Clinical:Case Study: Diets and Women with Metabolic Syndrome

Original materials created in May 2002 by Jan Werbinski, M.D. and Christina Minger, EdD

History

JLW is a 54 y/o G2P2 gynecologist who comes in to discuss weight loss. She has been obese since her teens, with maximum weight of 289 lbs. Average adult body mass index (BMI) has been 40. She has tried various weight loss plans, “fad” diets, and exercise programs without success. At age 36, she underwent stomach stapling, leaving her stomach with a capacity of about 125 cc, also without success. She heard about something called “Insulin Resistance Syndrome (IRS),” and attended a complementary and alternative medicine program to learn about it.

Medications

Atenolol, hydrochlorothiazide/ triamterene

Past Med Hx

Hypertension-stage II, pernicious anemia

Family Hx

Obesity, DM-2, hypertension, coronary artery disease

Exam

W-appearing, BP 130/80, weight 270#, height 5’10” Normal except for obesity, disproportionately truncal

Studies (prior)

Fasting blood glucose 110; cholesterol 245, HDL 35, triglycerides 290; TSH 2.5. Blood glucose profile ordered after a 3 day diet high in simple carbohydrates: fasting glucose 98, fasting insulin 10; 2 hrs after a 75 gm glucola: insulin 107, glucose 110.

Discussion

Insulin Resistance Syndrome (IRS) is a popular topic in endocrinology literature. Metabolic Syndrome, DM-2, and Syndrome X are all forms of IRS at different points on a single continuum. IRS affects as much as 25% of the US population, including many non-obese individuals. Women are twice as likely as men to experience complications of IRS.^[1]

Typical patients with IRS have a steady increase in BMI with inability to lose weight or control sugar cravings. Associated findings include hypertension, high triglycerides and low HDL, amenorrhea, hirsutism, and polycystic ovaries. Complications of IRS include Syndrome X, described over 10 years ago by Dr. G. Reaven.^[2] Understanding IRS requires understanding glucose metabolism and utilization, and response to insulin.^[3] Defects in the metabolism of glucose can appear at any level of insulin or glucose production and utilization. People with IRS generally require more insulin than average to utilize glucose. Consequently, these patients have excess levels of both in their blood stream, setting up a positive feedback cycle. Because insulin is an anabolic hormone, the body has a continuous message to build, making it almost impossible to lose or maintain weight.

Pharmaceutical therapies that enhance insulin sensitivity are the most helpful for IRS: biguanides (like metformin) and thiazolidinediones or “TZD’s” (like rosiglitazone). Nutriceutical therapies (considered “Functional Medicine”) are newly developed complementary nutritional supplements designed to aid in the metabolism, transport, and excretion of glucose and its byproducts.4

Our Integrative Women’s Health practice has developed a system that has been enjoying some unique success in the diagnosis and management of this syndrome. We summarize here:

• Diagnosis: To increase our sensitivity, in addition to fasting glucose:insulin ratio (a positive test value is <4), we measure glucose and insulin 2 hours after 75 gm of glucola. A 2 hr insulin level > 35 is indicative of IRS.

• Complementary and Alternative Treat ment: According to Functional Medicine protocols, our patients receive individually tailored supplementation.4 The medical food includes vitamins, minerals, soy protein, amylose starch, fiber & micronutrients. This diet enhances transport of glucose into the cell, which improves sugar cravings. Soluble fiber prevents a rapid glucose load from being released to the blood stream.^[4]

• Diet: The balanced diet contains 40% CHO, 30% protein, and 30% fat. Daily caloric recommendation is based on BMI. Simple sugars and saturated fats are avoided, but mono-and polyunsaturated fats are encouraged, and even supple mented, including omega-3 fatty acids. Research supports omega-3 role in reducing inflammation, and improving cell membrane function.^[5] The classic Food Pyramid, currently recommended by the USDA (which is strongly supported by the meat and dairy industries), is NOT recommended because it is too high in carbohydrates.^[6]

• Exercise: We have developed a set of enjoyable, relaxing exercises for the IRS woman, who tends to tire easily and have many muscle and joint pains associated with her defective glucose metabolism. Our programs encourage movement, deep breathing, and relaxation with out stressing lower extremities and joints.

Plan

JLW was relieved to encounter providers who believed her reports of attempted weight loss. She was energized by the idea that her health issues were not “all her fault, and due to lack of will-power.” Our plan for JW:

• Proprietary medical food as described above (see Addi tional Information)
• Diet low in glycemic index
• Supplementation of B12 and folate with intrinsic factor due to her pernicious anemia
• Supplementation of fatty acids: Omega-3, Linoleic, and Meta-Lipoic
• Exercise in the form of our Cardio-Maestro class, in which we train women to deeply breathe and increase upper body movement while using an orchestra conductor’s baton and listening to pleasing music that also contributes to stress reduction
• Return visits are scheduled at 3 wks, 6 wks, 3 mos, 6 mos & 12 mos

Follow up

JLW began our program in June of 2001. She reported increased energy and decreased appetite, including sugar cravings, within 2 weeks. She is satisfied with much smaller portions. Her weight gradually decreased from 270 lbs to 215 lbs over the next 6 months. She increased to a walking program. She has discontinued the medical food, but continues with low glycemic foods and the fatty acid supplementation. She is continuing to lose weight and the cravings for sugar have not returned. Currently, she has lost 79 lbs.

Conclusion

Obesity is a complex subject that integrates psychosocial, economic, and political factors, along with biomedical and genetic implications. For many individuals who have tried (and failed) multiple programs, the problem may be related to hormone imbalances and metabolic conditions rather than the simplistic assumption that they are “eating too much.”

References

1. ↑ Inzucchi, S., JAMA, 2002;287:360-372.
2. ↑ Reaven,G. Am J Med, 1983; 74: 3-17.
3. ↑ Shephard, PR. Kahn, BB. New Engl J of Med, 1999;341(4): 248-56.
4. ↑ Lukaczer, D Lerman, R., Schiltz, B, Darland, G. Functional Medicine Research Center, 2000: Report # 105.
5. ↑ Belury MA, Vanden Heuvel JP. Advances in Conjugated Linoleic Acid Research, 1999; Vol 1 1999.
6. ↑ Moya-Camarena SY, Heuvel JP Blandchard SG, et al. J Lipid Res: 40 (8):1426-33.