Obesity, diabetes, and the metabolic syndrome; a broad spectrum of disease.

Patient with the metabolic syndrome

Courtesy: James Heilman MD

Wikimedia Commons

When a patient visits a doctor with classic symptoms of diabetes (excessive thirst, urination and loss of weight) the patient often reports the symptoms have been present for a week or two when in reality the patient has been in the pre-diabetic phase of the disease for years.

Although there are few if any symptoms in the pre-diabetic phase of disease and these patients generally have normal blood glucose levels, they have high circulating blood insulin levels, sometimes up to ten times higher than normal. Insulin is the hormone that regulates the body’s blood glucose level, and is produced by the pancreas. In obesity the fat cells block insulin from reaching the proper target cells and those cells from properly utilizing the insulin. This is called insulin resistance. Increased secretion of insulin by the pancreas to keep the glucose level normal causes the pancreas (an enzyme rich organ) to work overtime to control the blood glucose but in so doing releases some of its other enzymes into the circulation. If the scenario persists a chain reaction is set up resulting in a increased production of triglycerides (fat in the blood) an elevation in LDL (bad cholesterol) and reduction in HDL (good cholesterol). There is also production and release of inflammatory mediators, (substances produced by cellular reactions) and associated with release of pancreatic enzymes. These inflammatory mediators can promote heart disease and liver disease. Elevated insulin level also has an effect on the kidney that results in elevated blood pressure.  So it is not unusual for the patient that is seen by the doctor for the first time with symptoms of type 2 diabetes mellitus (T2DM) will also have high blood pressure. In these patients the silent metabolic effects of obesity and pre-diabetes have been present for a long period.  And if abdominal obesity, high blood pressure, high blood glucose, and abnormal triglycerides and cholesterol exist together they fit definition of the metabolic syndrome.

The metabolic syndrome is a constellation of conditions that include central obesity, diabetes, high blood pressure, and derangements of cholesterol (good and bad). The syndrome was first described in 1988. When present together these finings form a perfect storm for the development of heart disease, strokes, and kidney disease. Body fat is thought to be essential for the condition to exist, although in certain ethnic populations visible obesity is not always apparent nevertheless the majority of persons are visibly obese. It is the fat within organs and surrounding organs (visceral fat) rather than fat directly under the skin (subcutaneous fat) that drives the metabolic derangement.¹ This explains why of removal of subcutaneous fat with procedures such as liposuction has limited effect in the treatment of T2DM (only subcutaneous fat is removed with the procedure). The metabolic syndrome is associated with T2DM, cardiovascular disease, strokes and kidney disease.  The good new is that a prudent diet and increased levels of exercise can mitigate the effects of the syndrome and its complications. But when diet and exercise is not enough medications will be needed to control glucose, blood pressure, and cholesterol. There is more good news however! There is a possibility of remission (slowing or reversing the disease) in newly diagnosed diabetics. This will be posted in the next discussion.

1- Int J Obes Relat Metab Disord 1995, 19:846–850