A Resource from the American College of Preventive Medicine
A TIME TOOL FOR CLINICIANS
ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals. Please refer to the Metabolic Syndrome Clinical Reference for more information.
METABOLIC SYNDROME: We can diagnosis and code it … Now what?
The metabolic syndrome (MetS) is a constellation of interrelated risk factors of metabolic origin – factors that directly promote atherosclerosis and increase the likelihood of developing Type 2 diabetes.
The Metabolic Syndrome is still somewhat controversial
- The primary risk factors are central obesity, hypertension, atherogenic dyslipidemia, and impaired glucose metabolism.
- Other lipid disturbances, pro-thrombotic, and pro-inflammatory factors also involved. Risk increases as the number and extent of abnormalities increase.
- In general, doubles the risk for CVD, 5 times the risk for Type 2 diabetes.
- Currently one in three adults in the U.S. has the syndrome. Over age 60, nearly half (45%). Increasing in children.
Differing definitions – many criteria, some (e.g., insulin resistance) not practical to measure; optimal combination not certain; groups are working toward a consensus.
But the syndrome is vital to consider in clinical practice
- Some (ADA) contend that diagnostic criteria are incomplete, thresholds ill-defined, that it does not change risk prediction or treatment decisions, and has no clear etiology.
It is a by-product of the obesity epidemic; identifies those with genetic predisposition to health risks, especially CVD and diabetes. It is important because it:
- adds to CVD risk beyond LDL cholesterol,
- emphasizes the deleterious impact of central fat accumulation,
- allows lifestyle-associated risk to be quantified,
- provides a huge Red Flag that lifestyle modifications are needed now.
The MetS was never intended to be a global risk predictor. It is a syndrome …not perfectly defined or understood, but describing a constellation of related disorders that deserves attention...from clinicians, scientists and especially those who have it.
The driving force behind the syndrome is expanding fat massThe NCEP ATP III definition is the standard -- designed for clinical practice.
There is little disagreement on this. Expanding abdominal fat cells begin a cascade of metabolic abnormalities, stemming from the increased release of free fatty acids, pro-inflammatory cytokines, and hormones that affect appetite and energy balance. The resulting insulin resistance is the best, albeit not only, explanation for the metabolic abnormalities.
It is pragmatic, easily understood and easily applied in the practice setting.
The diagnosis is made when any three of the following risk factors are present:
- Uses simple vital signs – blood pressure and waist circumference.
- Is economical – routine fasting blood work for glucose and lipids.
- Is broadly acceptable and codeable – ICD-9: 277.7
The Metabolic Syndrome is all about lifestyle.
- Waist circumference ≥ 40” (men) or ≥ 35” (women)
- Blood pressure > 130/85 (either number)
- Triglycerides ≥ 150 mg/dL
- HDL cholesterol < 40 mg/dL (men) or < 50 mg/dL (women)
- Fasting glucose ≥ 100 mg/dL
It is caused by lifestyle and cured by lifestyle.
Second line is pharmacotherapy -- if lifestyle modifications are not enough or risk factor levels too high.
- Lifestyle modification is the first line of treatment -- a healthier diet, more exercise and modest weight loss; it can reverse the syndrome in many.
- Patients can avoid medications, feel more in control, more confident in managing their own well being
The Challenges for Primary Care
- No single drug for the syndrome at this time; each condition treated individually, in the context of the syndrome. Need to prescribe drugs that do not worsen other aspects of the syndrome.
- Recognize the Metabolic Syndrome, evaluate associated risk conditions, develop a medical plan, educate patients on why it is important, discuss needed lifestyle modifications and a plan for achieving them.
- Need an efficient approach to cover all of the issues in a brief consult.
Two Solutions that Can Help
- Develop office systems that support and facilitate on-going chronic condition management and behavior change.
- Develop office teams that can provide the counseling, support and follow-up to help patients change their lifestyles to lose weight, eat healthier, and become more physically active.
- Reorganize practice systems according to the Chronic Care Model - to support self care, lifestyle modification, and sustained follow-up.
- A guide for the brief consult that covers all related issues and sets the stage for the lifestyle intervention.
Integrating the Chronic Care Model
Six aspects to target:
1) Improve patient self management support
- Train non-physician staff in patient centered counseling, motivational interviewing
- Includes encouraging, educating, goal setting, action plans, teaching healthy behaviors and problem solving skills, providing support, and follow-up
2) Re-design the practice to provide self management support:
- Use planned visit protocols – pre-determined agenda using individual or group visits, phone calls or emails, internet programs
- Develop care teams – identify roles, provide training; includes clinicians, nurses, dietitians, social workers, behavioral health professionals, health coaches, exercise therapists, community health workers
3) Provide decision support based on evidence-based guidelines
- Integrate chart reminders for recommended services, protocols
- Provide balanced information to support and involve patients in decisions about their care
4) Develop clinical information systems to assist tracking care
- Develop patient registries for specific conditions, such as the MS
- Designate a team member to periodically review, update, identify needed services, reminders to send out
5) Develop the foundation for re-organizing the practice:
- Leadership buy-in – must understand and embrace the Chronic Care Model
- Financing restructuring – comprehensive per-patient payments rather than fee for service financing, which may not reimburse non-physician services
6) Develop a community resources directory of available services
- Primary care practices can seldom provide all of the services needed for patients with chronic conditions – need to use local resources to fill the gaps
Guide to the Office Visit
Prior to Visit
Any patient with excessive abdominal fat, CVD risk factors, or a family history of diabetes or cardiovascular disease is a candidate.
Pre-Consult -- Nurse
- Obtain standard blood panel
- Measure/record waist circumference and blood pressure
- Calculate a Framingham CVD Risk Score (age, gender, smoking status, SBP, blood pressure meds, HDL-C, total cholesterol) – 10 year CVD event probability
- Checklist of Metabolic Syndrome criteria (NCEP ATP III)
- Syndrome present if 3 or more criteria met.
- Code as "Dysmetabolic Syndrome", ICD-9 code: 277.7
Review Risk Factors And Diagnosis
Explain the Syndrome
- Review patient’s risk factors, diagnosis of metabolic syndrome
Discuss the Risks
- Metabolism – the break down of food and beverages for energy and nutrients; genes favor fat storage.
- Syndrome -- a group of abnormalities with same underlying causes – in this case, weight gain, too little exercise, unhealthy diet.
- Expanding abdominal fat cells – insulin resistance, inflammation, weight regulation.
- Inactivity -- muscles need less energy, become resistant to insulin.
- More sugar in the blood – excess insulin, exhausts pancreas.
- More bad fat in the blood -- damages blood vessels.
- Process progresses depending on genes.
Outline a Plan to Reverse the Syndrome
- 4-5 times more likely to develop Type 2 diabetes and all its problems -- can't separate the syndrome from diabetes. It’s part of the natural course.
- Doubles the risk for heart attacks and strokes -- the syndrome accelerates atherosclerosis.
- Risk for several other disease processes increased as well.
Assess Willingness to Try Lifestyle Approach
- The good news: lifestyle is the cause, and the cure.
- The first step -- eating healthier and getting more physical activity every day – the first line and primary therapy.
- The pros -- it improves every risk factor, you get healthier, look and feel better, fewer medications (perhaps none)
- The cons – it’s not easy, takes discipline, commitment
- Drug therapy is the alternative; many will need some meds, hopefully temporarily
- The pros – it’s easier; helps to improve lifestyle but don’t have to do as much
- The cons – no single drug for the syndrome, probably need multiple drugs, side-effects/interactions possible, cost
- Discuss options – recommended drug therapy at this time (including current regimen)
Would you like to try the lifestyle modification approach?
- YES – Describe team (may include community resources) who will provide guidance; provide hand-outs on Metabolic Syndrome and lifestyle modification process
- NO – Prescribe pharmacotherapy [ABCD approach]
Pharmacotherapy Planning Using the ABCD Approach
- Recommend daily low dose (81 mg) aspirin if intermediate or high risk AND no contraindications
|B:Blood pressure – Goal is < 130/80|
- First line therapy: ACE inhibitor or angiotensin receptor blocker
- Avoid beta blockers, diuretics – may increase glucose intolerance
- LDL goal is < 130 mg/dL (intermediate risk), < 100 mg/dL (high risk)
- First line: Statin therapy
- Non-HDL goal is < 160 mg/dL (intermediate risk), < 130 mg/dL (high risk)
- First line: Statin intensification, then fenofibrate
- Consider omega-3 fatty acid supplement
- HDL goal is > 40 mg/dL (men), > 50 mg/dL (women)
- Consider long-acting niacin
- Metformin first, then consider pioglitazone
Describe Follow-Up Plan
- Provide checklist for scheduling
- Lifestyle counseling plan – orientation, meetings, phone calls
- Follow-up check-up with physician
A Final Thought
The Metabolic Syndrome is about the patient's future quality of life. It is about:integrating preventive approaches to obesity, diabetes and heart disease, identifying patients with the syndrome as early in the process as possible, establishing the urgency of lifestyle change, and using drug therapy as needed to control risk conditions. Such an intense and multi-factorial approach can reverse the bad prognosis associated with the syndrome. Without such changes, progression and serious consequences are nearly inevitable.
Supporting references and additional information:
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For other information and useful links, visit the American College of Preventive Medicine website at www.acpm.org.
ACPM recommends using the following citation when referencing this educational program.
Excerpted with permission from the American College of Preventive Medicine. Metabolic Syndrome Time Tool: A Resource from the American College of Preventive Medicine. 2009. Retrieved from http://www.acpm.org/?metabolic_clinician.
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Copyright 2009. American College of Preventive Medicine. All Rights Reserved.