Clinical identification of metabolic syndrome: Any three of the following risk factors
|
NO WONDER METABOLIC syndrome is called syndrome X. Instead of being recognized as a separate disease, it is considered a constellation
of many conditions. "The biggest problem is a failure to address the underlying problem—insulin resistance," says Robert Epstein,
MD, chief medical officer for Medco Health Solutions in Franklin Lakes, N.J. He calls metabolic syndrome one of the country's
top five health problems.
Patients with metabolic syndrome have three or more of the following risk factors: excessive abdominal fat, low amounts of
HDL, elevated triglyceride levels, high blood pressure and abnormal blood sugar. They are at three-and-a-half times greater
risk of death from coronary heart disease and have increased risk for liver and kidney disease.
Although the prevalence of metabolic syndrome increases with age, it is present in as many as 5% of elementary school children,
according to Family Practice News, which reported the results of a study presented in July at the annual meeting of the American College of Sports Medicine.
DEFINING METABOLIC SYNDROME
"Is there a problem called 'metabolic syndrome?'" asks Michael Fleming, MD, past president of the American Academy of Family
Physicians and a practicing family physician in Shreveport, La. "It's academic. Metabolic syndrome is an amalgamation of diseases
that begs for treatment by a primary care physician. It doesn't make sense to be treated by different physicians for each
problem."
To David Katz, MD, director of the Prevention Research Center, Yale School of Medicine, metabolic syndrome is not viewed as
a disease but rather, it is considered a precursor to diabetes. "By using metabolic syndrome as an indicator for diabetes,
we can pull back patients from the brink by addressing obesity—the root cause of metabolic syndrome—and identifying treatable
cardiovascular conditions," he says.
In August, the American Diabetes Assn. and the European Association for the Study of Diabetes issued a joint statement, saying
that "metabolic syndrome" was poorly defined, inconsistently used and in need of further research. The president of the European
diabetes association says that there is "no combination of risk factors that boost a person's cardiovascular risk beyond the
sum of its parts, or constitutes a separate disease."
A paper published in the September issue of Diabetes Care and Diabetologia warned doctors that they should not diagnose people with the syndrome or treat it as a separate condition until the science
behind it is clear.
In response, the American Heart Assn. (AHA) and the National Heart, Lung and Blood Institute (NHLBI) issued a statement, saying
that metabolic syndrome consists of multiple, interrelated risk factors that increase the risk of cardiovascular disease by
one-and-a-half to three times, raise the risk of diabetes 2 three to five times and affect more than 26 million adults in
the United States.
Although the two organizations confirmed the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP
III) guidelines, they did some tweaking: fasting glucose drops from equal to or greater than 110 milligrams per deciliter
to 100; triglycerides greater than or equal to 400 milligrams per deciliter, if not fasting, and glucose greater than or equal
to 140 milligrams per deciliter two hours after eating have been added; and less emphasis has been placed on waist circumference.
A joint AHA/NHLBI panel states that an increased waist circumference serves as an effective diagnostic tool, but it is not
necessary for the diagnosis of metabolic syndrome if other criteria are present. The panel also says that some persons who
are not obese by traditional measures, may still be insulin resistant and have other metabolic risk factors.
THE GUIDING PRINCIPLES
The NCEP's ATP III guidelines, which were updated in 2001, identify metabolic syndrome as a secondary target of therapy after
coronary heart disease—perhaps providing more recognition of the syndrome—and recommend that patients with metabolic syndrome
be identified and treated aggressively. The guidelines outline treatment for metabolic syndrome:
- Treat underlying causes (over-weight/obesity and physical inactivity) by intensifying weight management and increasing activity;
- Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies;
- Treat hypertension;
- Use aspirin for coronary heart disease patients to reduce prothrombotic state; and
- Treat elevated triglycerides and/or low HDL.
Medco recently released the result of an analysis of metabolic syndrome, finding that the average yearly pharmacy cost of
treating adults over age 20 years with the disease exceeds $4,000—more than four times the average annual drug spend for other
patients.
The analysis also revealed: 1) The number of patients with two risk factors for metabolic syndrome jumped 20% between 2002
and 2004; 2) The number of adults being treated for the conditions associated with metabolic syndrome increased more than
36% during the same time period; and 3) Patients with metabolic syndrome and at-risk for related conditions accounted for
$4 out of every $10 spent on prescription medications for adults.
One of the other major concerns related to treating metabolic syndrome, according to Medco data, is that on average, patients
with metabolic syndrome are prescribed medications by five different physicians, 25% see seven different prescribing doctors
and many often visit three or more pharmacies, making coordination of care difficult and medication errors more likely.
Medco's RationalMed Patient Safety Solutions integrated data system can alert physicians that a patient has two or more of
the risk factors for the condition, as well as inform them if a patient is taking a contraindicated drug. The alerts, Dr.
Epstein says, also engage physicians in talking about lifestyle changes with their patients, such as losing weight and/or
increasing exercise, which can prevent or reverse metabolic syndrome.
Medco says that in 2004, RationalMed identified 879,000 conflicts that could lead to hospitalization and unnecessary healthcare
costs. Out of the 937,769 alerts sent, 50% resulted in a therapeutic change. The total savings was 2% for pharmacy costs and
3% for hospitalizations.
OBESITY: THE ROOT OF THE PROBLEM
Metabolic syndrome can become a vicious cycle, starting with obesity, which can worsen insulin resistance and often lead to
diabetes when the body cannot produce enough insulin to overcome resistance. The action forces blood sugar levels to rise.
Excessive weight also negatively affects blood pressure, triglycerides and HDL.
"If you can eliminate abdominal fat, you can get rid of the syndrome," Dr. Katz says. "The major problem is a deficiency in
medical care. Interventions start once there are symptoms, but we are not particularly good at prevention—even though it is
easier to prevent than treat. If a person develops metabolic syndrome and is never disabled, no one thinks about it. The key
is knowing how to diagnose metabolic syndrome, liberalizing the definition to include anyone with excess abdominal fat and
nipping it in the bud before it progresses to critical consequences."
CIGNA HealthCare in Bloomfield, Conn., is doing just that with a new program. "Employers are asking for well-defined strategies
for addressing obesity," says Andrea Gelzer, senior vice president. "We are focusing resources on obesity subsets—those who
face urgent medical needs—who we recognize through predictive modeling."
CIGNA communicates patents' risk to their physicians and invites members into either a high-risk obesity DM program, which
will help participants stabilize or lose weight, or a comprehensive weight loss program, along with lifestyle behavior coaching,
addressing depression, and encouraging the right use of drugs for different components of metabolic syndrome.
Mari Edlin is a frequent contributor to Managed Healthcare Executive. She is based in Mill Valley, Calif.
We subscribe to the HONcode principles of the Health On the Net Foundation