Metabolic syndrome: 5 risk factors guide therapy

Current Psychiatry. 2005 April;04(04):73-88

April 1, 2005|Psychiatry

Easy-to-use clinical values tell when to intervene.

Table 2

Suggested monitoring intervals for patients taking atypical antipsychotics*

	Baseline	4 weeks	8 weeks	12 weeks	Quarterly	Annually	Every 5 years
Personal/family history	X					X
Weight (BMI)	X	X	X	X	X
Waist circumference	X					X
Blood pressure	X			X		X
Fasting plasma glucose	X			X		X
Fasting lipid profile	X			X			X
*Clinical status may warrant more-frequent assessments
BMI: Body mass index
Source: Reference 6.

MANAGING METABOLIC PROBLEMS

Managing metabolic abnormalities or metabolic syndrome is aimed at preventing type 2 diabetes and CVD. Levels of intervention include:

weight management, weight control education, and promoting regular exercise and a healthy diet
switching to a psychotropic that is less likely to cause weight gain, if clinically appropriate
working with the patient’s primary care physician to manage dyslipidemia, hypertension, obesity, or hyperglycemia.

Weight management. Start by controlling weight and promoting regular exercise and healthy eating. Switching medications—often the first response—may not be the best option, particularly if the offending agent is relieving the patient’s psychiatric symptoms.

Losing weight, increasing exercise, and reducing fat and carbohydrate intake can reverse metabolic syndrome and delay onset of type 2 diabetes and CVD.⁷ Even a small weight loss, such as 10% of baseline body weight in persons who are overweight (BMI >25) or obese (BMI >30) can significantly reduce the risk of hypertension, hyperlipidemia, hyperglycemia, and death.⁷

Rather than promoting a single diet, tailor dietary advice to each patient’s metabolic abnormalities (Table 3). Although researchers disagree over whether a low-fat or low-carbohydrate diet produces better results, either diet will work as long as the patient consumes fewer calories than he or she expends. This is because weight loss alone reverses metabolic syndrome.

Likewise, exercise can reverse metabolic syndrome independent of diet change. Regular exercise at modest levels improves HDL,² triglycerides,¹⁷ blood pressure,¹⁸ and hyperglycemia.¹⁹

In one prospective study,²⁰ 621 subjects without chronic disease or injury underwent supervised aerobic training three times weekly for 20 weeks. Participants were told not to otherwise change their health and lifestyle habits.

Of the 105 persons in the cohort who had metabolic syndrome at baseline, 32 (30%) no longer had it after the aerobics program. Among these participants:

43% had lower triglycerides than at baseline
16% had higher HDL cholesterol
38% had lower blood pressure
9% had improved fasting glucose
28% reduced their waist circumference.

Table 3

Interventions for specific metabolic complications

Metabolic complication	Nondrug interventions⁸	Medications
Abdominal obesity	Encourage weight loss	Sibutramine^*†
	Increase physical activity	Appetite suppressant
		Orlistat^*†
		Lipase inhibitor
Hypertriglyceridemia	Encourage weight loss	Fibrates^9*
	Increase physical activity	Reduce fasting and postprandial triglycerides 20% to 50%
	Increase low-glycemic-index food intake	Shift small dense LDL to large buoyant particles
	Reduce total carbohydrate intake	Increase HDL particles 10% to 35%
	Increase consumption of omega-3 fatty acids	Nicotinic acid¹⁰
	Limit alcohol consumption	Reduces triglycerides 20% to 50%
		Statins¹¹
		Reduce fasting and postprandial triglycerides 7% to 30%
		Reduce LDL particles
		Increase HDL particles
		Reduce major coronary vascular events
Low HDL	Encourage weight loss	Nicotinic acid^*
	Increase physical activity	Increases HDL particles 15% to 35%
	Stop smoking	Fibrates⁹
	Increase monounsaturated fat intake	See above
		Statins¹¹
		See above
Hypertension	Encourage weight loss	ACE inhibitors^*
	Increase physical activity	May slow progression to diabetes¹²
	Reduce saturated fat intake	Decrease CVD events¹³
	Reduce sodium intake	Delay progression of microalbuminuria¹³
	Limit alcohol consumption	Angiotensin receptor blockers
		May improve dyslipidemia associated with metabolic syndrome¹⁴
		Delay progression of microalbuminuria¹³
Hyperglycemia	Encourage weight loss	*Metformin,^ thiazolidinediones**
	Increase physical activity	Slow progression to diabetes in persons with insulin resistance^15,16 (metformin less effective than lifestyle changes)¹⁵
	Reduce total carbohydrates
^* Suggested first-line therapy.
^† For patients with BMI 30 kg/m2
ACE: Angiotensin-converting enzyme
CVD: Cardiovascular disease
HDL: High-density lipoprotein cholesterol
LDL: Low-density lipoprotein cholesterol

Selling the benefits of exercise and weight loss to a mentally ill patient can be difficult. Attention, memory, and motivation deficits as well as smoking and substance abuse often get in the way.

By teaming up with clinicians with expertise in dieting such as nurses, dietitians, and recreational therapists, psychiatrists can more effectively promote long-term diet, exercise, and lifestyle changes.²¹

In a prospective 12-month trial,²² 20 patients who were taking atypical antipsychotics for schizophrenia or schizoaffective disorder completed a 52-week program that incorporated nutrition, exercise, and behavioral interventions. Twenty similar patients received treatment as usual. Patients in the program saw significant improvements in weight, blood pressure, exercise habits, nutrition, and hemoglobin A1c compared with the treatment-as-usual group.²²

Psychiatrists who treat privately insured patients should collaborate with the patient’s primary care physician. Many insurance plans will pay for 1 or 2 personal or group sessions with a dietitian, especially if the patient is diagnosed as being obese (BMI >30). Some large plans, such as Kaiser Permanente, will cover intensive multimodal treatment, especially for patients with a BMI >35. Calculating the patient’s BMI can help you document the need for antiobesity treatment (see Related resources).

Medication. If weight control and exercise do not reduce metabolic risk factors after 3 to 6 months, consider switching to an atypical antipsychotic with a lower propensity for causing metabolic effects.

Which agents most decrease metabolic risk has been debated. Preliminary evidence indicates that switching from other antipsychotics to aripiprazole or ziprasidone may reduce weight and improve cholesterol ratios.^23,24 These findings are consistent with the ADA/APA consensus guidelines, which indicate that metabolic risk varies among atypical antipsychotics (Table 4).⁶

References