Metabolic syndrome is an umbrella term for a range of lipoprotein abnormalities such as high blood pressure, obesity, insulin resistance, and high cholesterol that contribute to the risk of heart disease and diabetes. Patients with metabolic syndrome have three times the risk of coronary heart disease, myocardial infarction and stroke than the general population. In recent years, as research on metabolic syndrome has intensified, the seriousness of the co-occurrence of metabolic syndrome in patients with psychiatric disorders has become more important. Research on the etiology and prevention and treatment of metabolic syndrome has also attracted a lot of interest. Wang Biao, Department of Psychiatry, Shanghai Mental Health Center
Etiology of metabolic syndrome
1. Insulin resistance
Insulin resistance is related to centripetal obesity. Insulin resistance causes hyperglycemia, atherosclerosis, diabetes mellitus and hypertension, and disorders in lipid metabolism, especially elevated LDL cholesterol and cholesterol, which causes a large amount of lipid deposition on the vascular wall and aggravates atherosclerosis. Insulin resistance causes endothelial damage due to oxidative stress, thus promoting atheromatous plaque formation.
2, hypothalamus-pituitary-adrenal axis dysfunction
Chronic stress leads to elevated cortisol, which subsequently causes abdominal obesity, insulin resistance and dyslipidemia. Interestingly with schizophrenia Hypothalamic-pituitary-adrenal axis dysfunction hypothesis and its consistency.
The relationship between antipsychotic drugs and metabolic syndrome
As early as the 19th century Henry Maudsley wrote in his book on psychopathology that “diabetes mellitus is common in families with a high incidence of psychosis”. Many years before the introduction of atypical antipsychotics, the prevalence of diabetes in schizophrenics was documented, and in the 1920s it was noted that the prevalence of diabetes in family members of schizophrenics was as high as 30%, higher than in the general population, and that a history of diabetes in family members increased the risk of developing diabetes in the patient himself by a factor of two. Patients with schizophrenia required higher doses of insulin than other patients to receive “insulin coma therapy”.
The term “phenothiazine diabetes” appeared in the literature in 1968, after several studies showed that phenothiazines themselves may increase the risk of developing diabetes. More recent studies have also confirmed that any antipsychotic (typical or atypical) is associated with an increased incidence of newly diagnosed diabetes mellitus.
Ryan et al (2003) conducted a study in unmedicated patients with first-episode schizophrenia found an increase in fasting glucose in 15.4% of patients compared to 0% of controls. Insulin levels were significantly higher in the schizophrenic group than in the control group, insulin resistance was greater in the schizophrenic group than in the control group, and cortisol levels were significantly higher in the schizophrenic group than in the control group.
Ryan MCM, et al (2004) found increased visceral adiposity and total adiposity in schizophrenic patients compared to the normal group in a CT investigation of the abdomen of unmedicated first-episode schizophrenic patients compared to the normal group.
McEvoy J et al (2005). In an evaluation of schizophrenic patients on antipsychotic medication and the normal population, statistically significant differences were found in mean waist circumference, mean triglycerides (mg/dl), mean triglyceride compliant HDL (mg/dl), HDL compliant, blood pressure compliant in female patients, and blood glucose (mg/dl) in schizophrenic patients compared to the normal population
Smoking-related deaths (respiratory, cardiovascular, etc.) are significantly higher in schizophrenics than in the normal population, substance abuse (more common in schizophrenics) is known to exacerbate the condition and increase mortality, and schizophrenics have a diet with more saturated fat and less fiber compared to the general population, in addition to a lack of physical activity. For this reason, it has been found that their average life expectancy is about 20% shorter than that of the normal population.
Risk factors for the development of metabolic syndrome in psychiatric patients.
1. Age over 40 years.
2, one or more components of the metabolic syndrome (such as obesity, hypertension, hyperlipidemia, etc.) but do not yet meet the diagnostic criteria.
3, suffering from cardiovascular disease, non-alcoholic fatty liver, gout, polycystic ovary syndrome and other diseases.
4. have a family history of related diseases: obesity, type 2 diabetes, cardiovascular disease, hypertension, dyslipidemia. Especially those with multiple combinations.
5. Long-term use of antipsychotic drugs
6.Long-term hospitalization and low activity level
7.Substance abusers
Diagnostic criteria of metabolic syndrome
NCEP (National Cholesterol Education Program) ATPIII (³3)
Abdominal obesity/waist circumference (male > 102 cm, female > 89 cm)
Fasting triglycerides ³ 1.7 mmol/L, or on treatment
HDL: M < 1.00mmol/L, F < 1.3mmol/L, or on treatment
BP ³ 130/85 mmHg or taking antihypertensive medication
Fasting blood glucose ³ 6.2 mmol/L or on insulin or glucose-lowering medication
AHA recommended fasting glucose ³ 5.6mmol/L
WHO
Diabetes or impaired glucose tolerance or insulin resistance
2 of the following:
Dyslipidemia: triglycerides > 1.7 mmol/L and/or HDL: male < 0.9 mmol/L or female < 1.0 mmol/L
BP > 140/90 mmHg or on treatment
Obesity: BMI > 30 kg/m2 and/or Waist-to-hip ratio: M > 0.9 or F > 0.85
Microalbuminuria
Treatment
The treatment of metabolic syndrome is basically a lifestyle disease, and the basic strategy of treatment is to improve insulin resistance as the basis for comprehensive prevention and treatment of cardiovascular risk factors, including lifestyle intervention, diet control and exercise therapy, and to consider pharmacological treatment when it is not effective. Diet control and exercise therapy are used as the basic measures for long-term intervention, with the ultimate goal of reducing body weight, lowering insulin resistance, reducing hyperinsulinemia, improving dyslipidemia and hypercoagulability to reduce the risk of type 2 diabetes and cardiovascular disease as well as death. Pharmacological treatment focuses on eliminating lipotoxicity, protecting beta-cell function, correcting dyslipidemia, restoring endothelial function and acting as an anti-inflammatory agent. Glitazones, at present, are considered to be the drugs of choice to address these problems.
Implementation of lifestyle interventions begins with understanding the patient’s daily diet, behavior, lifestyle habits, and psychosocial stress. However, in psychiatric patients, we should pay special attention to the effects of antipsychotic drugs on metabolism, as well as the patient’s abuse of psychoactive substances, and encourage and guide the patient to quit smoking. At the same time, doctors should develop individualized life prescriptions and use behavioral therapy to help patients establish a healthy lifestyle.
The core of metabolic syndrome is the ectopic deposition of fat, especially centripetal obesity which is most likely to trigger metabolic syndrome. Weight control is extremely important. Weight loss, which must reach 7%, is necessary for metabolic disorders to improve. Calorie restriction, balanced diets, and increased dietary soluble fiber are essential to ensure successful weight loss. Exercise and exercise can reduce body weight; eliminate centripetal obesity. ; lower blood pressure, especially for systolic blood pressure is particularly effective. Regulate lipid metabolism, i.e., lower triglycerides and raise high-density lipoprotein; improve fibrinolytic enzyme activity and increase insulin sensitivity.
Scientific exercise prescription is fundamental to the treatment, and should be formulated according to the patient’s personality characteristics and medication use. When formulating the prescription, the clinician should conduct a comprehensive disease review and physical examination of the patient to avoid deterioration of the original disease due to improper exercise and increase the risk of comorbidities and accidents. The type of exercise, too, should be adjusted according to the patient’s preference and existing physical condition. Choose aerobic exercise, supplemented by appropriate strength exercise. Aerobic exercise intensity is initially 40% to 50% of maximum heart rate and gradually increases to 60% to 65% of maximum heart rate,. Beneficial metabolic improvements can be obtained with 3 to 4 exercise sessions per week, and 4 to 5 sessions per week can help reduce body weight.
The metabolic aspects of the patient should be observed at a basic level and followed up in a timely manner before the use of antipsychotics. In patients known to have metabolic syndrome, medications with metabolic effects should be avoided in the selection of medications. If the patient does need to use these drugs, they should be started in small doses and added slowly. Antipsychotic drugs that have less effect on body weight, such as ziprasidone and aliprazole, can also be used. Glucose-lowering and lipid-lowering drugs can be used at the same time.