Lorraine Albon, an acute medical physician with a special interest in obesity medicine, talks to us about the metabolic syndrome
At a fast pace, Lorraine gives us a comprehensive overview of the metabolic syndrome. At its core is insulin resistance and hyperinsulinaemia.
Lorraine points out that how we view weight in society is changing, and that “overweight” is now being seen as normal. What do we think of our patients in our ICU beds? Are we normalising obesity and making it acceptable?
The metabolic syndrome consists of a pro-inflammatory and pro-coagulopathic process. It is becoming increasingly recognised that adipose tissue is highly active hormonal tissue. The interaction between excess adopts tissue and the other body hormonal systems (e.g. HPA axis) is complex but important.
Lorraine presents graphical data of coronary heart disease for cohorts of patients with and without diabetes and metabolic syndrome. Interestingly, patients with diabetes but not metabolic syndrome have the same risk as those without either disease. It appears that it’s not the diabetes but the metabolic syndrome that causes the cardiovascular disease. This can be measured by testing glucose tolerance and C-reactive protein.
Key message: cardiologists should view coronary heart disease and a part of metabolic syndrome and their patients should be tested for it.
The bigger picture of metabolic syndrome is the small detail. Do you think about ferritin and vitamin levels in obese patients presenting for surgery or when critically ill? Deficiencies are very common (vit D ~ 80% of patients presenting for Tier 3 obesity management [tier 4 is surgery]).
Lorraine hits hard with a message about bias. “There are three groups in society we allow ourselves to tease: white van drivers, those with certain hair colour, and the obese.” And this is just the explicit bias. There are implicit biases that affect our decision making every day. Patients know this. For example, overweight women will delay presentation to their doctor for post-menopausal bleeding due to expectations and embarrassment – the consequence is late diagnosis of endometrial cancer in obese individuals.
Can we make a difference? Yes. Improving diabetic management so that HbA1c falls by 1% (~ 8 mmol/mmol) will reduce cardiovascular events by 15%.
Lorraine goes on to show that long-term weight loss is hard to maintain. Once the intervention stops, studies show a rebound weight gain. This is probably because calorie restriction leads to release of appetite inducing hormones – individuals feel more hungry and the psychology of this is negative. This is a good argument for bariatric/metabolic surgery, which modifies the hormonal response in addition to reducing caloric intake.
- Record obesity and code for it
- Treat deficiencies in the obese
- Consider effect of drugs, such as long term steroids
- Consider referral to sleep study and obesity pathways
- Warn people and their families about how hard it will be to maintain weight loss
The concluding slide is Tom Hanks “before and after”, who now suffers from Type 2 Metabolic Syndrome!
Lorraine also spoke at Wessex ICM Specialty Training teaching in December 2015.