perpetuating…
MANAGEMENT: Dietary
2. Quantity: Best way to assess caloric needs
is to measure Basal Metabolic Rate
Rule of Thumb: Weight in
pounds X 10 then add the
weight. For example: 220 lbs
X 10 = 2200 + 220 = 2400
To lose 1 pound a week,
prescribe a diet 500 cal less
than BMR. In this case,
about 1800 calories.
Goal: Lose 1% of weight per
week. 200 lbs = 2 lbs/week
Weight Reduction
Prescribe Weight Reduction through Energy Deficit
Select a Realistic Goal Weight
1.
2.
Select a BMI 2 units below current BMI
Approximate BMR
BMR = Wt in lbs X 10 + Wt
= (200 X 10) + 200 = 2200
Reduce BMR by 500 to 1000 calories = 1500-1800 cal
3.
Use a Bio-impedance Analyzer to measure BMR
BMRc BMRa
2200 1670
BMI
28
%Fat
33
MANAGEMENT: Dietary
3. Quality: Each meal
must have proteins,
fats and carbohydrates
B
S
L
S
D
300 150 400 150 500
300
Cal
1/3 CHO
100
1/3 Prot
100
1/3 Fats
100
100
2/3 Prot
& Fats
200
Choosing Foods
Breakfast: 300 calories
Carbohydrates
(100cals)
1 sl multigrain bread
4 c salads/veggies
½ c rice, pasta, oatmeal
6 inch pita or wrap
½ c beans
1 small potato
Proteins and Fats
(100cals)
1 oz red meat
1-1/3 oz white meat
1 oz seafood
1 slice cheese
1 whole egg
2 eggwhites
Rule of Hand
 Dinner should be
about 500 calories
 Each finger = 100
Kcal
 3 fingers = protein
 Index = complex
carbohydrates
 Thumb = simple
carbohydrates