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Insulin Resistance SyndromeAka: Impaired Glucose Tolerance, Impaired Fasting Glucose, Insulin Resistance, Glucose Intolerance, Metabolic Syndrome, Syndrome X

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  1. See also
    1. Type II Diabetes Mellitus
  2. Epidemiology
    1. Prevalence in U.S.
      1. Total estimated at 70-80 million
      2. Affects 25% of adults and 4% of teens
  3. Pathophysiology
    1. Diminished Insulin response results in hyperInsulinemia
      1. Fewer Insulin receptors on cells
      2. Less glucose transporter (Glut 4) in cells
    2. HyperInsulinemia predisposes to cardiovascular disease
    3. Precursor to Type II Diabetes Mellitus
  4. Risk Factors
    1. Strong Family History of Diabetes Mellitus
    2. Prior Gestational Diabetes Mellitus or Fetal Macrosomia
    3. Obesity
      1. Body Mass Index 30 kg/m2 or higher
      2. Waist to hip ratio increased
        1. Men: 1.0 or higher
        2. Women: 0.8 or higher
  5. Diagnosis: Three or more conditions below
    1. Insulin Resistance (see labs below)
    2. Hypertension (Blood Pressure 130/85 or higher)
      1. Seen in up to 40% of Metabolic Syndrome patients
    3. Hyperlipidemia (see labs below)
    4. Coronary Artery Disease
    5. Polycystic Ovary Syndrome
    6. Acanthosis Nigricans
    7. HAIR-AN Syndrome
    8. Abdominal Obesity
      1. Men with Waist Circumference >40 inches or 102 cm
      2. Women with Waist Circumference >35 inches or 88 cm
  6. Labs
    1. Screening Indications
      1. See Risk Factors above
      2. Body Mass Index >25 kg/m2
      3. Family History of Diabetes Mellitus
      4. Prior history of Gestational Diabetes
      5. Age over 45 years
      6. HDL Cholesterol <35 mg/dl
      7. Serum Triglycerides >250 mg/dl
      8. Polycystic Ovary Syndrome
      9. Hypertension
    2. Impaired Glucose Metabolism
      1. Fasting Glucose: 100 to 125 mg/dl
        1. Known as Impaired Fasting Glucose
        2. New guidelines suggest bottom cut-off of 100 mg/dl
        3. Metabolic Syndrome defined as 110 mg/dl or higher
      2. Two hour Glucose Tolerance Test (75 g): 140-199 mg/dl
        1. Known as Impaired Glucose Tolerance
    3. Lipid Profile
      1. Serum Triglycerides >150 mg/dl
      2. Serum very Low Density Lipoprotein (VLDL) increased
      3. Serum HDL Cholesterol decreased
        1. Men <40 mg/dl
        2. Women <50 mg/dl
    4. Best lab markers for Insulin Resistance
      1. Plasma Insulin level (or Glucose to Insulin Ratio)
      2. Plasma Triglyceride levels
      3. Triglyceride to HDL ratio
      4. McLaughlin (2003) Ann Intern Med 139:802
  7. Management: Prevention of progression to Diabetes
    1. Moderate aerobic Exercise for 30 minutes every day
      1. Example: Brisk walking for total of 150 min/week
    2. Decreased caloric intake
      1. Keep fat intake <30% with saturated fat <10%
      2. Salad, vegetables, fruits
      3. Whole grains and legumes
      4. Fish high in Omega-3 Fatty Acids and lean meats
      5. Reduce intake of simple sugars
    3. Foods associated with improved Insulin sensitivity
      1. Coffee
        1. Salazar-Martinez (2004) Ann Intern Med 140:1
        2. Tuomilehto (2004) JAMA 291:1213
      2. Cinammon (1/2 teaspoon per day)
        1. Appears to have Insulin-like activity
        2. May increase Insulin sensitivity
        3. Improves lipid profile
        4. Khan (2003) Diabetes Care 26(12):3215
      3. Moderate alcohol consumption
        1. Howard (2004) Ann Intern Med 140:211
    4. Weight Reduction (lose 7-15% of prior weight)
    5. Increase Dietary Fiber to 15 gram per 1000 calories
    6. Cardiac Risk Management
      1. Same as Diabetes Mellitus and Coronary Artery Disease
      2. Aspirin 81 mg PO qd
      3. Hyperlipidemia
        1. LDL Cholesterol <100 mg/dl
        2. HDL Cholesterol >40 mg/dl (50 mg/dl in women)
        3. Triglycerides <150 mg/dl
        4. Statins are preferred agents
          1. Sowers (2003) Am J Cardiol 91:14B
      4. Hypertension
        1. Goal Blood Pressure < 125/75 mmhg
        2. Consider ACE Inhibitor or Angiotensin Blocker
    7. Consider pharmacologic agents for glucose control
      1. Glucophage (Metformin)
      2. Acarbose (Precose)
      3. Avandia or Actos
    8. References
      1. (2002) N Engl J Med 346:393
      2. Scott (2003) Am J Cardiol 92(2 suppl):35i
      3. (2006) Lancet 368:1096
  8. Course
    1. High risk for Type II Diabetes Mellitus
    2. Diabetes Prevention Program (DPP)
      1. Basic diet and Exercise: 11% develop diabetes/year
      2. Metformin 850 bid/diet/Exercise: 7.8% develop DM/year
      3. Intensive diet, Exercise: 4.8% develop diabetes/year
        1. Classes and coaches
        2. Weight Reduction of 7%
      4. Reference
        1. (1999) Diabetes Care 22:623
  9. References
    1. (1997) Diabetes Care 21:310
    2. (2001) JAMA 285:2486
    3. Goutham [AU] AND 2001 [DP] AND Am Fam Physician [TA] " class="LinkRef">Goutham (2001) Am Fam Physician 63(6):1159

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