How is metabolic syndrome treated?

The major goals are to treat both the underlying cause of the syndrome, and also to treat the cardiovascular risk factors if they persist. As has been discussed, the majority of people with metabolic syndrome are overweight and lead a sedentary lifestyle. Lifestyle modification is the preferred treatment of metabolic syndrome. Weight reduction usually requires a specifically tailored multifaceted program that includes diet and exercise. Sometimes medications may be useful. Diet A detailed discussion of diet therapies, pros and cons of various diets etc. is beyond the scope of this article. However, there is now a trend toward the use of a Mediterranean diet -- one that is rich in "good" fats (olive oil) and contains a reasonable amount of carbohydrates and proteins (such as from fish and chicken). The Mediterranean diet is palatable and easily sustained. In addition, recent studies have shown that when compared to a low fat diet, people on the Mediterranean diet have a greater decrease in body weight, and also had greater improvements in blood pressure, cholesterol levels, and other markers of heart disease -- all of which are important in evaluating and treating metabolic syndrome. Exercise A sustainable exercise program, fore example 30 minutes five days a week is reasonable to start, providing there is no medical contraindication. (If you have any special concerns in this regard, check with your doctor first.) There is a beneficial effect of exercise on blood pressure, cholesterol levels, and insulin sensitivity, regardless of whether weight loss is achieved or not. Thus, exercise in itself is a helpful tool in treating metabolic syndrome. Cosmetic surgery to remove fat Some people may ask: Why not just have liposuction of the abdomen and remove the large amount abdominal fat, which is a big part of the problem? Data thus far shows no benefit in liposuction on insulin sensitivity, blood pressure, or cholesterol. As the saying goes, "If it's too good to be true, it

probably is." Diet and exercise are still the preferred primary treatment of metabolic syndrome. What if lifestyle changes are not enough to treat metabolic syndrome? What if changes in lifestyle do not do the trick, what then? Drugs to control cholesterol levels, lipids, and high blood pressure may be considered. If someone has already had a heart attack, their LDL ("bad") cholesterol should be reduced below 100mg/dl. (Some experts now say it should be under 70mg/dl.) A person who has diabetes has a heart attack risk equivalent to that of someone who has already one and so should be treated in the same way. What remains controversial is whether metabolic syndrome should be considered a coronary equivalent or not. If you have metabolic syndrome, a detailed discussion about lipid therapy is needed between you and your doctor, as each individual is unique. Blood pressure goals are generally set lower than 130/80. Some blood pressure medications offer more than simply lowering blood pressure. For example, a class of blood pressure drugs called ACE inhibitors has been found to also reduce the levels of insulin resistance and actually deter the development of type 2 diabetes. This is an important consideration when discussing the choice blood pressure drugs in the metabolic syndrome. The discovery that a drug prescribed for one condition, and has other beneficial effects is not new. Drugs used to treat high blood sugar and insulin resistance may have beneficial effects on blood pressure and cholesterol profiles. A class of drugs called thiazolidinediones [pioglitazone (Actos) and rosiglitazone (Avandia)] also reduce the thickness of the walls of the carotid arteries. Metformin (Glucophage), usually used to treat type 2 diabetes, also has been found to help prevent the onset of diabetes in people with metabolic syndrome. Indeed, in my practice, I routinely discuss metformin with my patients who have metabolic syndrome. Many of my patients who have insulin resistance associated with metabolic syndrome opt for metformin therapy. However, there are currently no established guidelines on treating metabolic syndrome patients with metformin if they do not have overt diabetes.

How Is Metabolic Syndrome Treated?

Healthy lifestyle changes are the first line of treatment for metabolic

syndrome. Lifestyle changes include losing weight, doing physical activity regularly, following a heart healthy diet, and quitting smoking. If lifestyle changes aren't enough, your doctor may prescribe medicines. Medicines are used to treat and control risk factors such as high blood pressure, high triglycerides, low HDL cholesterol, and high blood sugar. Blood-thinning medicines, such as aspirin, also may be used to reduce the risk of blood clots. Excessive blood clotting is a condition that often occurs with metabolic syndrome.

Goals of Treatment
The major goal of treating metabolic syndrome is to reduce the risk of heart disease. Treatment is directed first at lowering LDL cholesterol and high blood pressure and managing diabetes (if these conditions are present). The second goal of treatment is to prevent the onset of type 2 diabetes (if it hasn't already developed). Long-term complications of diabetes often include heart and kidney disease, vision loss, and foot or leg amputation. If diabetes is present, the goal of treatment is to reduce the increased risk of heart disease by controlling all of your risk factors. The main focus of treating metabolic syndrome is managing the risk factors that are within your control, such as overweight or obesity, an inactive lifestyle, and an unhealthy diet.

Lifestyle Changes
Losing Weight In general, people who have metabolic syndrome and are overweight or obese should try to reduce their weight by 710 percent during the first year of treatment. For example, if you weigh 250 pounds, you should try to lose 18 to 25 pounds. If you weigh 300 pounds, you should try to lose 21 to 30 pounds. After the first year, you're urged to continue to lose weight to the extent possible, with a long-range target of lowering your body mass index (BMI) to less than 25. BMI measures your weight in relation to your height and gives an estimate of your total body fat. A BMI between 25 and 29.9 is considered overweight. A BMI of 30 or more is considered obese. A BMI of less than 25 is the goal for prevention and treatment of metabolic syndrome. You can calculate your BMI using the National Heart, Lung, and Blood

Institute's (NHLBI's) online calculator, or your health care provider can calculate your BMI. For more information on losing weight or maintaining your weight, see the Diseases and Conditions Index article on Overweight and Obesity. Following a Heart Healthy Diet A heart healthy diet is an important part of a healthy lifestyle. Choose a variety of fruits, vegetables, and grains; half of your grains should come from wholegrain products. Choose foods that are low in saturated fat, trans fat, and cholesterol. Healthy choices include lean meats, poultry without skin, fish, beans, and fat-free or low-fat milk and milk products. Try to limit foods that have a lot of sodium (salt). Too much salt can raise your risk of high blood pressure. Recent studies show that following the Dietary Approaches to Stop Hypertension (DASH) eating plan can lower blood pressure. Choose foods and beverages that are low in added sugar. If you drink alcoholic beverages, do so in moderation. Aim for a healthy weight by staying within your daily calorie needs. Balance the calories you take in with the calories you use while doing physical activity. For more information on following a heart healthy diet, see the NHLBI's Aim for a Healthy Weight Web site, "Your Guide to a Healthy Heart," "Your Guide to Lowering Your Blood Pressure With DASH," and "Your Guide to Lowering Your Cholesterol With TLC." All of these resources provide general information about healthy eating. Doing Physical Activity Regularly Being physically active, along with following a healthy diet and not smoking, is one of the most important things you can do to keep your heart and lungs healthy. Many Americans are not active enough. The good news is that even modest amounts of physical activity are good for your health. The more active you are, the more you'll benefit. Before starting any kind of exercise program or new physical activity, talk with your doctor about the types and amounts of physical activity that are safe for you.

The four main types of physical activity are aerobic, muscle-strengthening, bone strengthening, and stretching. You can do physical activity with light, moderate, or vigorous intensity. The level of intensity depends on how hard you have to work to do the activity. People who have metabolic syndrome usually are urged to keep up a moderate level of activity. For more information about physical activity, see the U.S. Department of Health and Human Services "2008 Physical Activity Guidelines for Americans," the Diseases and Conditions Index Physical Activity and Your Heart article, and the NHLBI's "Your Guide to Physical Activity and Your Heart." Smoking If you smoke, quit. Smoking can raise your risk of heart disease and heart attack and worsen other heart disease risk factors. Talk to your doctor about programs and products that can help you quit smoking. Also, try to avoid secondhand smoke. If you have trouble quitting smoking on your own, consider joining a support group. Many hospitals, workplaces, and community groups offer classes to help people quit smoking.

Medicines
If lifestyle changes aren't enough, your doctor may prescribe medicines to help you control your risk factors. Medicines may be prescribed to help treat unhealthy cholesterol levels, high blood pressure, and high blood sugar. Unhealthy cholesterol levels are treated with medicines such as statins, fibrates, or nicotinic acid. High blood pressure is treated with medicines such as diuretics or ACE inhibitors. High blood sugar is treated with oral medicines (such as metformin), insulin injections, or both. Low-dose aspirin can help reduce the risk of blood clots, especially for people at high risk of heart disease.