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Metabola Syndromet

Bakgrund
Metabola Syndromet anses vara orsaken till,alternativt vara orsakat av, insulinresistens och även vara förstadiet till metabol Diabetes (pre-diabetes) vilket in sin tur orsakar hjärt-kärlsjukdom.
I USA anses ungefär 25% av hela befolkningen lida av det metabola syndromet eller metabol diabetes, (typ 2 diabetes) och ungefär 60% av befolkningen över 50 år.
Insulin resistens, metabola syndromet samt pre-diabetes är i stor sett synonymer men ändå finns en turorning i jnsjuknandet som varierar från individ till individ.
Skillnaden mellan typ 2 diabetes och metabola syndromet är blodsocker-förhöjningen (bukspottkörteln orkar helt enkelt inte producera tillräckligt stor mängd insulin för att hålla blodsockret "normalt")och därmed ökar därmed riskerna ytterligare för de metabola komplikationerna.
Metabola syndromet är ett kluster av minst tre av följande medicinska symtom: bukfetma, högt blodtryck, förhöjt blodsocker, höga triglycerider, och/eller lågt HDL-kolesterol där bukfetaman anses vara det centrala.

Riskfaktorer för det Metabola Syndromet
genetik, epi-genetik, låg fysisk aktivitet, tobaksbruk, högt intag av så kallad Western pattern diet och småätande.

Komplikationer till det metabola Syndromet
Metabola Syndromet har många kända och sannolikt även okända komplikationer så som: typ-2 diabetes, hjärt-kärlsjukdomar, njur- och leversjukdomar samt flera typer av maligniteter (1).
Metabolic dysfunction–associated steatotic liver disease (MASLD) is a type of chronic liver inflammation that leads to insulin resistance and fatty liver. Insulin resistance contributes to the accumulation of toxic fat in the liver in several ways.


Metabolic syndrome and Insulin resistance causes systemic inflammation, including C-reactive protein, IGF-1, fibrinogen, interleukin 6, tumor necrosis factor-alpha (TNF-α), and others are often increased.
This inflammation leading to low levels of Sex Hormone Binding Globulin (SHBG), which is compensated by the gonads producing less sex hormones, which in turn leads to a normal sex hormone/SHBG ratio. Because these low total levels of sex hormones cause women to have more masculine traits and men to have more feminine traits, because the adrenal glands produce small amounts of all sex hormones.
Other associated conditions include hyperuricemia, polycystic ovarian syndrome and erectile dysfunction.
It is not uncommon for patients to experience a hormonal imbalance with fibromyalgia-like symptoms and to insist on overdoses of various hormones, such as thyroid hormone and testosterone.
A contributing factor to this may be that most hormone carrier proteins (e.g thyroid hormone and SHBG) are formed in the liver and are likely affected by insulin resistance and fatty liver. There is very little research on this and it needs to be investigated further.

Treatment of Metabolic Syndrome
The aim of such treatment is to achieve permanent weight loss with as few side effects as possible.
There are many "miracle cures" for rapid weight loss, but virtually none of them have any long-term follow-up.
Various surgical procedures
are practically impossible to carry out on a population basis and there is little long-term follow-up. Initially, patients experience significant weight loss and improved risk factors, but also experience various deficiency symptoms fairly immediately.
I have had a handful of patients who up to 40 years after such a procedure, still having trouble with postprandial hypoglycemia they have to compensate for with fast carbohydrates.
When I have mentioned this to other patients they recognize these symptoms, probably there may be a pretty large hidden number.
Far from everyone is satisfied after such a procedure and the result on weight is not impressive either.
Those I have met, several years after such procedure, have gone from having a severe obesity to a more mildly obesity.
Incretins
Cause weight loss, but we don't know much about the long-term effects.
Many of the "risk factors" for metabolic diseases and for death are improving by both surgical intervention and incretins. But the "risk factors" are not a direct "link" of metabolic diseases and death, but an indication.
My opinion is that long-term studies are needed before we can use incretins and surgical intervention as treat and preventions metabolic diseases complication and death..


Meformin
Is an old diabetes drug that has been used since the 1950s, where many of the "new" diabetes drugs often originate. Metformin is no longer patented, which may be the reason why industry cannot/does not want to research this. Despite this, Metformin is gaining more and more indications. Metformin is nowadays the first-line treatment for type 2 diabetes and gestational diabetes. It is also uses as a complement in the treatment of certain cancers and last but not least, it is also indicated in many countries for weight reduction purposes.
The advantage of Metformin is that since it has been used since the 1950s, there is very good knowledge about its long-term effects.

Behandling av det Metabola Syndromet
Beroende på hur patienten kommer till mig försöker jag designa en behandling för den enskilda patienten. Många är övertygade om att de lider av någon hormon brist. Hos kvinnor ofta sköldkörtelhormon och hos män ofta Testosteron.

For these people, I usually do a hormone screening with C-peptide, thyroid hormones, cortisol, growth hormone and testosterone/SHBG.
At the next visit we will go over these answers.
In women it usually happens that all the tests are good but testosterone/SHBG is elevated. Then I say that everything looks good but you have a little too much testosterone.
In men I say that everything looks good but you have a little too little SHBG which is why your testicles compensate by reducing their production of testosterone.
Then I go into the fact that the cause is due to fatty liver and insulin resistance and the cure is to reduce insulin resistance.

Primary target, Insulin Resistance
The best is physical activity which is twice as good as Metformin.
Since we took C-peptide at the first visit, we start by recommending physical activity for 20 minutes daily. At the return visit, we check C-peptide again, which has then decreased significantly, which gives positive feedback.
We start by recommending a 20-minute walk daily, which some claim they are unable to do due to the strain of their excess weight. The second choice is cycling and/or swimming, as the burden of excess weight becomes significantly less. Even then some claim that it is not possible. My answer then is:
-it is very unfortunate if you are not capable of physical activity as the prognosis deteriorates considerably.. what do you think about starting with 10 minutes daily instead?

Intake and energy
Energy requirements to achieve a normal weight when working in a low energy consumption environment: A woman about 1600 kcal/day and a man about 1800 kcal/day. Under that energy restriction, you should get all the nutrients you need. It's not that easy...


My strategies
Self-care
1. Regular physical exercise as described in the "Background facts".
Before starting the regular physical activity I normally use to take a test, or some tests, of the insulin resistance/productions e.g: C-peptide and/ or IGF-1.
At the return visit, for an initial positive feedback, these samples are checked again which has decreased significantly.

2.Regular meal schedule as described in the "Background facts": with 2-3 meals/day and long fasting periods in between.
2. Beverage: water, possibly flavored with a slice of orange or lemon.
3. No sweets or snacking between meals and a long overnight fast.
Medical treatment
Since Metabolic syndrome, or as it is also called pre-diabetes, is a "light variant" of Type 2 diabetes, the main target is obesity/overweight.
If self-care does not have sufficient effects, I usually start with a cautious introduction of Metformin 500 mg at a time, which is increased by 500 mg/month up to the full dose.
If the overweight is significant, GLP-1 analogues can be used in combination with metformin on obesity indications.
I have never, so far, prescribed surgical procedures to anyone, but have had (more than one patient) with poor long-term outcomes. I have not yet seen any studies on what effect it has on long-term complications and death.