Early detection of metabolic syndrome and swift initiation of lifestyle-changes and nutrition-based therapies are the keys to averting the deluge of type 2 diabetes now threatening to capsize the nation’s healthcare system, said Mark Houston, MD, of the Department of Medicine, Vanderbilt University School of Medicine.

The tools now exist to enable primary care physicians to identify the earliest metabolic dysregulations underlying this complex disease, years if not decades before patients manifest obvious signs and symptoms. What’s more, at its earliest stages, these metabolic changes can be reversed, or at least attenuated by a shift toward a lower-carb, vegetable-rich diet, moderate exercise, and targeted supplementation with trace minerals like chromium and zinc.

“We need to start looking for this at much earlier stages. Once someone has clinical disease, it is already way past time. This disease starts 10 or even 20 years before a patient develops signs detectable with standard diagnostic lab tests like blood glucose and insulin levels, or basic lipid profiles,” said Dr. Houston, who also directs the Hypertension Institute at the St. Thomas Medical Group, Nashville.

Since Dr. Gerald Reaven first articulated the “Syndrome X” concept nearly 20 years ago, there’s been considerable debate about whether this is, in fact, a true syndrome, whether it’s a clinically useful concept, and if so, what the diagnostic criteria should be. According to Dr. Houston, who contributed a chapter on metabolic syndrome to the recently published Textbook of Functional Medicine, those debates have largely been resolved.

Five Red Flags

“Currently, the definition of metabolic syndrome is pretty consistent among the 4 or 5 committees (National Cholesterol Education Program, World Health Organization, American Association of Clinical Endocrinologists, among others) that have published on this. All agree that the five big features are: hypertension, dyslipidemia, glucose intolerance, insulin resistance and visceral obesity.” Insulin resistance—the progressive inability of insulin to exert its glucose-transporting effect in skeletal muscle tissue—is the primary driver of all further pathologies.”

For the purposes of thumbnail diagnosis, visceral obesity and BMI are the two major red flags. “If you see visceral obesity and a BMI over 40 in a man, or over 35 in a woman, odds are very good that they’re insulin resistant.”

Basic blood lipids can give some important signals, though not the complete picture. Patients often have normal or slightly elevated LDL, but markedly low HDL, elevated CRP, and very high TGLs. “The total TGL to HDL ratio is very telling. If it is greater than 3, there’s a 70% chance or better that the patient is insulin resistant.”

“Early” Ain’t Early Enough

While these may be “early” diagnostic signs according to conventional medical thinking, Dr. Houston feels they are signals that damage is already being done, and the patient has reached a point where it is all but too late to avert the ruthless course of the disease by simple nutritional and lifestyle means.

“Once you’ve got signs, you’re already well-advanced. If someone has a fasting blood glucose of 102, that’s not normal. It is borderline, and it means that someone’s heading toward metabolic syndrome. The risk threshold is a lot lower than people realize. Here at the Hypertension Institute, we see 75–80 mg as the threshold.”

The same principle holds for other markers. Dr. Houston and his colleagues consider a patient at risk if the blood pressure exceeds 110/70 mmHg, the LDL exceeds 60 mg/dl, the triglycerides exceed 75, and the homocysteine rises above 5.

According to conventional standards, a consistent blood pressure of 130/85 is considered “prehypertension.” But the reality is, by the time most patients get to that level, the vascular disease process is likely to be in full swing. Keep in mind that metabolic syndrome and diabetes are as much diseases of the vasculature and the endothelium as they are disorders of metabolism.

A Vascular Disease

The first vascular abnormality is endothelial dysfunction. Nitric oxide levels decrease, leading to a brittle, hypertensive, and atherogenic vascular system. From here, you progress to early stages of frank atherosclerosis and cardiovascular disease. This is also the process that leads to the ravaging of arterial beds in the retinas, brain and kidneys, resulting in blindness, stroke and renal failure. No one is really sure how insulin resistance and endothelial dysfunction are related, which starts first, or if the one causes the other. But it is clear that they co-occur.

Insulin itself can be damaging to the endothelium. In insulin sensitive people, it is not a problem: the hormone simply does its job and has no ill effects on endothelial tissue. In insulin-resistant people, not only is it present in higher concentrations, it also shunts into pro-atherogenic biochemical pathways, further fueling plaque buildup.

Using pulse-wave analysis, one can actually measure, noninvasively, the degree of endothelial dysfunction, and determine early on if the vessels are sick. “It’s a measure of vascular compliance. You use a tachometer to measure the pulsewave. It takes only 2 minutes to compute the compliance of small and large arteries, displaying the data as a “vascular age” estimation.”

For example, in a healthy 40-year-old male, arterial compliance should be between 6 and 7 in the small arteries. “If the patient shows a reading of 2, he’s got very stiff arteries, and a vascular age far in excess of his chronological age. So we need to treat that.”

Pulsewave analysis has, “excellent peer reviewed literature support, and is a vital tool for prevention-oriented physicians,” said Dr. Houston. The only major downside, however, is that the machines are expensive.

Dr. Houston has also found 64-slice CT angiography and electron beam tomography to be effective tools, in large part because they give direct visual images of the patient’s vasculature. This can really motivate patients to make changes. “Showing patients clear pictures of the abnormalities in their bodies at the same time you show them harrowing risk scores can really get their attention.”

Lipid Profiling

Advances in functional medicine have yielded new diagnostic testing methodologies that can help greatly in detecting the earliest pathogenic changes. Dr. Houston strongly advocated the comprehensive Cardiovascular Chemistry profiles developed by Spectra Cell Laboratories (www.spectracell.com), Houston, TX.

These panels provide detailed lipoprotein subgroup analyses, rather than simple cholesterol measurements. The new tests were developed in accordance with current National Cholesterol Education Program guidelines for emerging risk factors. They are based on the recognition that roughly 50% of all patients who suffer myocardial infarctions have essentially normal cholesterol levels.

Spectra Cell’s tests give quantitative analysis of the particle numbers of various lipoprotein subfractions, which begin to change very early on in the metabolic syndrome process. Insulin resistance almost always shows up, lipid-wise, as increased numbers of very low density lipoprotein (VLDL) particles, as well as LDL particles of markedly increased density.

Biochemist Jan Troup, who directs Spectra Cell’s lipid profile lab services, told Holistic Primary Care that it is entirely possible to “make the diagnosis of metabolic syndrome based on the lipids alone. We always see dense LDL, associated with increased triglyceride levels, low HDL, and a shift toward high VLDL levels.”

He believes that the tendency toward this lipid profile has a genetic basis, but that the expression of this genotype is amplified by poor diet and sedentary lifestyle. Fortunately, it is remediable through dietary changes as well as supplementation with omega-3 fatty acids and niacin.

Micronutrient Analysis

Spectra Cell also offers comprehensive micronutrient analysis obtained through a unique methodology that measures nutrient content inside lymphocytes. Dr. Houston said he finds these tests extremely useful in managing patients with metabolic syndrome. “You get measures of various antioxidants, vitamins, and minerals inside the lymphocytes, which gives you a picture of the patient’s nutritional status over the past 6 months, and it can identify a lot of important things that are part of the metabolic syndrome picture.”

Insulin-resistant patients show a pretty common profile characterized by low levels of magnesium, calcium, α-lipoic acid, and co-enzyme Q10. “You can ID these things and you can correct them, which often goes a long way to correcting the insulin resistance itself. Most doctors don’t do this, but they should.”

“This truly is functional medicine: you ID early biochemical parameters that relate to a pathogenic problem and treat those rather than treating a ‘disease.’ In this case, we’re teasing out some of the causative or contributing factors connected with insulin resistance, and if you reverse these, the insulin resistance gets better. The conventional view is to try and treat insulin resistance without knowing why someone has it.”

Magnesium deficiency is very common, and it is very difficult to gauge by blood levels alone. “You really need the intracellular measure,” said Dr. Houston. Potassium, which is easier to get a read on from conventional blood levels, is also low in many cases.

Zinc is often markedly deficient in meatabolic syndrome patients, and this is correlated with cardiovascular risk. Zinc is an essential cofactor for many of the enzymatic processes involved in intracellular metabolism, and it plays an essential role in glucose processing.

“Use the micronutrient measures to guide a supplement replacement program,” said Dr. Houston, who strongly disfavors wanton supplement-slinging. (Log on to www.holisticprimarycare.net and read “Basic Supplements for Reversing Metabolic Syndrome”.)

“Nutritional medicine should be rationally guided. The objective is to correct deficiencies so they’re back at normal healthy levels. So I test initially, start the supplementation regimen, and then do the micronutrient analysis again at 6 months. It takes at least 4–6 months to replete in patients who are severely deficient in multiple nutrients. It is not a quick fix.” The upside is that, unlike drug therapy, once you replete someone and get the metabolism running properly, you can usually back off on the supplements. It need not be a lifetime of capsule-gobbling.

Dietary Changes: White Ain’t Alright

Dietary changes are the second major component of Dr. Houston’s approach. The core is the modified DASH-2 Mediterranean style diet: 10 servings of uncooked vegetables and fruit, heavier on the vegetables, whole grains, low fat dairy, high quality protein especially cold water fish, reduced intake of red meat, modest quantities of soy protein, and most importantly, major reductions in refined sugar, trans fats and saturated fats, which should make up no more than 10% of total daily caloric intake.

Though each patient is different, two very basic rules apply to all. The first is, “If it’s white, it ain’t alright—unless it’s cauliflower!” This means, no white flour products, white sugar, white rice, white flour pastas, etc. The second is, Eliminate soda! “Get rid of the pop and you immediately jettison a whole lot of sugar,” not to mention a lot of weird chemicals. If followed, these alone can make a big difference.

Exercise is equally important. Dr. Houston likes his patients to do 60 minutes of aerobic exercise daily. “It can be whatever they like: swimming, jogging, brisk walking, recreational sports, dance.” He also recommends a minimum of 30 minutes resistance exercise thrice weekly. “You’re trying to build up lean muscle mass and reduce body fat down to 16% for men and 22% for women.”

Assuming you identify the disease process before serious symptoms emerge, it is entirely possible to reverse it without pharmacotherapy. “If patients follow a comprehensive program, within 6 months to a year, well over 50% of them and up to even 70% of them will show normal insulin sensitivity without medications.” This, he said represents a huge potential cost savings on a population basis.

A Really Stupid System

In other words, the surging tide of metabolic syndrome need not sink our healthcare systems. The problem is, insurance industry inertia coupled with physician conservatism is limiting the widespread adoption of the multidisciplinary approach that Dr. Houston advocates. “I have patients flying to Nashville from all over the country because they cannot find physicians in their communities who do this sort of integrative functional medicine.”

The big problem is that insurance companies won’t cover this. “They don’t cover the tests or the supplements, and they’re not too good at paying for nutritional counseling. It’s a really stupid system we have here, and it’s going to go belly up pretty soon if we don’t do something.”

Nonetheless, there are—or should be—strong incentives for physicians to begin to grab the metabolic syndrome beast by the horns.

First, it should appeal to that basic healer’s imperative of preventing suffering and helping people get better. More to the point, physicians who effectively manage metabolic syndrome will likely find themselves ahead of the game in terms of the “Pay-For-Performance” plans that are rapidly becoming the standard in insurance-based medicine.

“You get graded in P4P plans. If you don’t get people to certain clinical goals, you get a nasty letter and a reimbursement cut of 15%. On the other hand, if you’re in the top 10% in terms of measured performance, you get a 15% reimbursement increase. I think P4P will start motivating a lot of doctors.”