High Risk Conditions and Treatment Primary to Syndrome X
A Review of the Literature
Hope Olson
Advanced Nutrition
Professor Johnson
October 9, 2007
Abstract
Since the late 1980's Syndrome X has been of concern among medical experts and
dietitians. Several organizations have set standards on the core determinants of the disease, but
there are still no set standards on how to classify and treat patients. This literature review
inspects the various descriptions of Syndrome X, and how it came to be, how one can prevent it
from happening to them, and the latest methodology professionals are utilizing to help their
patients greet the road to improved health.
Nutritional Support for Metabolic Syndrome X Patients:
A Review of the Literature
During a lecture in 1988, Gerald Reaven, MD, of the Stanford University School of
Medicine, noted that several risk factors for CVD or cardiovascular disease commonly cluster
together. These factors include hypertension, hyperglycemia, and dyslipidemia. Reavan referred
to this group of factors as Syndrome X. Because insulin resistance underlies Syndrome X, this
phenomenon has also been called insulin resistance syndrome, and metabolic syndrome
(Meerschaert, 2005). The prevalence of Syndrome X varies slightly depending on the source
and criteria used to diagnose this condition, however it is reported that generally 23% of women,
and 24% of males have this condition (Davy & Melby, 2003). The astounding impact Syndrome
X has on individuals has spiked the interest of medical professionals and dietitians world-wide.
The lack of success in slowing the obesity epidemic, and the sparse nutrition and physical
activity education in our nation are environmental hazards that add to the genetic hazards some
individuals have of contracting the syndrome. This literature review considers the importance of
recognizing the features Syndrome X, reducing it's prevalence by habit changes, and treating it
with nutritional intervention. This review responds to the following questions:
1. What are the implications of Syndrome X?
2. How can individuals reduce their risks of contracting Syndrome X?
3. What are the current methods being practiced to treat this condition?
What are the Implications of Syndrome X?
Syndrome X has been categorized under slightly different definitions depending on
medical associations, such as the National Cholesterol Education Program's Adult Treatment
Panel III, and the World Health Organization, and also varies amongst physicians (Meerschaert,
2005). Table 1.1 offers the specific published criteria from the NCEP ATP III and WHO. Table
1.1 allows for the viability of different criterion, depending on the guidelines the practice treating
a patient adheres to. To professionals in the dietetics field however, Syndrome X can be loosely
identified in terms of the following signs and symptoms: insulin resistance, hypertension,
abdominal obesity, atherogenic dyslipidemia, and a prothrombotic state (Panagiotakos, 2007).
Brenda M. Davy, PhD, RD (2003) and her associate identify increased intra-abdominal adipose
tissue as a possible initial cause in the development of this syndrome. They also mark that
elevated stress-related cortical secretion, abnormal uric acid metabolism, inflammation, and
polycystic ovary syndrome contribute to Syndrome X. This abdominal or visceral obesity,
commonly referred to as the "apple shape" has been notorious for causing Diabetes Mellitus, and
onset of other chronic diseases, such as heart disease. Interestingly enough, "insulin resistance as
the primary defect" of Syndrome X has sparred the notion that it is a culprit in the development
of cardiovascular disease (Coulston, Peragallo-Dittko, 2004). It is estimated that 20-25% of US
adults have metabolic syndrome, "which means an increase in the risk of heart disease for a
quarter of the US population" (Knopp, et al., 2003).
Table 1.0 Published Criteria for Syndrome X Diagnosis
Hypertension
Dyslipidemia
Obesity
Glucose
NCEP ATP III
Current antihypertensive therapy
or BP > 130/85 mm Hg.
Plasma triglyceride level >
150mg/dL, HDL-c level <
40mg/dL in men, & < 50mg/dL
in women.
Waist circumference >/= 40 in.
for men, and >/= 35 in. for
women.
Fasting blood glucose level >
110mg/dL
Other
Requirements for diagnosis
Any three of the above disorders.
WHO
Current antihypertensive therapy
&/or BP > 140/90 mm Hg.
Plasma triglyceride level >
150mg/dL, &/or HDL-c level <
35mg/dL in men, & < 40mg/dL
in women.
BMI > 30kg/m &/or WHR >
0.90 in men, and > 0.85 in
women.
Type 2 diabetes or impaired
glucose tolerance (IGT).
Microalbuminuria (overnight
urinary albumin) excretion rate >
20ug/min [30mg/g Cr].
Confirmed T2 DM, or IGT & any
two of the above criteria. If
normal glucose tolerance, must
have three of the above.
Note: Information obtained from Coulston & Peragallo-Dittko, 2004.
This table identifies several traits that lead to the burdens and final contraction of the fullon condition and the reader has a chance to note some attention grabbing facts. Besides the fact
the NCEP ATP III differs slightly from that of the WHO, one can easily establish high blood
pressure, low levels of high density lipoproteins (HDL-c), obesity --specifically visceral,
diabetes, and protein excretion are problems that the disease thrives on.
According to Joyce Pastors, RD, MS, CDE, obesity and a sedentary lifestyle are the
driving forces behind Syndrome X. The complications of being overweight are increasing: not
only is type 2 diabetes affecting even younger populations; it's making them susceptible to a
chronic illness that is multifaceted in terms of risks. One body of evidence points to insulin
resistance as the essential cause of metabolic syndrome, and insulin resistance predispose people
to the development of type 2 diabetes mellitus (Pastors, 2006). Outcomes of the predispositions
include one hypothesis that has postulated a link between colorectal cancer, insulin resistance,
and hyperinsulinemia (Lukaczer, 2001). Even more recently, speculation has centered on the
link between hyperinsulemia and breast cancer (Lukaczer, 2001). Although these are frightening
outcomes of this condition, the good new is most of the sub-conditions of Syndrome X can be
prevented before they develop through lifestyle changes, behavioral changes, and education!
How Can Individuals Reduce Their Risks of Contracting Syndrome X?
Previous research has clearly shown that the individual components of Syndrome X are
all modifiable by exercise. There has been established an inverse relationship between the
prevalence of metabolic syndrome and cardio respiratory fitness, while adjusting for the potential
influence and confounding factor of macronutrient intake (Sullivan, 2006). This means that
Sullivan concurs exercise is a large factor in reducing one's risk of contracting Syndrome X, but
that diet could confound some of the data since those who work out choose healthier food, on
average. Of course, diet and exercise have complementary roles, and in the long run, they work
better together than either component alone. "Generally speaking, diet has been shown to be
more effective for overall weight loss, but exercise has more of an effect on weight maintenance
and changes in body composition over time," including controlling diabetes, and changing body
composition such as the HDL-C level (Sullivan, 2006). If a person consistently exercises and
maintains an accelerated cardiorespiratory function, they are less likely to become obese, and
contract this bundle of complications know as Syndrome X.
Diet plays a large role in deflecting the risks associated with Metabolic Syndrome. The
ATTICA study completed by Demosthenes Panagiotakos and his associates concluded "a dietary
pattern that includes cereals, fish, legumes, vegetables, and fruits was independently associated
with reduced levels of clinical and biological markers linked to the metabolic syndrome, whereas
meat and alcohol intake showed the opposite results." This diet was inversely related to the
likelihood of Syndrome X. Another evidence based study recommended by both the American
Heart Association (AHA) and the NCEP ATP III, is to limit the intake of foods with a high
content of cholesterol-raising fatty acids -- saturated fatty acids, and transfatty acids (Coleman,
2002). Both organizations encourage individuals to replace those foods with unsaturated fatty
acids from fish, vegetables, legumes, and nuts, and with carbohydrates from grains and fruits
(Coleman, 2002).
What are the Current Methods Used to Treat this Condition?
The diet can be used as a tool to promote a healthy lifestyle and combat the components
of Syndrome X. It is commonplace for people with high contents of LDL, or total cholesterol to
use a statin, which is drug that fixes part of the problem. One may temporarily fix insulinsensitivity or resistance with insulin shots. Individually or congressionally, these characteristics,
among others, that are clustered together forming Syndrome X can be treated through a diet high
in monounsaturated fats, and low in carbohydrate. "High carbohydrate diets can increase
triglycerides, lower high-density lipoprotein (HDL) cholesterol, and worsen glucose tolerance in
individuals with the metabolic syndrome" (Coleman, 2002). In one study recorded by Coleman
from Grundy and colleagues, discovered that a high carbohydrate, very low-fat diet lowers
HDL. That is not what most people would think since fat is "bad." It is the ratio of LDL to HDL
that is unhealthy, if the LDL is too high. The study went on to say that instituting a low-fat diet
supplemented with monounsaturated fat resulted in less HDL lowering than a very low-fat diet
(Coleman, 2002).
The "Dietary Effects on Lipoproteins and Thrombogenic Activity" (DELTA) study
found that high monounsaturated fat diets reduced HDL cholesterol by only 4% compared to the
7% for the low fat diet. In addition, the high-monounsaturated fat diet did not increase the
triglycerides compared to the 7% increase on the low-fat diet (Coleman, 2002). Another benefit
from a higher monounsaturated fat diet (providing the patient still looses weight) is the ability for
MUFA to be less susceptible to oxidation than polyunsaturated fatty acids. Since MUFA's are
not easily oxidized, they contribute much less to atherosclerosis, which is great news for treating
CHD.
The NCEP ATP III recommends a therapeutic lifestyle change as the first priority of
treatment for individuals with risk factors that can be related to lifestyle, such as obesity,
sedentary lifestyle, elevated plasma glucose levels, high triglyceride values, or low HDL-C
levels (Sullivan, 2006). The ways in which people would receive this treatment include but are
not limited to weight loss counseling, regular exercise, and therapeutic diet, similar to that of the
MUFA incorporated diet described above. This approach, though idealistic, would have benefits
such as improved "plasma triglyceride and HDL cholesterol values while offering promise for
reducing the burden of medication required to improve the risk factor profile" (Sullivan 2006).
The approach is idealistic in terms of the patients’ readiness for this kind of commitment, and
psychological strength. It will require persistence and careful planning of exercise, diet, and
behavioral change.
Almost all of the signs and symptoms of Syndrome X are acquired over a long period of
time, and can result in serious medical treatment. Treating hypertention, dyslpidemia, visceral
obesity, and insulin resistance is difficult, costly, and time consuming with the use of drug
therapy, and in the case of obesity, is not an answer. There are numerous evidence based studies
concluding that therapeutic lifestyle changes and a diet high in monounsaturated fatty acids and
low in carbohydrate offer great hope to patients with Syndrome X. Prevention of the syndrome
is directly correlated with a moderate diet consisting of fruits, vegetables, legumes, cereals, fish,
and MUFAs. This ultimately leads to educating the public on the benefits of these foods and
how easy it is to obtain these nutritional resources. Exercise will aid in weight loss and
maintenance, a key to preventing the onset of visceral obesity, the precursor to Syndrome X.
While the conditions of Syndrome X are unique in that they are, for the majority, preventable by
behavior changes and healthy food attitudes, they still need to be further analyzed in depth in
light of dietary treatment.
References
Coleman, Ellen. (February, 2002). Monounsaturated Fat, Metabolic Syndrome, and CHD. Today's
Dietitian, 15-17. Exert obtained from Betty Larson, RD, FADA.
Coulston, Ann M., Peragallo-Ditkko, Virginia (2004). Insulin Resistance Syndrome: A Potent Culprit in
Cardiovascular Disease. Journal of the American Dietetic Association, 104, 176-178.
Davy, Brenda M., Melby, Christopher L. (2003). The Effect of Fiber-Rich Carbohydrates on Features of
Syndrome X. Journal of the American Dietetic Association, 103, 86-93.
Knopp, R. H., Retzlaff, B., Fish, B. et. al. (2003). Obesity, Insulin Resistance, and Heart Disease.
Nutrition Close Up, 20, 1-3.
Lukaczer, Dan. (2001). Nutritional Support for Insulin Resistance. Applied Nutritional Science Reports.
1-5. Pages 1-5 are those of an exert from ANSR, obtained from Betty Larson, RD.
Meerschaert, Carol M. (December, 2005). Metabolic Syndrome: What's in a Diagnosis? Today's
Dietitian, 40-43. Exert obtained from Betty Larson, RD, FADA.
Panagiotakos, D. B., Pitsavos, C., Skoumas, Y., Christodoulos, S. (2007). The Association Between Food
Patterns and the Metabolic Syndrome Using Principal Components Analysis: The ATTICA
Study [Electronic version]. Journal of the American Dietetic Association, 107, 979-986.
Pastors, Joyce Green. (March, 2006). Metabolic Syndrome: Is Obesity the Culprit? Today's Dietitian,
12- 16. Exert obtained from Betty Larson, RD.
Sullivan, Vicki K. (2006). Prevention and Treatment of the Metabolic Syndrome with Lifestyle
Intervention: Where Do We Start? [Electronic version]. Journal of the American Dietetic
Association, 106, 668-670.