Metabolic Syndrome (Syndrome X) was identified less than 20 years ago, but it is becoming increasingly common. It tends to run in families, and the risk of it increases with age. People with Metabolic Syndrome are overweight or obese. The condition predisposes to cardiovascular diseases and Type 2 diabetes. It also puts one at risk of certain cancers, liver disease and Alzheimer’s.
But what is it? Metabolic Syndrome is a cluster of metabolic disorders, which include insulin resistance, high blood pressure, an increased risk of blood clotting, an elevated blood sugar level, a low blood HDL (good) cholesterol level, a high blood triglyceride (fat) level and excess abdominal fat. In fact, any three of these clinches the diagnosis.
The causes of Metabolic Syndrome are complex, but poor lifestyle choices play a major role. These include eating too much sugar and other refined carbohydrates, not exercising, not getting sufficient sleep and high levels of stress. However, of all the influencing factors, poor food choices in the form of sugar and refined carbohydrate contribute between 80% and 90% of the total effect.
How do these food choices lead to metabolic syndrome? There are several ways. The first and most obvious is that excess intake of sugar and refined carbohydrate is stored as fat, and people with metabolic syndrome are all overweight or obese.
Another mechanism is due to fructose, and sugar – or sucrose – is 50% fructose. It may surprise you to learn that fructose is not good for you. Leptin, a hormone that regulates appetite, plays a key role in energy regulation. It is produced in our fatty tissues in direct proportion to the amount of stored fat, and it acts on receptors in the brain to inhibit appetite, which makes perfect sense. But it is now clear that the consumption of large amounts of fructose causes leptin resistance. The result is that an ever increasing accumulation of fat does not curb our appetite.
We also know that fructose, when consumed in excess, increases blood fat levels – triglycerides, total blood cholesterol and LDL (bad) cholesterol. It also increases the prevalence of type 2 diabetes, high blood pressure, abnormal blood clotting and heart disease. But, wait a moment – aren’t these the things that constitute metabolic syndrome? You’ve got it!
Let’s now take a look at obesity, which is a major factor in the development of Metabolic Syndrome. Obesity is a modern problem – statistics for it did not even exist 50 years ago. It is defined as a Body Mass Index (BMI) above 30. Your BMI is your weight in kilograms, divided by your height in metres, divided again by your height in metres. A healthy BMI lies between 18.5 and 24.9. If your BMI is between 25 and 30, you are overweight. If it is over 30, you are obese. So, if your weight is 80kg and your height is 1.60m, then your BMI is 80 / 1.6 / 1.6. This equals 31.25, which means that you are obese.
Now for some scary statistics. The prevalence of obesity has doubled worldwide in the past 25 years. World Health Organisation (WHO) figures for 2005 show that 1.6 billion adults were overweight and 400 million were obese. WHO predicts there will be 2.3 billion overweight adults in the world by 2015 and more than 700 million of them will be obese.
In the UK, the proportion of adults with a healthy BMI (18.5- 24.9) had fallen to just 34% in men and 39% in women by 2011. There had been a marked increase in obesity rates over the previous 18 years – in 1993, 13% of men and 16% of women were obese. By 2011, this had risen to 24% for men and 26% for women. For children attending reception classes (aged 4-5 years) during 2011-12, 9.5% were obese.
In 2011, there were 11,736 hospital admissions for obesity – 11 times more than in 2001. That same year, 53% of obese men and 44% of obese women were found to have high blood pressure.
There has also been a worldwide explosion in the prevalence of Type 2 diabetes. This disease occurs in the presence of sufficient insulin, but where insulin receptors have become less sensitive. This insulin resistance is the common factor in metabolic syndrome. Type 2 diabetes already afflicts four million people in the UK. Its prevalence is expected to rise to six million by 2020, when its ‘management’ will account for twenty five percent of the total health budget.
Let us take a look at how metabolic syndrome presents, progresses and is typically managed by the medical profession. It begins with weight gain, which used to be common in middle age, but is now common even in children. Weight gain has only one cause – an imbalance between our energy consumption and our energy expenditure. Obese people need to eat less and exercise more. Unfortunately, many consider it offensive to mention a person’s weight or to dictate what they should or should not eat. The doctor suggests adherence to the mythical balanced diet, but does not believe that the patient will comply.
At this stage, because the patient argues that it is probably all due to genes or glands, the doctor decides to check thyroid status. Finding that the level is borderline, he prescribes thyroid hormone in the vain hope that increasing the metabolic rate may reduce the excess weight. This fails, the weight increases and the patient develops high blood pressure and diabetes. The high blood pressure is treated with medication which often makes the diabetes worse. The diabetes cannot be effectively treated without serious attention to diet and weight loss. If the patient complies, the problem is often solved, but some drug help may still be needed. If the patient does not comply, the medication cannot work, but it is prescribed anyway.
By now, the patient’s blood cholesterol is elevated, so a statin is prescribed. Obesity is putting a strain on the low back and knees, our patient complains of pain, and anti-inflammatories are prescribed. These drugs cause indigestion and exacerbate acid reflux – another consequence of obesity – which makes sleeping difficult. A proton pump inhibitor is prescribed to switch off the stomach acid, together with some sleeping tablets. By now, our patient is so unhappy with their lot that the doctor prescribes an anti-depressant.
Our patient is incapacitated by increasing pain, and eats even more for consolation. At this stage, such patients may be taking up to twelve different medications, many of which have unpleasant side effects. They are yet to have a stroke or a heart attack, both of which are imminent, but many are using an inhaler for angina and a positive pressure ventilator for sleep apnoea. The joint pains worsen, and the orthopaedic specialist confirms that nothing surgical can be done. Ever stronger pain killers are prescribed, to which tolerance quickly develops. We have now added drug dependency to the woes of our patient, who has by now lost their job and their self-esteem.
It is interesting that such patients frequently claim to eat very little. They are in denial. They should be furious with a health service that has not served them well. The cost of their treatment is astronomical and would be unaffordable if it had to come out of their pocket.
This was the situation faced by many of my patients in Swaziland, so a different strategy was needed. Using all the techniques of cognitive behavioural therapy (CBT), we challenged the denial, the addictive behaviour and any claim to victimhood. We educated our patients, so that they could fully understand their condition, and we set targets. Above all, we empowered them to heal themselves. When there was no support group like Weight Watchers, we started one, and called it Waist Disposal. Where there were no exercise classes, we started them. My physiotherapist wife even opened a gym.
It is our experience that patients are seldom capable of making minor lifestyle adjustments, but they can make major ones. I challenged my patients with metabolic syndrome to adopt, as treatment, a fat-free, wholefood, vegan diet. No meat, no fish, no eggs, no dairy, no fat, no oil, no sugar, no refined carbohydrate, no fruit juices and no alcohol. In most cases, the weight loss was sufficiently rapid to encourage continued compliance. Once a normal weight was reached, many patients required no medication at all. Nor did they need to stay vegan or teetotal. They had discovered the wisdom of moderation in all things. There is nothing more empowering than the realisation that you can and should be responsible for your own health.
I find it interesting that when I recount this story to friends, they usually remark that, under this regimen, there seems to be nothing left that one can eat. They are genuinely surprised when I list all fruit, all vegetables, all pulses, all grains and seeds, coffee, tea and even rice or soya milk. I am not talking here about calorie restriction, and I am not talking about going hungry. It is perfectly acceptable, for example, to eat any amount of whole grain bread, brown rice, wholemeal pasta and potatoes. Nor am I talking about a fad diet, for there are millions of healthy people in the world who are vegan.
What I am talking about is a radical lifestyle change. The fact that it is radical is important, because it is about discipline and empowerment. I have no interest in empowering someone to eat two donuts instead of three. Whilst on this subject, it is often said that it is extraordinarily difficult to change eating habits, because they are culturally engrained. Like so many things that are often said, this is complete nonsense. If you do not believe me, ask McDonald’s, KFC and Pizza Hut, who have totally changed eating patterns across the world.
There are other ways to lose weight and manage metabolic syndrome. Scientists have discovered that periods of eating very little or nothing may be the key to controlling chemicals produced by the body that are linked to the development of disease and the ageing process. Before we look at the science, this makes sense if we consider our ancient, hunter-gatherer ancestors. They must have gone to bed hungry on many occasions, and I am certain they did not stop their hunting or gathering for three meal breaks a day.
The key, according to researchers, is insulin-like growth factor-1 (IGF-1). We need adequate levels of IGF-1 when we are growing, but high levels later in life appear to lead to accelerated ageing. IGF-1 stimulates our metabolic rate and keeps our cells constantly active, encouraging them to replicate. One way to dramatically reduce IGF-1 levels, which slows the ageing process and encourages cells to repair, is by fasting. In the process, we also lower blood sugar and cholesterol levels, blood pressure and our risk of cancer.
These findings chime with recent reports that reaching an ideal Body Mass Index (BMI) may not be enough – to be fully fit, we need to be slim. Studies with monkeys have confirmed that calorie restriction delays the onset of cancer, coronary heart disease and diabetes, as well as staving off dementia. It also, of course, helps us to lose weight, and it is the inspiration behind the currently fashionable 5:2 diet.