Stacy Cliff Metabolic Syndrome Case Study November 1, 2013

1. Evaluate the labs and identify which components lead to the medical diagnosis of metabolic syndrome. Discuss the roles of each in contributing to morbidity. Metabolic syndrome is defined by a group of 5 risk factors that raise your risk for heart disease, diabetes, and stroke among others. You must have 3 of the below risk factors to be diagnosed as having metabolic syndrome. Risk factors include: 1) Android obesity. In this type of obesity fat accrues in the upper body, specifically the abdominal region. Waist measurement >40 inches in males, and >35 inches in females 2) High triglyceride level = TG>150 mg/dL 3) Low HDL or good cholesterol = <40 mg/dL in males, and <50 mg/dL in females 4) High blood pressure = BP 130/85 5) High fasting blood glucose level = FG 100 mg/dL These criteria are from the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) and are the most widely used.1 Taking medications for numbers 2-4 above indicates risk as well. An individual diagnosed with metabolic syndrome is twice as likely to develop heart disease and five times as likely to develop diabetes as someone who does not have metabolic syndrome.2

Mr. Cohens risk factor analysis: 4 of 5 risk factors

Android obesity- His waist circumference is 48 inches. This indicates that Mr. Cohen carries the majority of his weight in his abdominal region. Contribution to morbidity- Excess fat located in the abdominal region out of proportion to total body fat is an independent predictor of risk factors and morbidity. For patients with a BMI between 25 and 34.9 kg/m2, a high waist circumference was found to be associated with an increased risk of diabetes mellitus 2 (DM2), hypertension, cardiovascular disease (CVD), and dyslipidemia.3 High triglyceride (TG) level- 257 mg/dL Contribution to morbidity- Elevated triglyceride levels are a risk factor for atherosclerosis. Atherosclerosis is the build-up of plaque on artery walls, and can lead to heart attack, stroke, and peripheral artery disease. Extremely elevated triglyceride levels may also cause fatty liver disease and pancreatitis.4

Longitudinal and cross-sectional studies have suggested that high TG levels may be a predictor of CVD risk.5 Elevated TG levels were also associated with myocardial infarction (MI) and stroke in NHANES III.6 Low HDL level- 46 mEq/L (within normal limits) It is important to keep HDL levels at a desirable range as evidence suggests HDL is protective against atheroscleorsis.1 High blood pressure- 144/92 mmHg Contribution to morbidity- Hypertension may lead to unwanted consequences in the heart, brain, vasculature, kidneys, or eyes. Chronic high blood pressure results in an acceleration of atherosclerosis, CHD, heart failure, and renal failure. The higher the pressure, the more likely these various diseases will develop. If untreated, approximately one half of all hypertensive patients will develop heart failure, and a majority will die prematurely of cardiovascular or renal disease.7 High fasting blood glucose level- 146 mg/dL Contribution to morbidity- The beginning stages of hyperglycemia in patients with the metabolic syndrome appears to speed up atherosclerosis. This direct consequence of hyperglycemia probably contributes to the microvascular disease underlying nephropathy and retinopathy, and likely promotes macrovascular disease as well.1 Insulin resistance usually precedes the onset of DM2 and is commonly accompanied by other cardiovascular risk factors: dyslipidemia, hypertension, and prothrombotic factors. Individuals with the metabolic syndrome have impaired fasting glucose even when they do not have DM2, and the metabolic syndrome can, and usually does, precede the development of DM2 by years.8 ***In addition to the NCEP ATP III criteria, Mr. Cohens Framingham cardiovascular disease risk score is 19%. Which means 19 out of 100 people with this risk score will have a heart attack in the next 10 years.9

2. Why did the physician order the second set of labs to be fasting? If a lipid profile is obtained using non-fasting levels, then only the values for total cholesterol and HDL cholesterol are valid. If these values are high and low respectively, a fasting profile will be ordered to determine management based on LDL levels. Chylomicrons carry triglycerides and cholesterol from the diet to the liver. When a meal high in dietary fat is consumed more chylomicrons and their remnants are present in the blood. When fasting plasma levels are taken, chylomicrons are usually absent. A fasting lipid profile, taken after 9-12 hours to eliminate any recent dietary fat, will contain valid values for total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides.1

3. What are the target ranges for outcome markers for a patient like Steve? Mr. Cohens metabolic syndrome treatment plan should focus on the reduction of risk factors that cause CVD and DM2, including hypertension, hyperlipidemia, and hyperinsulinemia. Desirable target ranges for outcome markers for these risk factors are as follows: 1) LDL goal <130 mg/dl We must address Mr. Cohens LDL cholesterol level. While not used as a risk factor in a metabolic syndrome diagnosis, the NCEP ATP III guidelines focus on lowering LDL cholesterol first. At 192 mg/dl he is in the very high category. Individuals in this category usually have genetic forms of hypercholesterolemia: monogenic familial hypercholesterolemia, familial defective apolipoprotein B, and polygenic hypercholesterolemia. Combination drug therapy is often required.1 In addition to the LDL cholesterol number, risk determinants include the presence or absence of coronary heart disease (CHD) or other atherosclerotic disease. There major risk factors that modify LDL treatment are listed in the following table.

Cigarette smoking Hypertension (BP 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/d) Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years) Age (men 45 years; women 55 years) Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals:1

Mr. Cohens LDL goal is <130 due to his having over 2 risk factors, and a 10-year Framingham risk score of 20%. 2) Triglycerides closer to normal levels 150 mg/dl Non-HDL goal <160 mg/dl Mr. Cohens TG level of 257 mg/dl is in the high category. Research suggests that elevated serum Triglycerides are independent risk factors for CHD10. This independence would suggest that TG rich lipoproteins including remnant VLDL and IDL are atherogenic similar to LDL.

Very low density lipoproteins (VLDL) are produced by the liver, precursors to LDL, and contain 10-15% of total serum cholesterol. In individuals with high TG levels, such as Mr. Cohen, LDL and VLDL are summed and termed non-HDL cholesterol. Non-HDL is atherogenic and is a secondary therapy goal following LDL in cholesterol treatment.1 Following NCEP ATP III guidelines treatment should include TLC. Drug therapy may be necessary and can include: 1) Intensifying therapy with a LDL-lowering drug or 2) adding nicotinic acid or fibrate to achieve the non-HDL target by lowering VLDL cholesterol.1 Physical activity, weight reduction in addition to drug therapy is recommended. 3) Weight loss goal of 7-10% or 15-21#s Weight reduction of 7-10% will lower LDL cholesterol and reduce all risk factors of metabolic syndrome. Epidemiologic research supports an inverse relationship between physical activity and cardiovascular health. Research also supports similar findings for hypertension. Epidemiologic literature also strongly suggests a protective effect of physical activity on the development of DM2.1 Intervention for all risk factors associated with the metabolic syndrome are weight loss and increased physical activity. NCEP ATP III guidelines identify individuals with metabolic syndrome as candidates for intensified therapeutic lifestyle changes (TLC).1 Therefore, after LDL cholesterol levels are appropriate, TLC should focus on weight loss and increasing physical activity. The TLC eating plan will be introduced to Mr. Cohen and following its principles his weight loss goal will be 7-10% or 15-21# in approximately 6-12 months. He will walk 30 minutes a day, 6 days a week, for a total of 180 minutes of physical activity. 4) Fasting blood glucose level under 110 A1c level below 7% Mr. Cohens fasting blood glucose levels and his A1c are both in the range to be diagnosed with diabetes. However, since an official diagnosis has not been made by his physician at this time we will treat his underlying insulin resistance. We can make recommendations and treatment goals to get his blood glucose levels into the normal range. Individuals at risk for developing diabetes can prevent or delay the onset by losing a modest amount of weight through a diet low in fat and calories and regular physical activity. In the Diabetes Prevention Program trial (DPP)11, the lifestyle intervention group participants weight loss was the main predictor of reduced risk for developing diabetes. Researchers concluded that diabetes risk reduction efforts should focus on weight loss.12 Mr. Cohens A1C number depicts how well his blood glucose plan was implemented by him over the last 2-3 months. It may help to determine if metformin is warranted. Mr. Cohens fasting blood glucose level should be under 110 and his A1c, which is a better prediction of his ability to manage his glucose levels over time, under 7%. 5) Blood Pressure goal <130/80 mmHg The reduction of morbidity and mortality from stroke, hypertension related heart disease, and kidney disease are the goals of hypertension management. Patient evaluation includes: identify potential causes, assess for organ disease and CVD and determine other present risk

factors to decide treatment priority. Several months of lifestyle modifications is the first step in managing hypertension to hopefully avoid drug therapy. Drug therapy should be considered if blood pressure does not normalize after 6-12 months. Lifestyle modifications must stay in place along with drug therapy if implemented. Mr. Cohen should understand that the management of his hypertension is a life-long commitment. Type 1 hypertension is defined as having a systolic blood pressure of 140-159 mmHg or a diastolic blood pressure of 90-99 mmHg. Currently Mr. Cohen meets this criteria as his blood pressure is 144/92 mmHg. 4. Actions, side effects and implications of Steves current medications? Micardis- (Telmisartan) Used to treat high blood pressure. Micardis works by blocking the actions of natural substances that tighten the blood vessels. This allows the blood to flow smoothly and thus aids the efficiency of the heart. Side effects include: back pain, sinus pain and congestion, diarrhea, swelling, hoarseness, difficulty breathing or swallowing, pain in lower leg, and blistering of skin/rash.12 Nutrition implications: Do not use salt substitutes such as NuSalt, and Morton Lite Salt because they contain Potassium. Mrs. Dash or Bensons Gourmet Seasonings Table Tasty are Sodium and Potassium free alternatives. Hydrodiuril- (Hydrochlorothiazide) Water pill. Can control high blood pressure, but cannot cure it. Causes the kidneys to get rid of unneeded H20 and salt from the body into the urine for excretion. Nutrition implications: Low sodium diet, potassium supplements and increased amounts of potassium rich foods. Side effects include: muscle weakness, dizziness, cramps, thirst, stomach pain, nausea, vomiting, diarrhea, loss of appetite, headache, and hair loss. Severe side effects: sore throat with fever, unusual bleeding/bruising, severe skin rash/peeling skin, and difficulty breathing/swallowing.13

**Hydrodiuril may interact with Micardis**

It is advised not to take Micardis in conjunction with diuretics such as Hydrodiuril.13 Micardis increases the level of potassium in the body, and it is recommended to increase potassium when taking a diuretic. If Mr. Cohen increases his potassium content to satisfy the instructions for taking Hydrodiuril and still takes Micardis, he could become hyperkalemic. Hyperkalemia is the condition of too much potassium in the blood, and could cause dangerous and possibly deadly changes in heart rhythm. Diuretics are prescribed to prevent hyperkalemia in some cases, however, in this case I am concerned about the opposing messages the patient may receive on the drug fact sheet. Mr. Cohen could quit taking the diuretic without consulting his physician and not adjust his potassium intake as well. Patient should be advised on possible food and drug complications regarding his medicine. Mr. Cohen is being advised to adopt the TLC eating plan which includes 5-9 fruits and vegetables a day, or the DASH diet that includes 9 or more. Fruits and vegetables are naturally high in potassium. These diets, plus Micardis could cause a dangerous increase of potassium levels in the body and should be discussed with his physician before proceeding with TLC nutrition education.14

Possible medications after metabolic syndrome diagnosisStatins are the most effective in reducing LDL cholesterol. On average an 18-55% drop is achieved. Statins with triglyceride-lowering properties are beneficial for patients who are struggling to bring down LDL levels and are the initial step in the progression of drug therapy recommended by NCEP ATP III.1 With his recent diagnosis of metabolic syndrome, Mr. Cohen is considered high risk for CVD and must consider aggressive therapy in order to lower his LDL levels. Combination therapy which entails a statin plus a bile acid sequestrant or nicotinic acid may be recommended as the second step of drug therapy. It should be noted that Bile acid sequestrants are unable to reduce TG levels, therefore in Mr. Cohens case fibrates can be added in addition to statins. Fibrates are primarily effective in lowering triglycerides by around 40%, reducing LDL by 10-15%, and increasing HDL by 15- 20%. The third step would include intensifying drug therapy or referral to a lipid specialist. If blood glucose levels are not normalized Mr. Cohens doctor could prescribe Metformin. While Metformin is not intended to prevent DM2, it has been shown effective in reducing insulin resistance. Participants in the Diabetes Prevention Program trail (DPP)11 taking metformin reduced their risk of developing diabetes by 31 percent. Around 7.8% of the metformin group developed diabetes each year during the study, compared with 11% of the control group. Metformin may decrease the absorption of B12, folic acid, and may cause lactic acidosis. Alcohol should be avoided to decrease risk of lactic acidosis. 5. Assess information provided and write a nutrition diagnosis. Nutrition intervention for next 6 months? An individual diagnosed with metabolic syndrome will benefit tremendously from following the TLC program. The three main components of the TLC are diet, physical activity and weight management.1 The TLC diet stresses reductions in saturated fat and cholesterol intakes. When the metabolic syndrome or its associated lipid risk factors (elevated triglyceride or low HDL cholesterol) are present, TLC also stresses increased physical activity and weight reduction. Nutrition diagnosis #1: Less than optimal intake of types of fats including: cholesterol, trans fat, and saturated fat related to his food and nutrition-related knowledge deficit concerning type of fat he is consuming as evidenced by his fasting lipid panel results of total cholesterol 255 mg/dl, TG 257 mg/dl, and LDL 192 mg/dl.15 As advised in the TLC plan, we will first get Mr. Cohens LDL cholesterol, which is categorized as very high, under control. This will be goal #1 in the following 6 month treatment plan. RD visit #1, Week 1 Mr. Cohen is advised to: 1) Lower his saturated fat to 7% of total calories. Education component: Saturated fat raises blood cholesterol more than any other component of your diet. It is especially detrimental to LDL levels. The recommended diet will include 25-35% of kcals from total fat which includes 7% saturated fat. Saturated fat is usually solid at room temperature and is found in foods from animals, including: fatty cuts of

meats, poultry with the skin on, whole milk products and plant sources like coconut and palm oils. 2) Reduce cholesterol intake to less than 200mg a day. Education component: Learn to identify which food products have cholesterol by learning to read nutrition labels on food products. Learn sources of cholesterol are animal based for example egg yolks, shrimp, meat, dairy products. 3) Reduce or eliminate trans-fat from diet. Education component: Trans-fat tends to raise blood cholesterol similar to saturated fat. Sources of trans-fats include: hydrogenated vegetable oils, hard margarines, shortenings, baked goods, crackers, cookies, doughnuts, and breads. 4) Increase fiber rich foods to include at least 5-10 grams of soluble fiber a day, preferably 10-25 grams a day. Education component: Soluble fiber comes from plant sources and helps block cholesterol and fats from being absorbed in the digestive tract. Sources include hot and cold breakfast cereals like oatmeal, whole fruits like bananas and pears, vegetables like brussel sprouts and broccoli, and beans like pinto, black, lima, and kidney. In addition to these dietary recommendations Mr. Cohen is advised to include 30 minutes of moderate intensity activity such as brisk walking on most days of the week to aid in weight reduction. Mr. Cohen will also begin recording a daily food diary.

RD visit #2, Week 7 Mr. Cohen is advised on: 1) The importance of his continued compliance with the reduction of sat fat/trans fat/cholesterol in his diet. Review diet record to find any weak spots and easy food substitutions. Recommend other foods and discuss what to do when eating out, using the education materials provided on nutrition information from his favorite restaurants. Review good snack choices. 2) Adding plant stanols. Education component: Plant sterols or stanols are found in food products taken from soybean and tall pine tree oils. They work in a similar manner to soluble fiber by blocking the absorption of cholesterol in the digestive tract. They do not affect the absorption of TGs and HDL. They can reduce LDL levels by as much as 5-15% sometimes within weeks. 3) Increasing soluble fiber. If soluble fiber goal of 5-10 grams a day has been implemented, Mr. Cohen should now increase soluble fiber to 10-25 grams a day. Continue getting at least 30 minutes a day of physical activity, and continue recording food in food diary. For the next visit in 6 weeks, obtain a new fasting lipid panel from physician. Be aware that adherence to diet is extremely important if you want to avoid pharmacology which will likely be visited by his physician at this follow up.

RD visit #3, Week 13 Mr. Cohen will: 1) Bring in new, current fasting lipid panel from his physician 2) Disclose drug therapy suggested by physician if physician deemed it necessary

3) Focus on the treatment of metabolic syndrome. This will start with the main goal of weight reduction. While following the TLC diet over the past 13 weeks including the reduction of certain fats, cholesterol containing foods, and increasing the amount of fiber consumed, and implementing physical activity has hopefully resulted in some weight loss, we will now carefully look at Mr. Cohens diet and determine a caloric level sufficient to lose a pound a week. His dietary journal should be beneficial in guiding our planning as to his current habits and favorite food choices.

RD visit #4, Week 24 We hope to see that by looking at his food record he has succeeded in reducing saturated fats to 7% of total calories consumed, eliminated trans-fats completely, limited the intake of cholesterol consistently to less than 200 mg/day, is eating a diet rich in soluble fiber and plant sterols, and has successfully implemented a daily exercise routine. We hope to see a weight loss of 15 pounds, LDL levels close to his goal of 130 mg/dl, total cholesterol close to <200 mg/dl, TG levels close to <150 mg/dl. Mr. Cohen will be advised on his progress or lack of progress over the past 6 months. Nutrition diagnosis will be re-visited and revised to reflect current condition. 6. Meal plan with one day sample menuImportant considerations: Using Mifflin-St. Jeor due to Mr. Cohens BMI which is 30 kg/m2 (obese). Mr. Cohens resting energy expenditure is 1812 kCals/day. After adding TEF and PA (1.2), his total energy expenditure (TEE) for weight maintenance is 2391 kCal/day. In order to lose 1 pound a week he must have a calorie deficit of 500. Initially, his diet will reflect a 250 kCal deficit and incorporating more physical activity in his day for an additional calorie expenditure of 250. Total calories allowed= 2141 CHO= 55% 294g PRO= 15% 80g (98.6 x .08 = 78g) FAT= 30% 71g sat fat <7% or no more than 16 grams of total fat Fiber= 25-30g/day (10-25g soluble), plant sterols 2g/day, cholesterol <200mg/day Mr. Cohen is Jewish and his diet must be prescribed according to his religions dietary laws. TLC diet DASH diet

Exchange Table Starch (15,3,1) Fruit (15,0,0) Milk (12,8,1) Veg (5,2,0) Meat (0,7,3) Fat (0,0,5) Total grams Calories/gram Percent Cals Meal Plan Bfast Snack Lunch Snack Dinner Snack Starch 2 1 2 2 2 Fruit 1 2 1 2 Milk 1/2 Vegetable 1 1 1 4 Meat Fat 1 1 1 1 3 CHO # 51 50 50 48 50 48 Exchange 9 6 3 7 5 7 CHO 135 90 36 35 0 0 296 1184 55 PRO 27 0 24 14 35 0 100 400 18 FAT 9 0 3 0 15 35 62 558 26 Calories 80 60 100 25 55 45 2142

2 2 1
Snack: apple banana cup celery sticks cup hummus

1 1.5

Breakfast: Oatmeal 1 cup 1 tsp tub margarine cup strawberries cup skim milk Lunch: Turkey and veggie sub 2 slices whole wheat high fiber toast 2 ounces sodium free low fat turkey breast 2 slices tomato Romaine lettuce 6 slices cucumber, 3 green pepper rings avocado (fat) 1 TBS mayo

Snack: 1 cup fat free yogurt cup peaches cup blueberries cup raw baby carrots

Dinner:

Snack: 2 slices Whole grain toast 1 TBS peanut butter (meat subst) 1.5 Cup fat free milk

2 ounces salmon 1 TBS olive oil 1 Cup steamed broccoli 1 Baked sweet potato w/ 1 tsp tub margarine 1 cup romaine lettuce and cup cherry tomatoes drizzled with 1TBS olive oil and 1 TBS vinegar

Total cholesterol= 109 mg Total Fiber= 61g Soluble fiber= 14.6g

References 1. US Department of Health and Human Services. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). http://www.nhlbi.nih.gov/guidelines/cholesterol/ Published September 2002, Updated 2004. Accessed November 1, 2013. 2. US Department of Health and Human Services. What is Metabolic Syndrome? http://www.nhlbi.nih.gov/health/health-topics/topics/ms/. Published November 3, 2011. Accessed November 1, 2013. 3. US Department of Health and Human Services. Determination of degree of abdominal obesity. Guidelines of overweight and obesity electronic textbook. http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk/txgd/4112.htm. Accessed November 1, 2013. 4. Stoppler M. Triglyceride Test. MedicineNet Web site. http://www.medicinenet.com/triglyceride_test/article.htm. Accessed November 1, 2013 5. Miller M, Stone NJ, Ballantyne C, et al. Triglycerides and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2011;123(20):2292-333. http://circ.ahajournals.org/content/123/20/2292.full.pdf. Accessed November 1, 2013. 6. Ninomiya JK, LItalien G, Criqui MH, Whyte JL, Gamst A, Chen RS. Association of the metabolic syndrome with history of myocardial infarction and stroke in the Third National Health and Nutrition Examination Survey. Circulation. 2004;109:42 46. http://circ.ahajournals.org/content/109/1/42.full.pdf. Accessed November 2, 2013.

7. Cushman WC. The Burden of Uncontrolled Hypertension: Morbidity and Mortality Associated With Disease Progression. J Clin Hypertension. 2003;5(3):14-22. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-6175.2003.02464.x/pdf. Accessed November 2, 2013. 8. Grundy SM, Benjamin IJ, Burke GL, et al. Diabetes and Cardiovascular Disease : A Statement for Healthcare Professionals From the American Heart Association. Circulation.

100(10):1134-1146. http://circ.ahajournals.org/content/100/10/1134.long. Accessed November 2, 2013. 9. US Department of Health and Human Services. Risk Assessment Tool for Estimating your 1year of Having a Heart Attack. http://cvdrisk.nhlbi.nih.gov/calculator.asp. Updated May, 2013. Accessed November 2, 2013 10. Assmann G, Schulte H, Funke H, von Eckardstein A.The emergence of triglycerides as a significant independent risk factor in coronary artery disease. Eur Heart J 1998;19(suppl M):M8-M14. http://www.ncbi.nlm.nih.gov/pubmed/9821011. Accessed November 9, 2013. 11. US Department of Health and Human Services. National Diabetes Information Clearinghouse. Diabetes Prevention Program. http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/.Published October, 2008. Updated September 09, 2013. Accessed November 2, 2013

12. National Institutes of Health. MedlinePlus. Telmisartin. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601249.html. Updated October 30, 2013. Accessed November 1, 2013.

13. National Institutes of Health. MedlinePlus. Hydrochlorothiazide. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682571.html. Updated October 30, 2013. Accessed November 1, 2013. 14. WebMD. Hyperkalemia: Symptoms and Treatments. http://www.webmd.com/a-to-zguides/hyperkalemia-causes-symptoms-treatments?page=2. Updated September 20, 2013. Accessed November 1, 2013. 15. US Department of Health and Human Services. Your Guide to Lowering Your Cholesterol with TLC. http://www.nhlbi.nih.gov/health/public/heart/chol/chol_tlc.pdf. Published December 2005. Accessed November 2, 2013.