The metabolic syndrome

Syndrome X was first described in the late 1980s by Reaven. No, it has nothing in common with the famous “X-files” paranormal series. Indeed, apparently it is sadly quite normal in our society: 34% of adults in the US have a metabolic syndrome (MetS).1 With this word we mean a series of factors that, if verified, increase the risk of developing a cardiovascular disease of about twice. The criteria have changed several times and nowadays the American and European cardiology and endocrinology societies agree in asserting that the metabolic syndrome is such if at least 3 of the following criteria are observed:

MEASURE	CATEGORICAL CUT POINTS
WAIST CIRCUMFERENCE	Ø = 94 cm in males Ø = 80 cm in females (Europe)
BLOOD PRESSURE	Systolic >= 130 mmHg or diastolic >= 85 mmHg Or treatment
HDL-cholesterol	< 40 mg/dL (1.0 mmol/L) in males < 50 mg/dL (1,3 mmol/L) in females
TRIGLYCERIDES	>= 150 mg/dL 5 1,7 mmol/L) Or treatment
FASTING GLUCOSE	>= 100 MG/dL Or treatment

WAIST CIRCUMFERENCE

Visceral fat plays a major role in defining this syndrome. It means the amount of fat that accumulates in the abdomen. In this area, in fact, the fat cells cover not only the subcutaneous layer but also the internal visceral organs (intestine, spleen, liver, kidneys and pelvis). Here we tend to define the adipose panniculus as an endocrine organ in its own right. It produces cytokines and proinflammatory molecules directly involved in the development of said syndrome X. They define a state of chronic inflammation among other things is often responsible for infertility.[2]

BLOOD PRESSURE

Systolic blood pressure identifies the value of the force with which the heart pushes blood at the time of its contraction. The diastolic or minimum pressure represents the value of the pressure with which the blood returns to the heart and gives an idea of peripheral resistance (of the vessels). Both of these values are measured in the left arm placed at the height of the heart, thanks to the sphygmomanometer that detects to what level the blood vessels reopen after having been forced with the arm band. High tension values suggest a stiffening of the vascular walls; in most cases this hardness is conferred by a multiplicity of factors: stress, atherosclerosis, smoking and exciters. High blood pressure causes a considerable cardiac effort to pump blood into the vessels. Imagine that you are pumping air into a mattress that is rigid and does not follow the expansion due: after 3 minutes you would be exhausted and leave it alone; Well, pity our poor heart!

HDL

High Density Lipoproteins are lipoproteins whose function is to transport cholesterol from tissues to the liver; we could define them as a sort of cellular “sweeper” that retrieves the remains of cholesterol and takes them to the liver where it will separate waste. High HDL values were shown to be inversely proportional to the risk of cardiovascular disease.3 Other factors that increase HDL are: exercise, weight loss and estrogen level. For this and other reasons, women are less exposed to cardiovascular risk during childbearing age: estrogens protect the vessels.

TRIGLYCERIDES

Triglycerides are small trucks in which 3 fatty acids are transported. They are the main source of body fat and can be deposited in the tissues or be moving in the bloodstream. The amount of triglycerides is directly proportional to their intake through the diet. High levels of triglycerides increase the cardiovascular risk and the probability of inducing pancreatitis. 4.High values of triglycerides make the blood opalescent instead of the typical ruby red color (if you are not impressionable, look at the tube during sampling!).

FASTING GLUCOSE

The homeostasis of the human body is expected to remain at glucose levels between 0.7 and 0.9 Mg /dL of glucose. Glucose can enter cells thanks to the insulin that allows it to be transported or through muscle exercise. Without these two keys, the cell door does not open and glucose increases in the blood. In type 1 diabetes, insulin is not adequately synthesized due to an autoimmune pancreatic islet disease. In type 2 diabetes, the pancreas produces insulin which, however, fails to get glucose into the cell. There is a condition of insulin resistance for which the cells are not able to manage the entry of glucose into the blood so that its concentrations remain high even after 12 hours of fasting. Values above 1 mg / dl are called pre-diabetes.

PATHOGENESIS (or GENESIS OF PATHOLOGY)

There is no scientific agreement on what the Mets primum movens is; I summarize the mechanisms that are closely intertwined between them whose sum gives the complete picture:

• INSULIN RESISTANCE

We have already said that when the blood sugar level increases, the pancreas produces insulin so that glucose can enter the muscle, fat or liver cells to be stored or simply used freely (glycolysis). The cell door opens only thanks to insulin. If the cell is too full of saturated fat, insulin fails to pass glucose and is called insulin resistance5. This state of resistance determines:

• In the Central Nervous System: increases appetite and food intake thanks to a resistance to leptin (the satiety hormone) [6]
• In Adipose Tissue: increases the amount of deposited lipids (lipogenesis) and the inflammatory state through the secretion of pro-inflammatory cytokines (IL-6, TNFalpha, IL-1b) [6]
• In the liver: increases hyperglycemia and triglyceride synthesis[6]
• In pancreatic beta cells: prevents regeneration[6]
• In endothelial vessels: increases hypertension[6]
• In ALL cells, glucose toxicity increases oxidative stress and induces: carcinogenesis, obesity, diabetes and cardiovascular risk.

WHAT ARE THE FOODS THAT FAVOR THE METS

• Saturated fatty acids (mostly present in meat and dairy products)
• Trans fatty acids (they are those fats that were good and that the food industry has kindly turned into trans to make the foods that contain them last longer than not cured of the fact that they then close our arteries)
• Refined flours
• Sweet, light drinks
• Alcohol
• Too much protein a day

IN PRACTICE WHAT TO DO TO PREVENT IT?

• First thing I would recommend you do, take a tape measure and measure your waist circumference. Attention is measured parallel to the floor, between the belly and the rib cage7. Starting from this value, we understand what we are talking about.
• Check blood tests, check HDL cholesterol, triglycerides and fasting glucose values.
• Measure blood pressure in the pharmacy or from your primary care physician.

IN THE DAILY

• I will NEVER stop repeating that glucose enters the cell thanks to insulin or physical activity, therefore: movement 2 hours and a half per week (minimum) as recommended by WHO. Better yet, dare an hour a day.
• Take monounsaturated fats (olive oil, avocado oil, sunflower) unlike the bad satured Brothers, they reduce the cardiovascular risk
  
• Take omega-3 fatty acids (4% of total calories according to WHO): linseed oil, canola oil, hazelnuts, perilla oil, pumpkin seeds, chia oil. All the above are sources of alpha-linolenic acid (ALA) defined as essential since the human body cannot produce it independently. The recommended dose is 1 g / day.[8]
  
• Its function is a neuro-protector, it helps brain development during pregnancy. It has a cardioprotective effect and regulates the glycemic rate. The reason why it is so important it owes to its shape that you see in the image. Those double dashes you see make the tail of fatty acid very unstable. When it is inserted into the lipid bilayer which constitutes the cell membranes, it makes them malleable, elastic and ductile. The absence of these hyphens found in fatty acids of animal origin, makes the cell wall as rigid as a cod. And the messages hardly pass.
  
• Vegan diet, as described above, a diet with a prevalence of saturated fatty acids (animal), increases the cardiovascular risk.
• Weight loss

Weight loss, sa va sans dire, becomes the cornerstone for the resolution of the Mets. Weight loss is a random concept that depends on the starting weight and above all on the stabilization of the results. For this reason, the bariatric surgery is called into question. Batsis and his colleagues at the Mayo Clinic have shown that reversibility of risk factors is all the more effective as the excess weight lost is important. [9]

• I would not be exhaustive and correct if I did not also mention drug treatment.

o Statins, fibrates, ezetimibe to lower cholesterol and triglycerides

o Insulin, metformin to treat hyperglycemia

or Beta-blockers, ace-inhibitors, sartans, calcium channel blockers to limit pressure.

Those who know me know that I am a great supporter of a radical change in lifestyle. In other words, I find it paradoxical to give a statin so that the patient can eat 3 eggs a day; I find it useless to undertake an insulin treatment if there has not been a consistent effort to begin a suitable physical activity.

All these drugs have a cost: social and personal.

Social, as we all pay for public health costs;

Personal: paid by the patient through an endless list of side effects.

This is why the different health systems have begun to support bariatric surgery, because even if its cost is exorbitant immediately, it is still more affordable than paying the statins for a patient, insulin, to cover healthcare costs for the different recovery that will make for the various heart attacks and stents positioned to keep those poor coronary open.

I know, I have a very rigid vision. What hurts me is seeing a pandemic of diseases that are linked to our extremely unhealthy lifestyle. The International Obesity Taskforce requires socio-political interventions to combat the spread of obesity¹⁰. In my small and humble corner of the web, I struggle for this.

With gratitude,

[1] Aguilar M. Prevalence of metabolic syndrome in the United States, 2003-2012. JAMA 2015

[2] Li MC. Waist circumference in relation to outcomes of infertility treatment with assisted reproductive technologies. Am J Obstet Gynecoogy 2019

[3] HDL and cardiovascular disease, Rader D, The Lancet 2014

[4] Triglycerides and cardiovascular disease, Nordestgaard R, The Lancet 2014

[5] Furtado M. GLUT4 activation: thoughts on possible mechanisms. Acta Physiol. Scand. 2003

[6] Guo S. Insulin signaling, resistance, and metabolic syndrome: Insights from mouse models into diseasemechanisms. J Endocrinology 2014

[7] Wen-ya ma;Waist circumference in relation to outcomes of infertility treatment with assisted reproductive technologies. Diabetes care 2013

[8]  Blondeau n. Alpha-Linolenic Acid: An Omega-3 Fatty Acid with Neuroprotective Properties—Ready for Use in the Stroke Clinic? Biomed Res Int 2015

[9] Batsis et al. The Effect of Bariatric Surgery on the Metabolic Syndrome: A Population-based, Long-term Controlled Study, Mayo Clin Coll NHH access 2009

[10] World Health Organization, 1999. Obesity: Preventing and Managing the Global Epidemic. WHO Technical Report Series 894, Geneva: World Health Organization.