Case details –
The patient is obese and is also suffering from “Metabolic syndrome”. She has a history of obesity dating to early child hood and also has a positive family history. Her symptoms are suggestive of metabolic syndrome, a common complication of Obesity. Some of her features can be discussed as –
1) Obesity –She has an apple (android) pattern of fat distribution. Her waist to hip ratio is 41/39=1.05. Apple shape is defined as a waist to hip ratio of more than 0.8 in women, and more than 1.0 in men. She has therefore apple pattern of fat distribution which is common in males. Compared with other women of same body weight who have gynoid fat pattern, the presence of increased visceral or intra abdominal adipose tissue places her at greater risk for diabetes, hypertension,dyslipidemia and coronary heart disease. (The gynoid, “pear- shaped” or lower body obesity is defined as a waist to hip ratio of less than 0.8 for women and less than 1.0 for men. The pear shape is relatively benign health wise and is commonly found in females).
2) BMI (Body Mass Index)
BMI=Weight (kg)/height (m2).
For this patient
188 Pounds=85.5 kg (Approximately)
5 feet 1 inch height=1.55 meters (154.94 cm)
= 35.6 kg/ m2
World Health Organization (WHO) criteria based on BMI
Under this convention for adults,
Grade 1 overweight (commonly and simply called overweight) is a BMI of 25-29.9 kg/m2.
Grade 2 overweight (commonly called obesity) is a BMI of 30-39.9 kg/m2.
Grade 3 overweight (commonly called severe or morbid obesity) is a BMI greater than or equal to 40 kg/m2.
From the result calculated for the given patient, it is indicated that the patient is obese (Grade 2 overweight).
3) Metabolic syndrome The patient is also suffering from ‘Insulin resistance syndrome’.She has hypertension, dyslipidemia, Hyperinsulinemia and impaired glucose tolerance.
Metabolic syndrome also referred to as Syndrome X or insulin resistance syndrome consists of a number of metabolic risk factors that increase the risk for atherosclerotic cardiovascular disease (CVD) and other cardiovascular complications such as cardiac arrhythmias, heart failure, and thrombotic events.
a) Criteria for diagnosis According to the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) report, there are six major components of metabolic syndrome relating to the development of CVD:
1) abdominal obesity
2) atherogenic dyslipidemia
3) elevated blood pressure
4) insulin resistance (with or without the presence of glucose intolerance)
5) proinflammatory state, and
6) prothrombotic state.
Note- A prothrombotic state is characterized by abnormalities,specifically elevations, in procoagulant factors, anti fibrinolytic factors,platelet alterations, and endothelial dysfunction. A proinflammatory state is characterized by elevations of circulating inflammatory molecules such as C-reactive protein (CRP), tumor necrosis factor-alpha, plasma resistin, interleukin (IL)-6, and IL-18. CRP is a general marker of inflammation that has been linked to CVD in patients with metabolic syndrome.
b)Associated diseases– Cardiovascular diseases and type 2 diabetes mellitus can be present in association with metabolic syndrome. The relative risk for new-onset CVD in patients with the metabolic syndrome, in the absence of diabetes, averages between 1.5- and threefold. Overall, the risk for type 2 diabetes in patients with the metabolic syndrome is increased three to fivefold. Patients with metabolic syndrome are also at increased risk for peripheral vascular disease. In addition to the features specifically associated with metabolic syndrome,insulin resistance is accompanied by other metabolic alterations. These include increases in uric acid,microalbuminuria, nonalcoholic fatty liver disease (NAFLD) and/or polycystic ovarian disease (PCOS), and obstructive sleep apnea (OSA).
A person suspected of having this syndrome should have a through history taken especially with regard to family history and presence of other cardiovascular risk factors.
c) An examination should include:-
a) Recording the body weight
b) Calculating the BMI
c) Measurement of the waist circumference in inches
d) Calculating the hip-waist ratio
e) Measurement of the subcutaneous fat at 4 sites-biceps, triceps, sub scapular and supra-iliac
f) Blood pressure measurement.
d) Laboratory Tests
1) Fasting lipids and glucose estimations are needed to determine if the metabolic syndrome is present.
2) The measurement of additional biomarkers associated with insulin resistance must be individualized. Such tests might include apo B, high-sensitivity CRP,fibrinogen, uric acid, urinary microalbumin, and liver function tests.
3) A sleep study should be performed if symptoms of OSA are present.
4) If PCOS is suspected based on clinical features and an ovulation, testosterone, luteinizing hormone, and follicle-stimulating hormone should be measured.
e) Management of metabolic syndrome – is highly dependent on the control of all of the contributing factors. This includes both underlying risk factors as well as metabolic risk factors. Lifestyle modifications should be implemented immediately for all patients diagnosed with metabolic syndrome. Lifestyle modifications include weight reduction, increased physical activity and nutritional therapy. Additional risk assessments should be performed in patients to assure appropriate goals of therapy throughout the course of the syndrome.