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The deadly M&M syndrome |
You will not have heard of the M&M syndrome but it is a concept coined in this GPSpeak article to focus on a significant problem facing GPs looking after overweight and obese patients. You will have heard of the metabolic syndrome or syndrome X that seems to be afflicting more and more of our patients.
The metabolic syndrome has four components:
1. Hypertension
2. Dyslipidaemia
3. Obesity
4. Insulin resistance with or without hyperglycaemia
A more detailed definition proposed by the WHO includes microalbuminuria as the fourth component. It leaves off insulin resistance and hyperglycaemia and states that a person with type 2 diabetes or impaired glucose tolerance has the metabolic syndrome if two of the four criteria are fulfilled.
A person with normal glucose tolerance has the metabolic syndrome if two of the four are fulfilled plus being insulin resistant. Using this definition a recent large study from Scandinavia (1) showed the metabolic syndrome was found in about 10% of those with normal glucose tolerance, about 50% of those with impaired fasting glucose or impaired glucose tolerance and about 80% with type 2 diabetes.
Mechanical problems of obesity
GPs are now seeing a large number of people who not only have the metabolic complications of being obese but also have the concurrent problem of mechanical complications. Common mechanical problems of obesity are arthritis of the hips, knees or back or just sore knees or back, sleep apnoea, stress incontinence, leg oedema, varicose veins and ulcers to name a few.
Most of these mechanical problems also result in a more sedentary lifestyle, which in turn makes the metabolic state even worse - hence the mechanical and metabolic (M&M) syndrome. This vicious cycle results in potentially serious and progressive risk factors with resulting health problems particularly cardiovascular morbidity and mortality.
The challenge for these patients is to get some of the weight off or at least reduce their fat to muscle ratio. This needs to be tackled nutritionally, by reducing levels of inactivity and by bringing about certain behavioural changes. The worst thing to do is nothing, or to put the matter in the ‘too hard basket’.
Reducing fat in the diet
Nutritionally it is important to encourage our M&M patients to reduce the amount of fat in the diet, particularly saturated fat.
Where fats are used, preferably advise mono-unsaturated fats such as olive oil as used in a healthy Mediterranean diet. Recommend using foods that satisfy hunger and avoiding treats such as chocolates, particularly if hungry and when overconsumption is hard to resist.
Advise use of foods with low fat, low glycaemic index and high satiety index for weight loss and glycaemic control. Maintain or increase protein content (without increasing fat). Decrease portion size and alcohol intake if there is insufficient progress after fat and total energy reduction.
Physical activity
As regards physical activity follow the physical activity (PA) guidelines as mentioned in the last edition of GPSpeak. Appropriate PA will help to raise insulin sensitivity, which will delay disease progression for those not only with impaired glucose tolerance but also those with frank type 2 diabetes.
Attitudes need to be changed too so that people learn to look on any movement as an opportunity. Even fidgeting can help obese people increase their energy expenditure. Finding the most preferred activity is important for compliance and referral to exercise specialists may be helpful here.
Some patients with disability due to mechanical problems may be helped with Nordic walking poles or water aerobic activity, both of which will expend energy without too much strain on lower body joints. It is the large muscle groups that need a work out to have the most benefit. Emphasise longer duration rather than intensity during PA.
Behavioural aspects
Finally the behavioural aspects of weight management need to be addressed. Firstly the psychological state of readiness to change needs to be understood and respected.
Appropriate motivational techniques can be used. Barriers and facilitators for change needs to be addressed. The behavioural stimulus-response connections can be identified (eg. the automatic response of going to the fridge when a TV ad comes on can be interrupted if awareness is raised.)
Some patients have entrenched irrational beliefs, particularly about food, which may take some specialised counselling from a trained health professional to have any impact. Referral to a psychologist is sometimes needed for these patients, particularly when there are long term psychological issues that need to be dealt with.
Medication
There is also a role for medication for some of these patients. The pancreatic lipase inhibitor orlistat is a very useful drug for some M&M patients particularly for kick starting them with enough weight loss to help mobility. A new appetite suppressant drug sibutramine will be available early next year and will also be useful for selected patients.
GPs can make a difference
Managing the M&M syndrome is a huge challenge for us and there is no quick fix for this highly complex biomechanical and metabolic problem. However it is enormously satisfying when lifestyle and pharmaceutical intervention gives results and GPs are ideally placed to make a difference with this burgeoning epidemic.
Reference
(1) Cardiovascular Morbidity and Mortality Associated with the Metabolic Syndrome: B Isomaa et al: Diabetes Care 24(4) 2001
Ed note: Andrew Binns, who is well known for his interest in obesity and its complications, has just co-authored a book with Garry Egger called The Experts’ Guide to Weight Loss. Published by Allan and Unwin, it will be available in bookshops from October. It is written for doctors, allied health professionals and those serious about their health. A review by GP Chris Mitchell will appear in the next edition of GPSpeak.
20 Oct 2001
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