Learning objectives

1. Identify how to assess patients for metabolic syndrome.
2. Discuss the management of patients with metabolic syndrome.
3. Describe the nursing care for patients with metabolic syndrome.

The authors and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the end of this article to learn how to earn 1.2 CNE credit.

Expiration: 4/1/20

To promote holistic care and improve patient outcomes, all nurses need to know about metabolic syndrome. A combination of conditions that together increase the risk of cardiovascular disease (CVD) and diabetes, metabolic syndrome is the precursor to complications that may be lifelong, chronic, or even lead to death.

According to the American Heart Association (AHA), about 35% of U.S. adults have metabolic syndrome. Many experts believe the root cause is obesity. The National Health and Nutrition Examination Survey estimates about two-thirds of American adults and 15% of children and adolescents are either overweight or obese. These statistics are significant because Americans are developing diabetes and CVD at much younger ages than ever, due to overweight or obesity. Metabolic syndrome doubles the risk of CVD and quintuples the diabetes risk. Risk is especially high in men older than age 45 and women older than age 55.

Criteria for metabolic syndrome

Patients meet the criteria for metabolic syndrome if they have at least three of the five conditions below:

• hypertriglyceridemia or use of cholesterol-lowering drugs
• hypercholesterolemia or use of cholesterol-lowering drugs
• hypertension or use of antihypertensive drug therapy
• elevated fasting blood glucose or use of blood-glucose lowering drugs
• central obesity, defined as excess fat in the stomach area. (See the box below).

Management

Metabolic syndrome calls for management of hypertriglyceridemia, hypercholesterolemia, hypertension, elevated fasting blood glucose levels, and obesity, as appropriate.

Managing hypertriglyceridemia

Elevated triglyceride levels correlate directly with CVD. Medications that lower triglycerides include niacin and fibric agents, such as fenofibrate and gemfibrozil. Management includes exercise, smoking cessation, and dietary modifications. Advise patients to:

• restrict intake of dietary fats, refined sugars, white flour, and white rice
• eat fish high in omega-3 fatty acids, such as herring, sardines, and salmon
• eat more fruits and vegetables
• replace saturated fats with moderate amounts of monosaturated fats (such as cashews, cereal, olive oil, oatmeal, popcorn, and whole grains)
• stop smoking
• limit alcohol intake.

Be aware that high triglyceride levels are linked to insulin resistance (as occurs in type 2 diabetes). In this condition, cells don’t respond normally to insulin and don’t promote glucose entry into cells. Insulin resistance can stem from several factors—obesity, polycystic ovary syndrome, and a sedentary lifestyle. It leads to hypertension, low HDL levels, and high triglyceride levels. Insulin resistance commonly occurs in conjunction with other CVD risk factors, such as hypertension, hypercholesteremia, and a predisposition to blood clots. Managing insulin resistance involves dietary modifications (such as increased intake of whole grain foods and fiber) to improve tissue responsiveness to insulin.

Managing hypercholesterolemia

Cholesterol levels relate directly to CVD development. Patients with levels of high-density lipoprotein (HDL, the “good” cholesterol) below 35 mg/dL are more likely to develop CVD than those with levels above 65 mg/dL. Low-density protein (LDL, the “bad” cholesterol) causes plaque buildup; levels above 190 mg/dL indicate very high cholesterol—a precipitating factor for plaque development. HDL, on the other hand, removes LDL cholesterol; HDL levels below 40 mg/dL for men or below 50 mg/dL for women increase CVD risk.

Recommended hypercholesterolemia treatment includes medications that target high cholesterol levels, as well as an exercise plan; reduction of dietary saturated fats, trans fats, and cholesterol; smoking cessation; and alcohol restriction. Medications may include HMG-CoA reductase inhibitors (statins), bile acid sequestrants, and fibric acid agents. Statins are superior for lowering LDL cholesterol and reducing myocardial infarction (MI) and stroke risk.

Managing hypertension

Management of hypertension typically includes increased physical activity, a weight-loss regimen, dietary modifications, and antihypertensive drugs. AHA recommends restricting dietary saturated fats, trans fats, cholesterol, sodium, added sugars, and alcohol. Antihypertensives include diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, beta blockers, alpha blockers, and alpha-adrenergic antagonists.

Elevated glucose levels

According to the Centers for Disease Control and Prevention, nearly 26 million American adults and children had diabetes in 2011—a staggering statistic because elevated glucose levels are a risk factor for metabolic syndrome. Diabetes correlates directly to CVD; diabetic patients have a higher rate of atherosclerosis, which leads to CVD.

Diabetes treatment includes dietary modification (reducing intake of carbohydrates, fats, and sugar while increasing whole grains, fiber, and lean meats), exercise, and weight control. Studies show that exercising 150 minutes a week and losing 7% of body weight (about 15 lb for someone weighing 200 lb) can prevent or delay type 2 diabetes. Diabetes medications include insulin and oral drugs, such as sulfonylureas, biguanides, incretin therapies, and meglitinides.

Maintaining blood glucose and hemoglobin (Hb) A1C levels within normal range is crucial to preventing complications that can lead to CVD. The HbA1C level reflects the average blood glucose level over the previous 2 or 3 months, indicating the level of diabetes control. Ideally, HbA1C should be less than 7% in patients with diabetes. The higher the glucose level over the past few months, the higher the HbA1C level. (See the box below.)

Obesity

One in every three U.S. children ages 2 to 19 (about 23 million) is overweight or obese; more than one in three U.S. adults (at least 75 million) are obese. Experts expect obesity to replace smoking as the leading cause of chronic illness and preventable death. Being overweight can increase the risk of diabetes, heart disease, and stroke. Overweight is defined as a body mass index (BMI) of 25 to 29.9; obesity, a BMI above of 30 kg/m² or higher; and morbid obesity, a BMI above 40 kg/m².

The primary treatment for obesity is weight reduction, usually by decreasing caloric and fat intake and getting adequate exercise. Foods appropriate for diabetic patients include fruits, whole grains, lean meat, nonfat dairy products, and fish. Specific weight-loss diets include:

• Atkins^® diet, which limits carbohydrates and calories and encourages a high intake of fat and protein
• Weight Watchers Diet^® , which lets the dieter choose from a list of foods with designated point values, not to exceed a certain numbers of points per day
• South Beach Diet^® , which emphasizes protein and certain carbohydrates.

For some patients, bariatric surgery may be an option. (See the box below.)

Medications used to promote weight loss include megestrol, sibutramine, phentermine, orlistat, and diethylpropion. These drugs can have serious side effects, so patients must be monitored closely. Typically, they’re prescribed only for patients with BMIs above 27.

The only over-the-counter (OTC) weight-loss preparation approved by the Food and Drug Administration is Alli. Other OTC weight-loss products include dexedrine and certain herbal supplements. Caution patients that OTC ingredients may cause serious side effects and that some can lead to or worsen heart disease.

Inform patients that successful weight loss takes time, patience, and motivation. At times, weight loss may not occur despite dietary modification, exercise, or drug therapy. Lack of progress and eagerness to see quick results may cause some patients to give up, leading to depression. Stay supportive while monitoring patients for signs and symptoms of depression.

Assessing patients for risk factors

To evaluate for risk factors of metabolic syndrome, obtain a thorough health history, perform a physical examination, and check laboratory findings.

Hypercholesterolemia and hypertriglyceridemia. Review the patient’s cholesterol and triglyceride levels to see if they fall within the high-risk zone. Ask patients if they’re taking drugs that lower triglyceride or cholesterol levels.

• Hypertension. Take the patient’s blood pressure and ask if he or she is taking antihypertensive drugs. Hypertension is defined as a systolic pressure of 130 mm Hg or higher or a diastolic pressure of 85 mm Hg or higher.
• High blood glucose level. Check the fasting blood glucose level. Ask patients if they’re taking medications that lower blood glucose, such as insulin or oral antidiabetic medications.

• Obesity. Weigh the patient and calculate BMI. Be sure to observe weight distribution. Studies show a correlation between abdominal fat and development of insulin resistance and type 2 diabetes. For a diagnosis of metabolic syndrome, obesity is defined by a waist circumference of 40” (102 cm) or more for men and 35” (89 cm) or more for women.

Because a diagnosis of metabolic syndrome raises the risk of other serious conditions, assess patients for signs and symptoms of the following associated conditions:

• Coronary heart disease. This condition can lead to MI and ischemic strokes. When taking the health history, ask if the patient has had chest pain or heaviness, shortness of breath, or weakness. Inquire about a history of smoking and alcohol intake and a family history of heart disease. Obtain weight, BMI, and blood pressure and assess quality of peripheral pulses.
• Atrial fibrillation. Metabolic syndrome puts patients risk for atrial fibrillation. Assess for such signs and symptoms as hypotension, shortness of breath, syncope, and angina. Palpate peripheral pulses and check for a harsh systolic murmur. Atrial fibrillation causes irregular pulses of variable amplitude; suspect this arrhythmia if pulse pressure narrows to 30 mm Hg or less.
• Aortic stenosis. This condition obstructs blood flow from the left ventricle to the aorta during systole. In early stages, it may be asymptomatic, but as it progresses, dyspnea on exertion, angina pectoris, and exertional syncope may occur. Check for elevated pulse pressure and a harsh systolic murmur.
• Obstructive sleep apnea (OSA). Marked by intermittent absence of airflow through the mouth and nose during sleep, OSA can be serious or even life-threatening. It correlates directly with insulin resistance and can cause systemic inflammation. Combined with insulin resistance, OSA can raise CVD risk, particularly in patients with BMIs above 40 kg/m². Obtain the history and ask about daytime fatigue and sleepiness, morning headache, depression, intellectual impairment, impotence, heartburn, and gastroesophageal reflux disorder. Ask the spouse or another person who has witnessed the patient sleeping about the following OSA signs during sleep: loud, cyclic snoring; periods of apnea; gasping or choking; restlessness; and thrashing.

Nursing interventions

Metabolic syndrome can be controlled largely through lifestyle changes (the preferred treatment). To help patients make recommended lifestyle changes, teach them about risk factors and how to alter them. Point out that dietary modifications that may help prevent or control diabetes also can lower the CVD risk.

• Diet, weight loss, or both. For overweight patients, the goal is to decrease weight by 7% to 10%. A low-fat diet commonly is recommended. Help patients select foods low in fat and avoid those high in saturated fats and cholesterol, which can increase cholesterol levels. Foods high in saturated fats include cream, cheese, butter, and fatty meats. Point out that vegetable products, such as coconut oil, cottonseed oil, and palm kernel oil, as well as chocolate and many prepared foods may be high in saturated fats and cholesterol as well. Emphasize that a low-fat diet can accomplish more than just weight loss; it also can reduce cholesterol levels and blood pressure. Encourage patients to consume plenty of fiber-rich foods, such as whole grains, beans, fruits, and vegetables, which can help lower insulin levels. As needed, refer patients to a dietitian for meal-planning guidance.
• Exercise. Advise patients to increase physical activity to reduce their weight and improve blood pressure. Encourage them to get 30 minutes of moderately intense exercise, such as walking, 5 to 7 days per week. Instruct them to consult a physician before starting an exercise regimen.
• Smoking. Smoking can raise the CVD risk and increase insulin resistance. Nicotine is highly addictive, making it hard for many people to stop smoking. Teach patients about the link between smoking and CVD and refer them to smoking-cessation resources.
• Alcohol use. Excessive alcohol use can adversely affect cholesterol levels and cause weight gain. Like nicotine, alcohol is addictive. While some people can stop drinking on their own, others need medical help to manage physical withdrawal. Numerous resources are available for those who want to stop drinking. In most areas, Alcoholics Anonymous (AA) meetings are available, as are inpatient and outpatient treatment centers or hospitals and alcohol treatment hotlines.

With the increasing prevalence and life-threatening implications of metabolic syndrome, all nurses need to be familiar with this condition and skilled in assessing for signs, symptoms, and laboratory markers. Your knowledge can make a life-saving difference.

Helene Harris and Carla J. Smith are clinical educators at Central Texas Veterans Healthcare System in Temple, Texas.

Selected references

Adams MP, Koch R. Pharmacology: Connections to Nursing Practice. Upper Saddle River, New Jersey: Pearson; 2019.

Alberti KG, Eckel RH, Grundy SM, et al; International Diabetes Federation; Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation, International Atherosclerosis Society; and International Association for the Study of Obesity Harmonizing the metabolic syndrome: A joint interim statement of the International Diabetes Federation; Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation, International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009;120(16):1640-5.

Barrios de Castro A, Nunes V, Ionut V, et al. Is visceral fat a better predictor of the incidence of impaired glucose tolerance or type 2 diabetes mellitus than subcutaneous abdominal fat: a systematic review and meta-analysis of cohort studies. 2014; PeerJ PrePrints 2:e199v1. http://dx.doi.org/10.7287/peerj.preprints.199v1. Accessed March 10, 2014.

Bolton M. Sounding the alarm about metabolic syndrome. Nursing. 2010;40(9):34-9.

Cena H, Fonte M, Turconi G. Relationship between smoking and metabolic syndrome. Nutr Rev. 2011;69(12):745-53.

Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care. 2010; 33(12):e147-e167.

Hodgson B, Kizior RJ. Saunders Nursing Drug Handbook 2014. St. Louis, Mo.: Saunders; 2014.

Ignatavicius DD, Workman ML. Medical-Surgical Nursing: Patient-Centered Collaborative Care. 7th ed., St. Louis, Mo.: Saunders; 2012.

McClendon DA, Dunbar SB, Clark PC, et al. An analysis of popular weight loss diet types in relation to metabolic syndrome therapeutic guidelines. Medsurg Nurs. 2010;19(1):17-24.

Mayo Clinic Staff. Metabolic syndrome. 2012. April 15, 2013. http://www.mayoclinic.org/diseases-conditions/metabolic-syndrome/home/ovc-20197517. Accessed March 10, 2014.

Metabolic syndrome: Insulin resistance syndrome; Syndrome X. Last reviewed: June 2, 2012.
www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004546. Accessed March 6, 2014.

Polotsky V, Patil S, Savaransky V, et al. Obstructive sleep apnea, insulin resistance, and steatohepatitis in severe obesity. Am J Respir Crit Care Med. 2009;179(3):228-34.

Tanner RM, Baber U, Carson AP, et al. Association of the metabolic syndrome with atrial fibrillation among United States adults (from the REasons for Geographic and Racial Differences in Stroke [REGARDS] study. Am J Cardiol. 2011;108(2):227-32.