METABOLIC SYNDROMEin

LOW BMI

BILL ROMERO, MD, MS, CNS

Body Mass Index (BMI)

BMI is a weight to height ratio. The heavier the weight, relative to the same

height, the higher the BMI. Estimates the fat percentage Same weight and height will have the same

BMI, regardless of body fat percentage. May have normal BMI even if Body Fat %

is in Obese Range (>25%).

BMI Table BMI = [( lbs/inches² ) (weight in pounds X 703 )] / height in inches²

BMI vs. Fat Percentage

Same weight and height but varying fat percentages.

Fat Percentage

Most commonly measured by bio-impedance

Small amount of electricity is passed through body and resistance is measured

The more fat, the more resistance.

Normal Weight Obesity It is possible that one can weigh “normal’ and be

medically obese Normal Weight Obesity Same risk factors as “overweight” obesity

Classifications:– Normal: 25% and below– Overweight: Above 25 to 29%– Obese: 30 to 40%– Morbidly Obese: Above 40%

Carbohydrate Metabolism

An unhealthy diet, high in refined carbohydrates, causes rapid elevation of blood sugar. The pancreas responds by increasing insulin output.

Keith Vosseller, Lance Wells, M. Daniel Lane, and Gerald W. HartElevated nucleocytoplasmic glycosylation by O-GlcNAc results in insulin resistance associated with defects in Akt activation in 3T3-L1 adipocytes PNAS 2002; 99: 5313-5318.

Insulin Resistance

If the capacity of the insulin receptors is compromised due to nutrient insufficiencies and excess in sugar consumption the internal message to the cells is reduced and the efficiency of the cell is compromised.

Premise

Obesity causes a biochemical change: insulin resistance

Insulin resistance leads to progressive weight gain (vicious cycle)

Insulin resistance must be recognized and treated

Proper nutrition, exercise and medications can reduce insulin resistance and reverse obesity.

Metabolic Syndrome

Obesity Insulin Resistance Hypertension Hyperlipidemia

Prothrombotic State Proinflammatory State

DIAGNOSIS

Insulin Resistance– Fasting Glucose to Fasting Insulin (G:I Ratio) <

4.5 (Legro, et al)– 2-Hr Insulin 5X greater than Fasting Insulin– Fasting Insulin >20– Elevated insulin levels in OGTT with Insulin

Test– Waist to Hip Ratio

Glycemic Index Ranks carbohydrates on

how fast their sugar can raise glucose compared to equivalent amount of sugar.

Practical Use: allows us to choose “slow-release” carbohydrates

Included in Nutritional Data of food in Europe; proposed to be included in the US

FOOD KCal GI

Table Sugar 100 100

White Bread 100 70

Pumpernickel Bread

100 51

Fruit GI

Pear 33

Apple 45

Pineapple 63

Glycemic Load

Compares carbohydrates on volume needed to raise blood sugar. For example, watermelon has a high glycemic index but because it is mostly water, you can eat more of it than table sugar to raise your blood sugar

A GL of 20 or more is high, a GL of 11 to 19 inclusive is medium, and a GL of 10 or less is low

Pharmacologic Intervention

Morbid obesity with laboratory verified insulin resistance

Not compliant with diet or exercise Metformin 500 mg BID or 1000 mg XR OD

with meals

MANAGEMENT: Dietary

Three Fundamental Principles1. Timing: Eat small meals every three hours

Levels of Satisfaction

>140 Stuffed

120-140 Full

90-120 Satisfaction

70-90 Hungry

<70 Starving

Adrenaline - shaky, irritable, hungryCortisol – store sugar from already depleted supplyGlucagon – release sugar from liver

MANAGEMENT: Dietary1. Timing: Eat every three hours regardless of

hunger.

Inadequate caloric intake during the day leads to:

a. Reactive Hypoglycemia

b. Nocturnal Eating Syndrome

c. Central Adiposity

Many of us do not eat enough during the day.

It is self-perpetuating…

MANAGEMENT: Dietary2. Quantity: Best way to assess caloric needs is to measure Basal

Metabolic Rate

Rule of Thumb: Weight in pounds X 10 then add the weight. For example: 220 lbs X 10 = 2200 + 220 = 2400

To lose 1 pound a week, prescribe a diet 500 cal less than BMR. In this case, about 1800 calories. Goal: Lose 1% of weight per

week. 200 lbs = 2 lbs/week

Weight Reduction Prescribe Weight Reduction through Energy Deficit

Select a Realistic Goal Weight

1. Select a BMI 2 units below current BMI

2. Approximate BMR BMR = Wt in lbs X 10 + Wt

= (200 X 10) + 200 = 2200

Reduce BMR by 500 to 1000 calories = 1500-1800 cal

3. Use a Bio-impedance Analyzer to measure BMR

BMRc BMRa BMI %Fat

2200 1670 28 33

MANAGEMENT: Dietary3. Quality: Each meal

must have proteins, fats and carbohydrates

300 Cal

1/3 CHO 100 100

1/3 Prot 1002/3 Prot & Fats 200

1/3 Fats 100

B S L S D

300 150 400 150 500

Choosing Foods

Carbohydrates (100cals)

Proteins and Fats (100cals)

1 sl multigrain bread 1 oz red meat

4 c salads/veggies 1-1/3 oz white meat

½ c rice, pasta, oatmeal 1 oz seafood

6 inch pita or wrap 1 slice cheese

½ c beans 1 whole egg

1 small potato 2 eggwhites

Breakfast: 300 calories

Rule of Hand

Dinner should be about 500 calories

Each finger = 100 Kcal

3 fingers = protein Index = complex

carbohydrates Thumb = simple

carbohydrates