How Metabolic Syndrome Snuck Up on America

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One of the unforeseen lessons of the coronavirus pandemic is how vulnerable our poor metabolic health makes us. Even from the early days in Wuhan it has been known that people with certain underlying metabolic conditions – notably diabetes, hypertension and obesity – were more at risk of serious illness and death from COVID-19. As the pandemic swept America, this lesson hit home hard. The virus has feasted most greedily on the neighborhoods where these conditions are most prevalent, often communities full of minorities and the poor, where people were already more likely to live with non-communicable diseases and to die young. America has some of the world’s highest rates of obesity and diabetes, and the woeful state of our metabolic health has needlessly increased the misery and death caused by the coronavirus.

How did it get so bad? Everybody knows that these conditions are unhealthy, and there has certainly been much time and money spent on anti-obesity campaigns and healthy eating initiatives. Many billions of dollars, perhaps trillions, have been spent on medications to manage and combat these afflictions. And yet our poor metabolic health is an ever-worsening crisis, and had already inflicted staggering financial and emotional costs even before the coronavirus breached our borders.

A curious observer might wonder if our inability to prevent and treat these conditions indicates that we have pursued the wrong solutions, or perhaps that we misunderstood the problem in the first place.

To imagine how this woeful state of affairs snuck up on us, consider as a metaphor the progression of metabolic dysfunction in a single hypothetical average patient with Type 2 diabetes. He is over 50 years old, and he is overweight or obese. He probably has both high blood pressure and dyslipidemia (unhealthy cholesterol and triglyceride levels). He is now far more likely than his healthy peers to die early of stroke or cardiovascular disease.

This didn’t happen all at once, but over a period of years or even decades. When his cholesterol looked a bit too high, he was told to avoid saturated fats, eggs and red meat. When his blood pressure creeped up, to avoid salt. When his weight seemed to get out of hand, to cut calories. He has had many discussions with his doctor on these topics, but most of them were perfunctory, performed out of a sense of obligation more so than a real hope that they might inspire a change. His visits were always underpinned by a silent assumption, shared by both doctor and patient, that diets rarely work and that declining health is inevitable.

It didn’t need to happen this way. Of the many mistakes that hamper mainstream treatment of metabolic disorder, the central mistake is the failure to recognize that all of these different conditions are actually related. Visceral adiposity (excess weight near the belly), low HDL (“good cholesterol”), high triglycerides, hypertension and diabetes are generally all manifestations of a single common root condition: insulin resistance. Insulin resistance is usually associated exclusively with Type 2 diabetes, but diabetes is really just the tip of the iceberg, a particularly extreme and visible presentation of the condition. Lower levels of insulin resistance are extremely common, a subtle condition that impacts health in myriad ways.

Over the years, our hypothetical patient was given three or four distinct dietary and pharmacological approaches to follow, in order to combat what were believed to be three or four discrete medical conditions. Some of that advice was good, and some of it was outdated, but there’s no question that this piecemeal approach would have been far less effective than one specifically targeted to the root cause of his many different afflictions. Whether his first worrisome result came from a test of blood sugar, lipids, blood pressure or body fat, it should have been treated as a probable sign of insulin resistance.

When three or more of these dangerous health conditions are present in one patient, doctors call it “metabolic syndrome.” Metabolic syndrome was first identified in 1988. One reason it took so long to notice is that in prior to the rise of the obesity epidemic in the 1970’s it was comparatively difficult to find patients with several of these maladies at the same time. Today, only a generation or two later, we have the opposite problem: it is now so commonplace as to seem entirely unremarkable. About a third of American adults have full-blown metabolic syndrome, and a vast majority have at least one of these metabolic dysfunctions, which are therefore now so widespread that they may barely prompt much commentary from primary care physicians. Imagine you were a family doctor and some 50% of your patients all shared a condition such as obesity or hypertension: wouldn’t it begin to seem normal?

When it comes to potential solutions, we are lucky that it is widely understood, by experts and laymen alike, that every one of these conditions is largely caused by what we eat and how much we exercise. But we need to make a clean break with yesterday’s dietary advice, which has proved so futile.

Several promising interventions have been found. Best among them is a diet low in simple carbohydrates and high in healthy fats. This regimen has been shown to reverse insulin resistance rapidly and, as a bonus, to achieve impressive rates of patient adherence.

Our patient’s decline might have been checked and even reversed if he had been given a single consistent and appropriate message over these many years. With the right interventions, it is not too late to reverse our patient’s, and the nation’s, metabolic decline.

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