Nutritional Management of Metabolic Syndrome
Metabolic Syndrome:
More Than Just a Risk Factor for Disease
- fasting blood glucose >100 mg/dL
- blood pressure >135/85 mm hg
- triglycerides >150 mg/dL
- HDL-C < 40 mg/dL in men or <50 mg/dL in women
The majority of people with metabolic syndrome have prediabetes, defined as fasting blood glucose between 100-125 mg/dL and/or hemoglobin A1c between 5.7-6.4%. Interestingly, people with hypertension may have better overall glycemic control as a result of producing large amounts of insulin, but they often develop heart disease at higher rates because of persistent and significant hyperinsulinemia. Unfortunately, it’s easier to dismiss concerns about you’re health when you’re told you “only” have prediabetes.
Insulin resistance is defined as the inability of cells to respond normally to insulin, resulting in higher blood glucose and insulin levels. It’s the hallmark of metabolic syndrome. Recently it has been suggested that hyperinsulinemia may be what causes insulin resistance rather than the more commonly held view that insulin resistance leads to increased insulin output and subsequent hyperinsulinemia. Regardless of which occurs first, high levels of serum insulin result in elevated blood pressure, inflammation, and high triglycerides and VLDL cholesterol — all of which increase the risk for vascular events, i.e., heart attack and stroke. Unfortunately, most people who are diagnosed with prediabetes or metabolic syndrome don’t realize that they’ve already sustained damage. For instance, it’s estimated that 50% of people already have heart disease at the time diabetes is diagnosed.
Lifestyle Goals: Is Standard Advice Helpful or Harmful?
The goals of treatment for metabolic syndrome are obvious: weight loss and improvement in blood pressure and lab values. Aside from drug therapy for lipids and blood pressure, what can be done from a nutritional standpoint? Here is the standard advice I found on many highly regarded websites, including the National Heart, Blood, and Lung Institute (NHBLI) site:
Lose Weight
A typical recommendation is to achieve and maintain a BMI of <25, which may not be possible or even desirable for everyone, particularly muscular, large-framed men. The BMI is also meaningless for assessing abdominal girth and body fat vs. muscle. For instance, a man with a BMI of 28 with little body fat and a 32-inch waist is metabolically much healthier than a small-framed man with a BMI of 24, a 38-inch waist, and a considerable amount of visceral fat around his organs. Of course, in people with metabolic syndrome abdominal obesity is a given, but the goal should be decreasing waist circumference rather than BMI.
Follow a Heart-Healthy Diet
It really shouldn’t surprise me at this point that the “heart-healthy diet” — essentially the DASH diet — so often advised for people with metabolic syndrome isn’t the one I’d recommend. From the NHBLI website:
“Fill half your plate with fruits and vegetables. A healthy diet also includes whole grains, fat-free or low-fat dairy products, and protein foods, such as lean meats, poultry without skin, seafood, processed soy products, nuts, seeds, beans, and peas.”
Yes, “processed” soy products.
So according to these recommendations, the following meal plan would be ideal:
Breakfast:
Bowl of Raisin Bran cereal with sliced banana and skim milk
V8
Lunch:
Turkey sandwich with low fat mayo on whole grain bread, orange
Snack:
Yoplait Light yogurt with fruit
Dinner:
Tofu, rice, and vegetables with low-sodium teriyaki sauce
Apple
This advice is being given to individuals with metabolic syndrome, who by definition have insulin resistance and hyperinsulinemia with elevated triglycerides, low HDL, and/or impaired fasting glucose. Unless carbohydrate portions are kept very small and fat is added — neither of which is recommended on a low-fat diet — these guidelines are likely to exacerbate rather than improve biomarkers and weight. And, let’s face it, this plan doesn’t sound that appetizing or satiating and would be difficult to sustain for most people.
An Enticing Alternative: Carbohydrate Restriction
On the other hand, research has demonstrated that low-carbohydrate diets do the following:
- Reduce postprandial blood glucose and insulin levels
- Result in a spontaneous decrease in appetite, which promotes weight loss, leading to lower basal insulin levels
- Decrease triglycerides
- Increase HDL-C
- Decrease blood pressure
Clearly, metabolic syndrome responds extremely well to carbohydrate restriction. Is there any other diet that has shown such impressive results? Some would argue that the Mediterranean Diet has demonstrated health benefits in this population, and there are certainly studies that support this claim. However, if large quantities of fruits, starchy vegetables, and grains are consumed, a Mediterranean diet plan can be as high in carbs as the low-fat plan listed above. Dr. Steve Parker has devised two Mediterranean-based diets that are appropriate for people with Metabolic Syndrome: the Low-Carb Mediterranean Diet and the Ketogenic Mediterranean Diet.
Here’s an example of a low-carbohydrate meal plan based on Mediterranean Diet principles:
Breakfast:
Greek yogurt with raspberries and chopped walnuts
Lunch:
Shrimp, tomatoes, and cucumbers with olive oil and basil
Snack:
Mixed nuts or olives
Dinner:
Steak with grilled zucchini, mushrooms, and eggplant
Strawberries with whipped cream
I think that sounds like a pretty enjoyable and sustainable way of eating.
And yet in most papers, on most websites, and among most endocrinologists, carbohydrate restriction isn’t even discussed as an option for metabolic syndrome. “Lose weight” seems to be the primary directive, and the recommendation for achieving this is typically a low-fat, low-sodium, high-carb approach. Interestingly, much of the research on hyperinsulinemia and insulin resistance over the past two decades has been published in Diabetes and Diabetes Care, which are journals of the American Diabetes Association, an organization which recently changed its position statement to include low-carbohydrate diets as an option for people with diabetes and prediabetes. I hope other organizations will follow their lead and begin promoting carbohydrate restriction as an option — or better yet, the best option — for those with metabolic syndrome.
References:
1. Shanik MH, et al. Insulin resistance and hyperinsulinemia: Is hyperinsulinemia the cart or the horse? Diabetes Care 2008 Feb: 31 Suppl 2: S262-8
2. Reaven GM. Banting lecture 1988: Role of insulin resistance in human disease. Diabetes 1988 Dec;37(12); 1595-607
3. McGavock JM, et al. Cardiac steatosis in diabetes mellitus. Circulation 2007 Sep 4;116(10):1170-5
4. Winhofer Y, et al. Short-term hyperinsulinemia and hyperglycemia increase myocardial lipid content in normal subjects. Diabetes 2012 May;61(5):1210-1216
5. Volek JS, Feinman RD.Carbohydrate restriction improves features of the Metabolic Syndrome. Metabolic Syndrome may be defined by the response to carbohydrate restriction. Nutr Metab(Lond) 2005 ;2:31
6. Castorini CM, et al. The effect of Mediterranean diet on metabolic syndrome and its components. J Am Coll Cardiol 2011 Mar 15:57(11)1299-313
Thanks for the mention, Franziska!
One in six Americans has metabolic syndrome, and most probably don’t know it.
There’s also a Spanish Ketogenic Mediterranean Diet that cured all 26 cases of metabolic syndrome in a pilot study lasting 12 weeks. Here’s the link, if I may: http://www.ncbi.nlm.nih.gov/pubmed/21612461
-Steve
Thanks so much for your comments and the link to that study, Steve! Amazing results achieved via diet alone. I will add this to my Research page.
Excellent snapshot of the truth that so many refuse to believe. Thanks for so succinctly pulling it all together! The more that read this, the better! (man, I’m sounding like a human blog spammer, aren’t I? LOL)
Thank you so much for your kind words, Gwen! And I can see you are a very real person, with a fantastic blog! Congratulations on your weight loss and adopting a healthy low carb way of life 🙂
I consider myself one of the lucky ones – I realised I was pre-diabetic even before the doctor did… it was me who actually suggested it to him and he confirmed it. I took immediate action and changed to a low carb lifestyle and three years later I’m certainly hoping that diabetes will never be a part of my life.
Thanks very much for sharing your story, Lynda! It’s great to hear that you were so proactive about making the appropriate dietary change for your health. Congratulations.
Another great post Franziska! Thanks for trying to help us with Metabolic Syndrome. I think the LCHF diet is helping as well as the drugs I take, but I would like to lose the weight and get off the drugs!
Thank you so much, Luanne! I’m so glad you’re experiencing good results with LCHF. You may well be able to eliminate or at least lower the dosage on your medication as you continue losing weight and improving your health. Best of luck to you!
Excellent article about metabolic syndrome and insulin resistance Franziska.
You did a good job of explaining how low-carb eating is the best medical treatment for these conditions. It’s helpful that you gave examples of low-fat vs. low-carb menus for a day. What a difference!
As a clinician who treats these conditions, I know that your recommendations will result in improved metabolic health.
Thanks for being part of the team that challenges mainstream nutritional & medical beliefs in favor of science!
Thank you so very much for your kind words of support, Sandra! I really appreciate feedback from other practitioners who believe in a low carb approach. Your patients are very fortunate.
What a brilliant summary. How refreshing to see a low carb dietician. I am a pharmacist and are so saddened by the advice my patients are told by their dieticians after being diagnosed with diabetes or high cholesterol. Loving your site. Libby x
Thanks so much for your comments, Libby! I really like your website as well. Keep up the great work!
Hi Franziska
Top notch post as usual. Your readers may be interested in this guy.
David Mendosa shares his story of type 2 diabetes and how he is able to keep his diabetes “in remission” on a low carb diet without medication. David is not a Doctor of medicine, but he is one of the most knowledgeable type two diabetics in the world. This talk is well worth your time.
http://vimeo.com/93453985
Kind regards Eddie
Thank you so much for your continued support and for sharing the video on David Mendosa. He is truly an inspiration to all people with diabetes.
Continue your great work across the pond 🙂
Best,
Franziska
More good news !
Very Low-Carb Diet Beats ADA Diet in Type 2 Diabetes According to New Study !
We compared the effects of two diets on glycated hemoglobin (HbA1c) and other health-related outcomes in overweight or obese adults with type 2 diabetes or prediabetes (HbA1c>6%). We randomized participants to either a medium carbohydrate, low fat, calorie-restricted, carbohydrate counting diet (MCCR) consistent with guidelines from the American Diabetes Association (n = 18) or a very low carbohydrate, high fat, non calorie-restricted diet whose goal was to induce nutritional ketosis (LCK, n = 16).
We excluded participants receiving insulin; 74% were taking oral diabetes medications. Groups met for 13 sessions over 3 months and were taught diet information and psychological skills to promote behavior change and maintenance. At 3 months, mean HbA1c level was unchanged from baseline in the MCCR diet group, while it decreased 0.6% in the LCK group; there was a significant between group difference in HbA1c change favoring the LCK group (-0.6%, 95% CI, -1.1% to -0.03%, p = 0.04).
Forty-four percent of the LCK group discontinued one or more diabetes medications, compared to 11% of the MCCR group (p = 0.03); 31% discontinued sulfonylureas in the LCK group, compared to 5% in the MCCR group (p = 0.05). The LCK group lost 5.5 kg vs. 2.6 kg lost in MCCR group (p = 0.09). Our results suggest that a very low carbohydrate diet coupled with skills to promote behavior change may improve glycemic control in type 2 diabetes while allowing decreases in diabetes medications. This clinical trial was registered with ClinicalTrials.gov, number NCT01713764.
Link here http://www.ncbi.nlm.nih.gov/pubmed/24717684
It should be understood when you bring down elevated blood glucose numbers with medication, you are treating the main symptom not the disease. Type two diabetes medications come with side effects, and type two medications and injected insulin makes the disease worse ! Chronic insulin resistance is the disease, treat the disease not the symptoms. Check out Dr Jason Fung and he explains why this is true.
http://www.youtube.com/watch?v=mAwgdX5VxGc
Kind regards Eddie
Thank you for sharing these as well, Eddie! I’ll be referring to that impressive new study in my Low Carb Cruise presentation later this month.