Understanding Metabolic Syndrome: Diagnosis, Symptoms, Treatment, and Risks
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According to the NIH, metabolic syndrome is “a group of conditions that together raise your risk of coronary heart disease, diabetes, stroke, and other serious health problems. Metabolic syndrome is also called insulin resistance syndrome.”
Stanford endocrinologist Gerald Reaven, MD originally described it back in the 80s and coined it “Syndrome X”. After years of blaming most of these risk factors on saturated fat and cholesterol, this finally got us looking at the role of dysregulated glucose and insulin.
Common symptoms of metabolic syndrome include visceral adiposity (VAT), high blood pressure, elevated blood sugar levels, high triglycerides and low HDL cholesterol. If you have a few of these, you have a much greater risk of type 2 diabetes, coronary heart disease and stroke. Hormone imbalances are also seen, as metabolic syndrome is common in women with polycystic ovarian syndrome (1), and can lead to erectile dysfunction in men. (2)
Diagnosing Metabolic Syndrome
To meet the criteria for diagnosis, you must have 3 of the following symptoms:
A waist measurement of >40 inches for men or >35 inches for women
Blood pressure over 130/85 mmHg
Fasting triglyceride levels (TG) over 150mg/dl
Fasting HDL cholesterol less than 40mg/dl (men) or 50mg/dl (women)
Fasting blood glucose over 100mg/dL
The labs listed above are pretty reliable for predicting metabolic syndrome. The trick is recognizing them and taking action rather than the usual “wait and see” approach. Waiting and seeing at this point gives people a false sense of security that they don’t have diabetes yet. But you don’t need to have diabetes to have a much higher risk for a heart attack and early death. People are always so surprised by heart attacks or strokes in their 50s, but the signs have usually been there for at least 10 years. They usually had metabolic syndrome.
People are always so surprised by heart attacks or strokes in their 50’s, but the signs have usually been there for at least 10 years.
The Role of Insulin Resistance in Metabolic Syndrome Development
It’s fair to say that metabolic syndrome is caused by insulin resistance. When your cells are resistant to the action of insulin (trying to store glucose), it leads to higher levels of insulin (hyperinsulinemia). That’s because your body can’t have your glucose levels getting too high. That’s even worse than high insulin. So your pancreas is forced to crank out MORE insulin for the same meal that a few years ago would have required less insulin to deal with. After this meal, your insulin goes higher and stays higher longer. It’s this elevated insulin that leads to the symptoms listed in the image above.
You see, insulin does more than just help us store glucose in cells. It’s a master hormone in the body. High insulin impacts other hormones like cortisol, testosterone, estrogen, and more. It drives up blood pressure, it tells our body to store fat around the viscera (belly fat) including the liver (NAFLD) and pancreas. It drives up triglycerides. It drives up inflammation (and pain), too.
What’s the relationship between prediabetes and metabolic syndrome?
If you’ve got metabolic syndrome, you’ve got prediabetes. Prediabetes is an arbitrary cut-off point when insulin resistance is severe enough that your glucose levels start going up. They’re both just labels for similar situations.
At the beginning of insulin resistance, your glucose levels might look normal. Remember, your pancreas is working overtime to make more and more insulin to keep your glucose levels in a healthy range. But as time goes on, you’ll start seeing elevations in your glucose too (fasting blood glucose and HA1c). That’s why we call it prediabetes. It’s just the next stop on the way to diabetes.
If it sounds confusing, know that it’s just people trying to find ways to classify the same thing in different ways. You have insulin resistance. You have poor metabolic health. Your cells don’t handle carbohydrates well and your ability to make energy (mitochondrial function) is impaired.
We use continuous glucose monitors to assess and treat metabolic disorders like this. But even then, we have to infer insulin levels. The best way to REALLY see what insulin is doing is to get an oral glucose tolerance test (OGTT) and also test insulin at the 30, 60, 90 and 120 minute time points. It used to be the standard test for diabetes, so it’s not a big ask from your health care provider. The images below show you what I’m talking about. The purple line is glucose and the green line is insulin.
Insulin and glucose patterns from Meridian Valley Lab. The purple line represents glucose and green is insulin following an oral glucose tolerance test (OGTT).
Who is at risk of metabolic syndrome?
If I wanted to quickly gather together the highest number of people with metabolic syndrome, I’d search a database for shift workers, sleep apnea, and erectile dysfunction.
While poor diet is clearly a huge cause of metabolic syndrome, poor sleep or a sleep schedule that is not aligned with the natural light cycle puts a person at high risk. Think of healthcare workers like doctors, nurses, and EMTs as well as police officers, firefighters, security staff, and factory shift workers. These people will naturally have a higher risk. (3) and (4)
Obstructive sleep apnea (OSA) will also put someone at risk. In a study of 529 OSA patients, the prevalence of metabolic syndrome was 51.2% and that prevalence increased with OSA severity.(5) In one study, patients with OSA were given either CPAP treatment or a sham CPAP treatment (as a control). The CPAP-treated group reduced the frequency of metabolic syndrome by lowering blood pressure, serum total cholesterol, LDL cholesterol, triglycerides and HA1c. (6) Identifying OSA and treating it is one of our #1 jobs when assessing a patient with metabolic syndrome.
Identifying obstructive sleep apnea and treating it is one of our #1 jobs when assessing a patient with metabolic syndrome.
Understanding the Dangers of Metabolic Syndrome
Assessing the Risks: What Metabolic Syndrome Means for Your Health
Think of metabolic syndrome as a signpost on your path. It says, “It’s time to take this seriously, mate.”
The typical response is to wait until you have diabetes or a heart attack to take action. Unfortunately, our health care system and health insurance system is set up this way. You might have to be your own advocate here, but you’ll reap the benefits if you do.
The Link Between Metabolic Syndrome and Cardiovascular Disease
Having metabolic syndrome increases your risk of cardiovascular disease (CVD) and all-cause mortality. A 13-year prospective study done on 4,000 people, published in 2020, showed an increased risk of a major cardiovascular event (Myocardial infarction, stroke or other), death from an event, AND death from any cause. (7) A 2010 meta-analysis showed very similar results of increased risk of cardiovascular incidents and death from all causes. (8)
In other words, if you meet the criteria for metabolic syndrome when you’re 40, don’t be surprised if you have a stroke or heart attack in your 50s if you choose to adopt the wait-and-see approach.
Other Health Conditions Associated with Metabolic Syndrome
Cancer also seems to favor those with insulin resistance. A 2009 study included over 33,000 men and found that 28% of them had metabolic syndrome at baseline. During a 14-year period, they saw a 56% greater risk of all cancer deaths in the men who started out with metabolic syndrome. What was interesting was that when you broke down the number of cancer deaths, they increased according to how many of the metabolic syndrome components they had. Meaning, that if you had 3 symptoms, your risk was greater than if you had 2 or 1. (9)
Alzheimer’s disease is another concern. A 2021 study found an association between metabolic syndrome and Alzheimer’s disease (AD) and associations between AD and the individual components of metabolic syndrome. (10)
Erectile dysfunction (ED) is also common in men with metabolic syndrome. However, you can also think of it the other way around. If you have ED, it’s a red flag for metabolic syndrome and CVD. As I wrote in a previous article on the causes of ED, a 2014 paper concluded that ED and CVD are simply two different manifestations of the same metabolic cause leading to atherosclerosis and reduced blood flow. (11)
Lifestyle Changes for Treatment and Prevention
We have a lot of different tools for reversing metabolic syndrome. In our Hack Your Blood Sugar Using a CGM program, we discuss them as levers to pull on a blood sugar mixing board. The levers you choose depend on a few things:
Which lever correlates to your unique root causes (i.e. sleep apnea)
Which lever will give you the best return on investment
Which lever is easiest or most appealing
For example, if I am looking at your CGM data and notice a high baseline glucose level and you tell me that you snore and are sleepy during the day, you can bet that I will recommend a home sleep study. If I'm correct, that addresses a probable root cause and will have the best ROI.
For a client who has a lot of chronic pain and can’t really exercise, we won’t utilize that lever (yet). They will put their energy into other areas which are more accessible to them.
Sometimes, I get a client who doesn’t want to even think about food. For them, exercise and some time-restricted eating and fasting will probably be great strategies, along with some natural products.
Medications and Medical Intervention for Metabolic Syndrome
Conventional medicine doesn’t have much to offer in the way of metabolic syndrome. In many cases, they offer bandaids that help you live longer while the underlying issues keep getting worse. But that doesn’t mean you shouldn’t use some of them.
Medications like ACE inhibitors and beta blockers lower blood pressure. Statins lower lipids. Metformin lowers blood sugar and insulin. I suppose the metformin is the closest to addressing the root cause. But your metabolic syndrome can keep getting worse while you take it.
There’s nothing wrong with using medications. For example, in an earlier article on blood pressure, I explain how important it is to control high blood pressure with medications if you aren’t in a place to use the diet and lifestyle modifications yet. Just don’t be lulled into a false sense of security that these medications are solving the problem. The symptoms will keep piling on and so will the medications. I wouldn’t eliminate medications from your toolbox entirely, but you have to also include diet and lifestyle strategies or you won’t really get anywhere with them.
Diet and nutrition strategies
I wish I could tell you that there was a standard dietary protocol for treating metabolic syndrome that will work for you.
If there was, it would involve diet modifications with more whole foods, more plants, fewer simple carbs, healthy fats, and optimal protein intake. It might involve some modest time-restricted eating. It definitely involves more exercise. 150 minutes of Zone 2 training plus at least 2 one-hour weekly strength training sessions. It involves better sleep and stress reduction. It might include some supplements to help you move the needle faster. The problem is, that not everyone is ready to make this many changes.
The good news is, you don’t need to make all those changes. You just need to know which strategies will work best for you.
I love the quote by Michal Pollan that says, “Eat food. Not too much. Mostly plants.” In theory, it should do the trick. But the actual application of it often comes up short. I see many people interpreting it as only plants and not getting enough protein. I meet people undereating, especially when following an intermittent fasting protocol unskillfully. So, I find a little more detail is helpful along with a more personalized approach.
In fact, all this is exactly how I used to help my clients. I’ve been working with metabolic syndrome since 2002. If my patients stayed with me long enough and did everything I told them to do, they had great results. The problem is that it was a LOT. Most people didn’t have the time or interest to do all of these things. They really wanted to know the minimum needed to start turning their ship around and get back to their lives.
The good news is, that I have a tool for that now
Using a continuous glucose monitor to heal metabolic syndrome
We find there is an easier and faster way to reverse metabolic syndrome and that is a data-driven approach. This data comes from a combination of a detailed health history, conventional labs, and sometimes even a nutrigenomics test (genetics), hormone tests and advanced nutrient tests. But the best tool I have is a CGM.
Using a continuous glucose monitor (CGM) for even a few weeks allows us a rare window into your metabolism. It shows us minute-by-minute how everything affects your blood sugar (and we can infer how it affects your insulin levels, most of the time). Your blood sugar (aka glucose) levels are exquisitely sensitive to many environmental factors. It is impacted by the type of food you eat, the timing of your meals, exercise, stress, sleep, inflammation/infections, medications, and microbiome.
What has been interesting to me is that we are each fairly unique in which of these makes the biggest difference. For example, I’ve trained many dietitians in using CGM for their patients. As you’d expect, most of them have a really healthy diet and it shows in their glucose data. However, I’ve often seen their baseline (fasting) glucose levels going high. Their meals barely change their blood sugar levels, but their baseline is elevated. Prior to working with me, they were fasting or trying a keto diet with no success. For these people, lowering their carbs will not help. They need to relax on the diet front and focus on sleep and stress.
Sometimes, the solution is surprisingly simple and easy to fix.
Other clients have come with a diagnosis of prediabetes because of their elevated fasting blood glucose. Literally, within a week, we can get their fasting blood glucose down. They were eating too late at night and eating the wrong kind of food (in the wrong order). A few tweaks and we get their levels down. Another month of being consistent with those small changes and their sleep is better along with their daytime glucose levels.
A CGM helps us find the minimum change necessary to start turning your ship around.
Success with a CGM in lowering blood sugar
I put most of my patients on a continuous glucose monitor (CGM) these days. From this data, we can see clearly (and quickly) what the biggest issues are and what strategies work. So, it’s a tool to assess the problem and to see if a strategy is effective rapidly. If a strategy works, we keep it. If it’s not, we ditch it. We can decide in a matter of hours or days now instead of waiting 3 months. This means it usually takes only 4 weeks to see significant improvements. And when you have lost weight, have better glucose control, clothes fit better, and there is less pain in 4 weeks, it’s easy to stay motivated for another 4 weeks.
What’s more, is that CGM use isn’t that expensive. In my previous article on the cost of CGMs, I explained that my patients are able to obtain them for $80-$150/month (without insurance). And since we usually only need them for 1-2 months, it’s a great return on investment.
For my patients who are further along and have type 2 diabetes already with multiple medications, the CGM also allows us to safely decrease hypoglycemic medications (like metformin and insulin) to avoid hypoglycemia.
Some of my clients use these with me 1:1. But the beauty of this tool is it puts all the information and control into the hands of the user. Even in my small group programs where we meet for weekly Zoom calls for just 4 weeks with 15 people, my clients make astounding progress. If you’ve watched my interview with Ruth and Bob, you’ll learn just how transformative this process was for them. In Bob’s case, he was able to figure out exactly what he needed to do to turn his type 2 diabetes around. Within 4 weeks, he got his glucose levels down from the 200’s to consistently under 140mg/dl. And it wasn’t that hard once he could see what the problem was. And remember, I never met with Bob 1:1. This was in a 4-week group program over Zoom! The program set him up to be his own expert.
Another client, Mike, had prediabetes and all the signs of metabolic syndrome. He was told his next step was the endocrinologist and insulin. But as you’ll hear in this video interview with Mike, he was able to bring his glucose down very quickly in the same way. He thought he was eating healthy (and he was) but it wasn’t a good match for his body and his meal timing was off. Like Bob, he brought his blood sugar down into a healthy range relatively quickly and it didn’t feel like a diet. The changes were simple and effective and based on data, not guesswork.
The Urgency of Early Intervention with Metabolic Syndrome
It can’t be understated how important early intervention is. Type 2 diabetes and heart disease are decades in the making. All the while your insulin levels are elevated with metabolic syndrome, and you are damaging your blood vessels. The effect is cumulative but it can be reversed. However, the longer you wait, the harder it will be and the worse you will feel. If you catch it early at the first signs, then it’s just a few tweaks and things start to shift. But once you’re on a few different medications with their own side effects, you’ve lost a lot of muscle mass, your testosterone is low and you're in poor condition, it’s harder to turn the ship around. We can do it, but it will take more time.
Conclusion
Metabolic syndrome is a collection of symptoms indicating a significant imbalance in your hormones driven by insulin resistance. You’re at higher risk if you have poor sleep, higher stress, or a poor diet.
It’s common to ignore the warning signs of this syndrome and conventional medicine doesn’t have the tools needed to reverse it, only to help you live longer while the disease continues to progress.
However, it’s highly responsive to diet and lifestyle strategies. The key is to do your homework and figure out what YOUR personal triggers are to help you find the most effective strategies for reversing it. In my experience, using a continuous glucose monitor for a month or two with support is a key step in both assessing your triggers and uncovering the simplest dietary strategies to help you reverse it quickly.
Medications can be helpful and they can be used in conjunction with diet and lifestyle. Using a glucose monitor is also helpful in guiding their use and knowing when it’s time to go up or down in dose (particularly in the case of metformin and other hypoglycemic medications.)
You should always assess the contribution of diet, sleep, stress, and exercise in order to get the best results from your efforts. Don’t hesitate to enlist the help of experts in the areas of nutrition, fitness, sleep medicine, mental health, and your doctor in order to get the support you need. A bigger toolbox and bigger team can often provide the best results.
Why not join our Hack Your Blood Sugar Program?
If you are looking for a nutrition professional to support your use of a CGM to help you get a handle on your blood sugar and start turning your own ship around, why don’t you think about joining one of our 4-week programs? We run them every other month and cap them at 15 people (just like you) to keep the group small. You’ll have access to short videos to help you level up your own knowledge, a private group chat for questions and support, and twice weekly group Zoom calls where I take time to personally go over each person’s data to help you interpret your data and decide on your next step. In 4 weeks, I can promise that you’ll be your own blood sugar expert and have a good grasp of what levers will be the most important for you moving forward.
Not a group person? You’re not alone. We have 1:1 programs too. You can find more information about my CGM Programs HERE. We can just do an 8-week package to get you set up with a CGM and do all this blood sugar stuff together; or become a client and make use of my whole toolbox to review your labs, your diet, and be part of your healthcare team. Many people have more than just their blood sugar to be concerned about including digestive issues. That way we can work on the whole picture at once.
References
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Walton A, Usta MF, Wong, M and Hellstrom W. Metabolic Syndrome and Erectile Dysfunction. OBM Integrative and Complementary Medicine 2021, Volume 6, Issue 4, doi:10.21926/obm.icm.2104042.
Beyone-Jin Ye. Association between Shift Work and Metabolic Syndrome: A 4-Year Retrospective Cohort Study Healthcare 2023, 11(6), 802; https://doi.org/10.3390/healthcare11060802
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Gandaglia G, et al. A systematic review of the association between erectile dysfunction and cardiovascular disease. European Urology 2014 May;65(5):968-78. doi: 10.1016/j.eururo.2013.08.023