Natural remedies to reduce belly fat caused by metabolic syn

Flat Belly Fix

In Flat Belly Fix program, you learn the easy, tested and trusted method that saved the creator of this program (Todd Lamb) beautiful wife Tara from a life battling Type 2 Diabetes and experiencing possibly death. It was a very nasty experience with the couple during those times, but with the determination of Todd, he labored ceaselessly to finding a way out for his depressed and unhappy wife. Now they live together both happy and contented. Having used the same technique for people around (seeing the wonders it did to his wife) and also recording so much success, Todd Lamb wants to relate this secret to the world, to create this same atmosphere of joy produced in his immediate environment. Hence, he was motivated to put together this workable program. You also get to learn the secret to having a flat belly, and a healthy and fit body that has been hidden from you for so long now. The creator if this program is positive about the efficacy of this program and is so excited for you to personally experience what happens when you apply The 21 Day Flat Belly Fix in your life. More here...

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Definition of the metabolic syndrome

The clustering of insulin resistance, dysglycaemia, dyslipidaemia and hypertension was originally defined as syndrome X in 1988 (Reaven, 1988). Definitions of the metabolic syndrome that also include a measure of central obesity have been developed between 1999 and 2001 by the World Health Organization (WHO Consultation, 1999), the European Group for the Study of Insulin Resistance (EGIR Balkau and Charles, 1999) and the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults abbreviated to Adult Treatment Panel (ATP-III) (NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). The ATP-III criteria also recognized the association between the above factors of the metabolic syndrome and both pro-inflammatory and pro-thrombotic states as reflected by increased C-reactive protein and plasma plasminogen activator inhibitor levels, respectively, but these are not...

Available data on prevalence of the metabolic syndrome

An attempt to summarize the data on prevalence of the metabolic syndrome published before the end of 2004 is given in Table 1.2. Most studies suggest a prevalence of the metabolic syndrome in general adult populations of 15-30 per cent and are mostly based in developed countries or urban areas of developing countries. The majority of studies have used the ATP-III criteria and some studies have compared prevalence of the metabolic syndrome using more than one set of criteria. Generally speaking, prevalence of the metabolic syndrome was similar or higher using WHO criteria when compared with the use of ATP-III criteria (except for a study of Mexican men and women in which prevalence was higher using ATP-III criteria than WHO criteria Aguilar-Salinas etal, 2004). Using impaired glucose tolerance (i.e. 2-h glucose of 7.8 and

Factors that influence prevalence of the metabolic syndrome and variation between populations

Prevalence of the metabolic syndrome is affected by a myriad of both non-modifiable and modifiable interlinked factors. Many of these factors are inter-related but an attempt to consider them individually is made below. Prevalence of most individual factors within the metabolic syndrome increases with age, at least to late middle-age (when survival bias may cause prevalence of individual factors to level off or decline with increasing age), and prevalence of the metabolic syndrome is associated with age in the same way. For example, in the third National Health and Nutrition Examination Survey (NHANES III) performed in the USA the prevalence of the metabolic syndrome (defined using ATP-III criteria) increased from 6.7 per cent among participants of 20-29 years of age to 43.5 per cent for 60-69-year-olds and was 42.0 per cent for participants of 70 years or older. Given the importance of age as a risk factor for the metabolic syndrome,

Trends in prevalence of the metabolic syndrome

The only available data on trends in prevalence of the metabolic syndrome are available from comparison of data from 6436 men and women aged 20 years who participated in NHANES III (undertaken between 1988 and 1994) and 1677 participants from NHANES 1999-2000. Age-adjusted prevalences of the metabolic syndrome as defined by ATP-III criteria were 24.1 and 27.0 per cent (P 0.088), respectively. The age-adjusted prevalence increased by 23.5 per cent among women (P 0.021) and by 2.2 per cent among men (P 0.831) between these two cross-sectional surveys.

Pathogenesis of the metabolic syndrome

Resistance to the action of insulin is a central feature of the metabolic syndrome. Liver, skeletal muscle and adipose tissue are considered the major insulin-responsive tissues but the vasculature also can be considered as an insulin-responsive organ. In the metabolic syndrome insulin resistance is linked predominantly to a cluster of disorders involving triglyceride and glucose metabolism, increased blood pressure and vascular inflammation. Although to date there is no central unifying mechanism that explains all of the features of the syndrome, it is most likely that certain of the features occur as secondary consequences of a primary abnormality (or several primary abnormalities). Given that insulin resistance is fundamental to a diagnosis of the Table 1.3 Estimated prevalence and number of people 20+ years of age with the metabolic syndrome and diabetes by region for 2000 (see text for details of methods) Region Population Prevalence of the metabolic syndrome ( ) Number with the...

Ethnic variation in individual components of the metabolic syndrome

During the late 1980s there emerged the concept of an insulin resistance syndrome (also called the metabolic syndrome, Reaven's syndrome or syndrome X) where risk factors for CVD - hypertriglyceridaemia, lowered high-density lipoprotein (HDL)-cholesterol and hypertension - were associated with impaired glucose homeostasis in association with central adiposity (Reaven, 1988). At around the same time there was emerging evidence of ethnic differences in the presentation of the metabolic syndrome.

What Is Metabolic Syndrome

A person with metabolic syndrome has three or more of the following A large waist (forty inches or more for men and thirty-four inches or more for women to measure your waist size, don't go by your belt measurement instead, wrap a tape measure around the largest part of your midsection and make sure you keep the tape measure parallel to the floor) What does metabolic syndrome do to the body Doctors and researchers think that metabolic syndrome's impact on health is more than the sum of its parts. Basically, in people with this disorder, blood sugar levels stay high after a meal or snack instead

What Is Metabolic Syndrome continued

Even after heart disease appears, the metabolic syndrome continues to complicate things. Among almost sixty-five hundred men and women who had bypass surgery, for example, those with metabolic syndrome were four times more likely to have died within eight years of their surgery than those without it. This syndrome was especially hazardous for women, who were thirteen times more likely to have died. Researchers from the Centers for Disease Control and Prevention applied the given definition of metabolic syndrome to almost nine thousand people who took part in the Third National Health and Nutrition Examination Survey. In this sample, about 23 percent had the metabolic syndrome. Applied to the entire United States, this would mean about forty-seven million Americans have this problem. The treatments outlined in the next chapters can decrease the chance that you'll have the symptoms that characterize metabolic syndrome.

Consequences of the metabolic syndrome

The metabolic syndrome is associated with increased risk of a variety of disease outcomes, including diabetes, peripheral arterial disease (the association with cardiovascular disease is discussed in Chapter 10), fatty liver and non-alcoholic steatohepatosis (discussed in Chapter 11), polycystic ovary syndrome (discussed in Chapter 12), gallstones, asthma, sleep apnoea and selected malignant diseases. Studies that have described the association between the metabolic syndrome and diabetes and cardiovascular disease morbidity and mortality (including all-cause mortality where available) are summarized in Tables 1.4 and 1.5. The findings vary with the criteria for the metabolic syndrome, the definition of the outcome and the population studied, but the relative risk of diabetes is at least threefold higher among people with the metabolic syndrome than among those without the syndrome. Relative risks of the metabolic syndrome were generally highest for coronary heart disease mortality,...

Composite definitions of the metabolic syndrome

More than a decade after the concept of the insulin resistance syndrome, which generated much research into its individual components, two composite definitions were proposed to enable a single variable 'the metabolic syndrome' to be used in epidemiological studies, with the potential of use as a clinical utility. The first attempt to define a composite metabolic syndrome came in 1999 from the World Health Organization (WHO, 1999), and in 2001 the Adult Treatment Panel (ATP-III) of the National Cholesterol Education Programme proposed a new definition of the metabolic syndrome (NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). Further information about the differing definitions of the metabolic syndrome are given in Chapter 1. The only data on ethnic differences in composite definitions of the metabolic syndrome in the UK have come from our group. We pooled the Southall (McKeigue, Shah and Marmot, 1991) and Brent (Chaturvedi et al,...

Obesity and fat distribution

As mentioned above, prevalence of obesity is an important factor in influencing prevalence of the metabolic syndrome. The association of central or general obesity and the metabolic syndrome varies with gender (Ho etal., 2001). Distribution of fat influences prevalence of the metabolic syndrome for a given BMI. The NHANES III study showed that prevalence of the metabolic syndrome (defined using the ATP-III criteria) increased from 0.9-3.0 per cent for people with a BMI in the range 18.5-20.9 kg m-2 to 9.6-22.5 per cent for people with a BMI in the range 25.0-26.9kgm-2, depending on gender and ethnicity (St Onge, Janssen and Heymsfield, 2004). The influence of obesity on prevalence of the metabolic syndrome also has been observed in children. A detailed study of 439 obese, 31 overweight and 20 non-obese children and adolescents in the USA found that prevalence of the metabolic syndrome increased with the severity of obesity and around half of the severely obese participants had the...

Diet and physical activity

The major effects of diet (discussed in more detail in Chapter 13) and levels of physical activity (discussed in more detail in Chapter 14) on prevalence of the metabolic syndrome are probably mediated through their effects on fat distribution and obesity, although not all studies adjust for these factors. A study of health, nutrition and physical activity (with the latter assessed by questionnaire) in Greece reported that the odds ratios for the metabolic syndrome adjusted for age, gender, smoking habits, educational status and measurements of inflammation and coagulation factors (but not BMI) were 0.81 (95 per cent CI 0.68-0.98) among people who consumed a Mediterranean diet compared with those who did not eat this diet and 0.75 (95 per cent CI 0.65-0.86) among people who reported little to moderate physical activity compared with people having a sedentary lifestyle (Panagiotakos etal., 2004). In a study of 7104 women the age- and smoking-adjusted prevalence of the metabolic...

Menopausehormone replacement therapy

Limited data are available about the effects of menopause and HRT on prevalence of the metabolic syndrome. More data are available on the effects of menopause and HRT on various measures of central obesity but there are conflicting results. Menopause is associated with increased amounts of abdominal visceral fat and there appears to be an effect that is independent of ageing (Poehlman and Tchernof, 1998 Tchernof etal., 1998). Some cross-sectional studies have suggested that various measures of central obesity (and therefore presumably prevalence of the metabolic syndrome) may be lower in women using HRT but this study design cannot show that this is an effect of HRT (Sites etal., 2001 Green etal., 2004). Other cross-sectional studies have not shown a relationship between measures of central adiposity and HRT use (Kanaley etal., 2001 Ryan, Nicklas and Berman, 2002) Longitudinal study designs also have provided conflicting results. Women taking part in the in the HRT group of the...

Summary of available data

An attempt can be made to estimate the prevalence of the metabolic syndrome across broad population groups if the above problems in interpreting the available data are considered. Regions of the world were categorized as for the global burden of disease study estimates for diabetes prevalence for 2000 (Wild etal., 2004) and the estimates are presented in Table 1.3. In order to reflect the uncertainty of the estimates, a range of prevalence estimates were derived for each region. Where possible, prevalence estimates were derived from published studies and the reference is given, but for regions where data were less widely available attempts were made to produce an educated guess. The population denominator is given so that readers may adjust the estimates by altering the prevalence if they wish. As a consequence of the differing distribution of confounding factors (particularly age) between published data and populations, these estimates should be viewed with considerable caution....

Associations within ethnic groups

The Botnia (Isomaa etal, 2001) and Kuopio (Lakka etal, 2002) studies in Finland and Sweden were the first to report the clinical importance of the composite definitions of metabolic syndrome in prospective studies - both reported markedly elevated cardiovascular mortality in European Whites among those with the metabolic syndrome compared with those without. In the Botnia study of 4483 persons aged 35-70 years, risk of CHD and stroke was increased threefold among those with the WHO-defined presence of the metabolic syndrome (P

Associations between ethnic groups

Although there are studies of different ethnic groups that have reported the differential risk for CHD and examined the contribution of the metabolic syndrome to CVD CHD risk within the ethnic groups, to our knowledge the work of our group provides the only available data of the role of the metabolic syndrome in the observed ethnic difference in CHD risk (Table 2.2). Recently we have been able to examine the association of the metabolic syndrome with CHD mortality in Europeans and South Asians in the UK in a prospective follow-up of the Southall Study. Among 2935 men aged 40-69 years at baseline, at a median 14-year follow-up there were 399 total deaths, with 161 CHD deaths (91 in South Asians, 70 in Europeans) (Forouhi etal., 2005). The metabolic syndrome was significantly associated with CHD mortality in both ethnic groups in analyses adjusted for age, smoking and total cholesterol ATP-III hazard ratio 1.8 (95 per cent CI 1.0-3.0, P 0.035) in Europeans and 2.6 (1.7-4.1, P

Genetic or environmental explanation

Neel (1962) proposed the 'thrifty genotype' hypothesis to explain the emergence of insulin resistance and diabetes in populations shifting from vigorous activity and subsistence nutrition to abundance and obesity of urban societies. Such a genotype confers survival advantage in an adverse environment of chronic starvation and periods of famine, such as in rural areas of South Asia and Africa. Such a setting would become detrimental to health in conditions of more plentiful food supply, such as in the context of a Westernized or urban lifestyle. Support for the genetic basis of ethnic differences is found in a study of admixed populations in Nauru, where there is an inverse association of diabetes with genetic markers of European admixture (Serjeantson etal., 1983). Admixture in Nauru has resulted mainly from unions between Nauruan women and European men, thus introducing European genes but not a European maternal environment. The genetic hypothesis was challenged, however, when a...

Proinflammatory markers and adipocytokines

Insulin resistance is associated with a wide array of defects beyond dyslipidaemia, hypertension and obesity. There is plentiful evidence that C-reactive protein (CRP), an inflammatory marker, is strongly associated with metabolic syndrome and with CVD, and this subject has been reviewed in depth in Chapter 8. Furthermore, studies that include participants of different ethnic groups have confirmed recently that CRP is independently associated with the metabolic syndrome (Festa etal., 2000 Heald etal., 2003). There is emerging evidence that CRP concentrations vary between ethnic groups, and a suggestion has been made that CRP might even be used as a screening test for CVD risk in different ethnic groups (Anand etal., 2004). In this respect, we and others have shown elevated CRP in South Asians compared with Europeans (Chambers etal., 2001 Forouhi, Sattar and McKeigue, 2001 Chandalia etal., 2003). In a comparative study of 137 young healthy Asian Indian and European White men in USA...

Physical activity and diet

Unsurprisingly, some of the groups at higher risk for the metabolic syndrome are also the groups with lower levels of physical activity. In a systematic review of 17 studies in the UK, Fischbacher recently reported substantially and consistently lower levels of physical activity and fitness in South Asians compared with Europeans (Fischbacher, Hurt and Alexander, 2004). Ethnic differences were more marked in women, older people and Bangladeshis. In the Health Survey for England, for example, age-adjusted levels of physical activity were 14, 30 and 45 per cent lower compared with recommended levels in men and 33, 37 and 65 per cent lower in women, respectively, of Indian, Pakistani and Bangladeshi origin than the majority population (Fischbacher, Hunt and Alexander, 2004). There is also evidence that some of the minority ethnic groups in the USA have lower levels of physical activity than European Whites (such as Mexican-Americans and African-Americans) (Yusuf etal., 2001). Although...

Psychosocial stress and socioeconomic differences

Migration can be associated with maladjustment or isolation and stress on the one hand, but also with acculturation and integration on the other. It has been suggested that increased corticosteroid and cytokine activation may be potential links between stress and the metabolic syndrome (Yudkin etal., 2000 Brunner etal., 2002). In a study of 509 subjects in India there was evidence of an interaction between cortisol and adiposity in determining fasting glucose concentration (P 0.045) and insulin resistance (P 0.006), suggesting that increased glucocorticoid action may contribute to ethnic differences in the prevalence of the metabolic syndrome, particularly among men and women with a higher BMI (Ward etal., 2003). However, such studies have not been replicated in other ethnic groups or by other research groups, leaving a gap in our understanding of the potential role of glucocorticoids. Although socio-economic factors are unequivocally associated with coronary risk within ethnic...

Lessons and challenges of study of ethnicity in terms of disease risk

A challenge to the study of different ethnic groups is in the definitions of normal values and measurement instruments, which are mostly derived in European populations. For example, the BMI cut-offs of 25kgm-2 to define overweight and 30 kg m-2 to define obesity may not be appropriate in Asian populations, where lower cut-off values would be more applicable (Dudeja etal., 2001 WHO Expert Consultation, 2004). This is particularly the case because South Asians tend to have higher central obesity for a given level of generalized obesity or BMI. South Asians have higher waist hip ratio than European Whites for a given BMI (McKeigue, Shah and Marmot, 1991 Misra and Vikram, 2004) and also a higher CT-scan-derived visceral fat area for a given BMI. Thus there are potential problems with the use, in different ethnic groups, of the composite definitions of the metabolic syndrome. These include the fact that current composite definitions have not been validated against outcomes such as...

Clinical implications

There is good evidence that a healthy lifestyle can reduce the incidence of diabetes (Hu etal., 2001), as can treating impaired glucose tolerance with lifestyle modification (Tuomilehto etal., 2001). The Finnish Diabetes Prevention Study assigned 522 middle-aged overweight men and women (mean BMI 31 kgm-2) with impaired glucose tolerance into intervention (individual counselling on diet and physical activity) and control groups. At 3.2 years of follow-up the intervention group had a 58 per cent lower incidence of diabetes, significantly greater reductions in weight and dietary fat intake and greater increases in dietary fibre and exercise ( 4h per week) reversing the changes of insulin resistance and metabolic syndrome (Tuomilehto etal., 2001). Reports of specific interventions to reverse impaired glucose tolerance in people from ethnic groups are currently lacking and are an area for future study. There is, however, good rationale to manage the presence of the metabolic syndrome with...

Simon Cunningham and Mark Hanson

Chronic diseases have been shown to have their origins early in the lifecourse of an individual. A person's prenatal and subsequent development, eventual adult body mass index and lifestyle all affect the incidence of chronic disease during life. Such risk originates from a combination of adaptive responses made by the foetus to maintain homeostasis in the intra-uterine environment and to 'predict' its future postnatal environment. The biology of such processes, coupled with the rapidity and degree of the transitions in diet occurring in many societies, are thought to contribute to the rapidly rising incidence of type 2 diabetes, hypertension, obesity, dyslipidaemia and endothelial dysfunction, collectively known as the metabolic syndrome. The human environment has changed much faster than our evolutionary biology, and our development leaves us unprepared to live healthily in that environment. Taking a lifecourse view of the aetiology of disease is likely to be more effective than...

Hypothalamopituitaryadrenal axis

A negative feedback system controls the HPA axis. This regulates the release of corticosteroid-releasing hormone from the hypothalamus and subsequent release of glucocorticoids through the axis. In the context of low birthweight maternal nutritional imbalance, experimental evidence suggests changes to circulating cortisol, glucocorticoid receptor density and altered cortisol metabolism. When nutritional deprivation in utero in rat and sheep led to hypertension, an increase in glucocorti-coid receptor sensitivity in peripheral tissues was demonstrated (Bertram etal., 2001). Levels of corticotrophin-releasing hormone were raised in cord blood taken from growth-restricted foetuses, suggesting increased HPA activity (Goland etal., 1993). Low birthweight is associated with increased serum and urinary glucocorti-coid concentrations in children and raised basal cortisol concentrations and responsiveness to adrenocorticotrophic harmone (ACTH) in adults (Clark, 1998). Men born with lower...

Opportunities for intervention and screening

As a cause of death and disability, hypertension is second only to smoking in the developed world (World Health Organization, 2002a). The two are of course causally linked. The leading cause of mortality and morbidity in people with the metabolic syndrome is CVD (Lakka etal., 2002). Globally, CVD causes one-third of the world's deaths, i.e. 15.3 million annually (World Health Organisation, 1999). Within the UK this is the equivalent of 4 out of every 10 deaths (British Heart Foundation Statistics, 2004). A large percentage of the world's populations (South America, Africa, Mid Asia and China) is in transition from a rural to an urbanized economy. Such countries are experiencing large increases in the incidence of chronic adult diseases, including CVD. Several factors are thought to be responsible, including changes in nutrition, diminished physical activity and tobacco use (Reddy, 2002). In India the percentage of CVD-related deaths is expected to rise from 24.2 per cent in 1990 to...

Pharmacological interventions

The inter-relationship between the components of the metabolic syndrome is epitomized by the actions of statins. These were employed originally to reduce the incidence of CHD because of their efficacy in lowering lipid levels. Several other actions that may be protective are now apparent (Endres and Laufs, 2004). Statins appear to improve endothelial function by promoting NO production via increased synthesis of eNOS. They also may increase NO bioavailability by reducing oxidative stress. Other actions include the observation of lower levels of inflammatory mediators such as TNF-a and IL-6 and the ability to improve arterial compliance (Endres and Laufs, 2004 Matsuo etal., 2005). These actions may be responsible for up to a 30 per cent reduction in the risk of developing type 2 diabetes (Rosenson, 1999). Angiotensin-converting enzyme (ACE) inhibitors have also been demonstrated to increase NO bioavailability (Henriksen and Jacob, 2003), and a decrease in the progression of impaired...

Obesity and body fat distribution

A multitude of studies have shown that excess fat in the abdominal region (visceral adipose tissue) is strongly associated with metabolic alterations such as disturbed plasma lipoprotein profile, hyperinsulinaemia, insulin resistance and glucose intolerance. In comparative analyses, people of Black ancestry have the highest levels of generalized obesity (BMI 30kgm-2) and Mexican-Americans have the highest percentage body fat, but the highest levels of central obesity (as measured by waist hip ratio) are found among South Asians and Mexican-Americans compared with European White, Chinese and Black-origin groups (Misra and Vikram, 2004). Whether these differences are attributable to diet, lack of exercise, genetic factors or a combination of these has not yet been established. A recent study found that transgenic mice selectively overexpressing 11P-hydroxysteroid dehydrogenase type 1 (11BHSD-1) in adipose tissue developed abdominal obesity and exhibited insulin-resistant diabetes...

Ethnicity

Some ethnic groups have a higher predisposition to central obesity than others for example, prevalence of central obesity is higher among South Asians than Europeans and is higher among Europeans than Afro-Caribbeans. Other features of the metabolic syndrome show a differing pattern by ethnicity, e.g. prevalence of hypertension is higher among Afro-Caribbeans than other ethnic groups. Among Asian populations the prevalence of the metabolic syndrome is generally lower than among European populations. When waist circumference criteria are modified to a lower cut-point, as deemed appropriate for Asian populations, prevalence of the metabolic syndrome increases and becomes more similar to (for south-east Asian populations, e.g. from Korea) or higher than (for south Asian populations, e.g. urban Indians) than for European populations. Limited data are available for African populations in Africa but data on African origin populations based in the USA or UK suggest that prevalence of the...

Genetic factors

Each feature of the metabolic syndrome is determined by complex gene-environment interactions. The available data describing the role of genetic factors in determining prevalence of the metabolic syndrome are limited and many findings have yet to be replicated in other populations (Corella and Ordovas, 2004). Certain components of the metabolic syndrome may be influenced more strongly by the environment and others by genetic inheritence. For example, a study of twins in Denmark suggested that environmental factors were more important for WHR, fasting insulin and triglycerides, whereas genetic influences were most marked on glucose intolerance, overall obesity and low HDL-cholesterol (Poulsen etal., 2001). The role and relevance of genetic factors to the prevalence of the metabolic syndrome are considered further in Chapter 5.

Endocrine factors

Endocrine disturbances can influence prevalence of the metabolic syndrome, specifically hyperandrogenaemia and polycystic ovary syndrome (PCOS) (discussed in more detail in Chapter 12). The menopause also may influence development of the metabolic syndrome and a summary of the relationships between the metabolic syndrome and menopause hormone replacement therapy (HRT) is discussed below. Also, low total testosterone and sex hormone binding globulin (SHBG) levels both independently predict development of the metabolic syndrome and diabetes in middle-aged Finnish men (Laaksonen etal., 2004). For further discussion of the role of androgens in obesity, see Marin and Arver (1998). The growth hormone-insulin-like growth factor (IGF) axis also may play a role in the development of the metabolic syndrome and this hormonal axis is discussed in more detail in Chapter 14. Similarities between Cushing's disease and the metabolic syndrome also suggest that a role for the glucocorticoid axis is...

Inflammation

There is increasing evidence to suggest that chronic subclinical inflammation is associated with insulin resistance and the metabolic syndrome (Hanley etal., 2004). The majority of the components of the metabolic syndrome are positively associated with inflammatory parameters and this relationship appears to be independent of age, gender, physical activity, smoking and BMI (Temelkova-Kurktschiev etal., 2002). There appear to be gender differences in the role of inflammation as a predictor of subsequent metabolic syndrome in that C-reactive protein was a significant predictor of the development of the metabolic syndrome only in women and not in men (Han etal., 2002). Further consideration of the relationship between inflammation and the metabolic syndrome is given in Chapter 8.

Alcohol

Alcohol consumption is associated with increasing HDL-cholesterol levels, increasing triglyceride levels and increasing blood pressure, and therefore has different effects on different aspects of the metabolic syndrome (Vernay etal., 2004 Yoon etal., 2004). In a large study of a Korean population a positive association was found between alcohol consumption and prevalence of the metabolic syndrome (Yoon etal., 2004). The association between type of alcohol and various health-related outcomes may be confounded by other lifestyle factors. A cross-sectional population-based study of 4232 60-year-old men and women in Sweden reported that moderate wine drinkers generally had healthier lifestyles than either non-drinkers or spirit drinkers (Rosell, De Faire and Hellenius, 2003). In women, the metabolic syndrome was significantly more common in non-drinkers (20 per cent, P

Comorbidity

Among people with diabetes, hypertension or coronary heart disease the prevalence of the metabolic syndrome is considerably higher than among the general population. For example, the prevalence of the metabolic syndrome using WHO criteria was between 76 and 92 per cent in various European populations of people with diabetes (Bruno etal., 2004 Ilanne-Parikka etal., 2004 Relimpio etal., 2004). An exception to this pattern was the relatively low prevalence of the metabolic syndrome found in a small study of people with type 2 diabetes in Nigeria (Alebiosu and Odusan, 2004). This was the only study based in Africa and further data are required to establish whether this finding is replicated in other African populations both with and without diabetes. Among people with mental illness, notably schizophrenia, the prevalence of the metabolic syndrome was higher than among the general population. Symptoms of depression have been associated with each feature of the metabolic syndrome (McCaffery...

Confounding

Potential confounding factors between certain population characteristics, such as age, gender, obesity and co-morbidity, and the prevalence of the metabolic syndrome are considered above. Some prevalence studies have not considered potential confounding factors, and even among those that have considered these factors there remains the potential for residual confounding. A large proportion of the difference in prevalence of the metabolic syndrome between populations may be explicable by factors that are either confounders or on the causal pathway, such as age and obesity. A proportion of the higher prevalence of the metabolic syndrome among people with diabetes may be explained by the higher average age of people with diabetes than of the general population.

Conclusions

There is compelling evidence for marked ethnic differences in the risk for the metabolic syndrome and for its constituent features. The mechanisms of between-ethnic group differences are not yet elucidated, and there remain unanswered questions of validity of a unified set of diagnostic criteria in the form of composite definitions of the metabolic syndrome across ethnic groups. Intriguing paradigms exist, such as higher prevalence of insulin resistance, diabetes, hypertension and stroke but lower rates of CHD and the maintenance of a healthy lipid profile in African-descent populations, and the consistently adverse metabolic profile and elevated CVD risk in South Asians across different locations and generations. The ethnic variation thus suggests that a high prevalence of diabetes and insulin resistance in the population can be compatible with either a high or a low risk of CHD, depending upon the extent to which disturbances of lipid metabolism are present in association with the...

Epidemiology

As the association of low birthweight and CHD became defined, the risk factors of CHD were also scrutinized. Birthweight has now been found to be inversely associated with an increased risk of stroke, hypertension, impaired glucose tolerance, type 2 diabetes, vascular dysfunction, obesity, dyslipidaemia and the metabolic syndrome as a whole (Barker etal., 1989, 1990 Martyn etal., 1995 Frankel etal., 1996 Lithell etal, 1996 McKeigue, Lithell and Leon 1998 Bavdekar etal., 1999 Forsen etal., 2000 Leon, Johansson and Rasmussen, 2000 Eriksson etal., 2001, 2003 Barker, 2002 Fagerberg, Bondjers and Nilsson, 2004 Ong and Dunger, 2004 Yajnik, 2004). There is increasing evidence that chronic diseases represent the culmination of risk and environmental factors acquired during life. Several models now demonstrate the 'tracking' of conventional risk factors from childhood to adulthood as shown in Figure 3.2 (Ong and Dunger, 2004). They also model specific periods in development when changes...

Behavioural effects

Predictive adaptive responses are also thought to lead to changes in behaviour. Animal models have been used to demonstrate increased appetite and preference for fatty foods and a low propensity for exercise (Vickers etal., 2000, 2001 El Haddad etal., 2004 Terroni etal., 2004). Such changes are consistent with the concept of an individual adapted to maximize nutrient intake, conservation and storage (Beall etal., 2004). A recent study in which rats were selected over several generations for their ability to exercise showed that their exercise capacity was related to a broad range of pathological correlates of the human metabolic syndrome (Wisloff etal., 2005). The ways in which environmental influences affect this intergenerational development of risk have not been defined.

Nutrition

A growing percentage of the world's population is overnourished rather than undernourished and this is reflected as the term 'malnutrition' increasingly used also to express overnutrition (Darnton-Hill, Nishida and James, 2004). For populations undergoing urbanization, increases occur in the relative levels of nutrition over several generations (Reddy, 2002). Epidemiological work describes how such a pattern of nutrition facilitates subsequent catch-up growth, increased adult BMI and reduced lean body mass, all of which are important factors contributing to the risk of the metabolic syndrome (Sayer etal., 2004). For over 40 years it has been known that postnatal restriction of nutrition in animals enhanced longevity (Berg and Simms, 1960 McCay etal., 1975). Ozanne and Hales (2004) refined these findings, showing that control of the growth of male rats during suckling not only increased longevity but protected against the effects of an obesity-inducing diet later in life. Using a...

Screening strategies

The physiological demands of pregnancy are increasingly seen as a stress test for maternal physiological reserves and may present an opportunity for early intervention (Sattar and Greer, 2002). To date this has primarily concerned the occurrence of gestational diabetes. Women with a history of gestational diabetes are at an increased risk of developing type 2 diabetes postnatally. Over a 15-year period it is estimated that 30 per cent of lean and 60 per cent of obese women will develop type 2 diabetes (Catalano etal., 2003). Similarly there is evidence that women with a history of pre-eclampisa or gestational hypertension develop hypertension and the metabolic syndrome in later life (Wilson etal., 2003 Pouta etal., 2004). As Figure 3.1 suggests, PARs may lead to diminished physiological reserves and impaired maternal adaptation in pregnancy. Recent epidemiological studies suggest an increase in the risk of mortality from CVD in later life for mothers whose pregnancies were complicated...

Gender

As central obesity is one of the factors included in the definition of the metabolic syndrome and, for a given BMI, central obesity is more common in men, it might be expected that prevalence of the metabolic syndrome would be higher in men than in women. Among non-diabetic European men and women from eight populations the prevalence of the metabolic syndrome (defined using modified WHO criteria) was generally higher in men than in women (Hu etal., 2004). The effect of generalized obesity is also extremely important (see below) such that, in populations in which obesity is more common in women than in men, the prevalence of the metabolic syndrome will be higher in women than in men. This pattern can be observed in Indian, Iranian and Turkish populations (Onat etal., 2002 Azizi etal., 2003 Gupta etal., 2003 Ramachandran etal., 2003 Ozsahin etal., 2004). A cardiovascular risk factor survey in France identified that elevated body weight, waist girth and low HDL-cholesterol were...

Nita G Forouhi

Convincing evidence has emerged in the last decade that there are important ethnic differences in the prevalence of the metabolic syndrome. Estimates vary by country but generally show higher prevalence of the metabolic syndrome in non-European groups such as South Asians, Black African-Caribbeans, Hispanics and Aboriginals, with significantly lower prevalence in European Whites and the Chinese. Recent national estimates indicate a background prevalence of around 20 per cent in the USA, with disproportionately higher prevalence in Mexican-Americans compared with other groups. Population-based research studies have found more than double the prevalence rate in groups such as South Asians in the UK, Aboriginals in Canada and Native Americans compared with Europeans of equivalent age. Coronary heart disease and stroke are the leading causes of morbidity and mortality across the world and there is compelling evidence that the metabolic syndrome is a potent contributor to cardiovascular...

Therapeutic Strategies in Diabetes and Cardiovascular Disease

With management strategies for preventing and treating the cardiovascular complications of diabetes. I am indebted to Dr. Deedwania and the group of experts he has assembled for these two important issues. Editing one issue is a big job, let alone two. However, Dr. Deedwania has had a long-standing academic and clinical interest in diabetes and metabolic syndrome in cardiovascular disease. His dedication to improving care for these individuals is evident in these two issues of the Cardiology Clinics.

Obesity and Physical Activity

Excess body weight appears to place Mexican Americans at higher risk than whites for certain diseases such as diabetes and cardiovascular disease. National data indicate that the proportion of the population that is considered overweight (defined as a body mass index 25) has grown for both Latinos and whites over the last 20 years (National Center for Health Statistics 2000). Among Mexican Americans aged 20-74 years, combined age-adjusted data for 1988-1994 showed that 67.0 of the men and 67.8 of the women were considered overweight (vs. 59.9 of white men and 45.7 of white women) (National Center for Health Statistics 2000). The same trend has been observed in children and adolescents aged 6-17 years. Approximately 15.8 and 14.8 of Mexican American girls and boys, respectively, were found to be overweight based on combined data for 1988-1994 (compared with 11.9 and 11.8 of white girls and boys, respectively) (National Center for Health Statistics 2000). An analysis of NHANES III data...

Effect of glycemic control on cardiovascular disease

Role in a variety of other metabolic abnormalities, including high levels of plasma triglycerides, low levels of high-density lipoprotein (HDL) cholesterol, hypertension, abnormal fibrinolysis, and coronary heart disease 15,16 . This cluster of abnormalities has been called the insulin resistance syndrome or the metabolic syndrome 17 . The National Cholesterol Education Program Adult Treatment Panel III recently recognized the metabolic syndrome as a secondary therapeutic target for the prevention of cardiovascular diseases 15 . Patients who have the metabolic syndrome meet at least three of the following criteria triglycerides that are greater than 150 mg dL, HDL that is less than 40 mg dL, blood pressure that is greater than 130 85 mm Hg, fasting blood glucose that is greater than 110 mg dL, and waist circumference that is greater than 40 cm in men or 50 cm in women (Table 1) 15 .

Circulating Cells With Angiogenic Potential As Effectors And Biosensors Of Pathological Changes In Dm

Recently, the evidence was generated that individuals with DM present with reduced numbers of circulating cells with markers of immaturity, so-called endothelial progenitor cells (EPC). It has to be noted, however, that there is still no consensus in the field over the definition of EPC In fact, EPC is partly used for early and immature progenitor cells (such as CD133 + VEGFR2+ CD34+ CD45low), but also for in vitro modified monocytic cells. With regard to DM, the number of CD34 + VEGFR2+ circulating EPC 69 was decreased in the circulation of individuals with DM type 2 with and without PAD. The presence of DM-related PAD decreased the number of circulating CD34 + CD133 + VEGFR2+ EPC, which are real immature cells based on the expression of the CD133 molecule 70 . It was also shown that only DM type 1 has an adverse influence on the number of circulating CD34+ angioblasts 71 . Some ex vivo data indicate that the number of EPC, generated in vitro from blood-derived mononuclear cells...

Triglyceride and highdensity lipoprotein intervention

Unlike the plethora of trial evidence of CHD risk reduction with statins, the evidence from drugs to decrease triglycerides or increase HDL cholesterol is sparse. A meta-analysis of 17 observational studies suggested a significant relationship of triglycerides with CHD, even after adjustment for HDL cholesterol, especially in women 33 . In the 4S trial, in post hoc analyses, patients who had the lipid triad (elevated LDL, elevated triglyceride, decreased HDL cholesterol) had the highest event rates in the placebo arm and the greatest risk reduction with simvastatin 34 . Despite a mechanistic plausibility of increased risk with these lipid abnormalities in patients who had metabolic syndrome and diabetes, few long-term randomized trials have been completed (Table 2).

Role of renin angiotensin aldosterone system activation

Less well studied but seems to mediate beneficial effects that include vasodilation, inhibition of cell growth, and proliferation as well as cell differentiation 48,49 . The differential effects are shown in Fig. 1. The sequential progression of cardiovascular disease begins with the risk factors of hypertension, diabetes, smoking, metabolic syndrome, and dyslipidemia. These risk factors are independently associated with levels of angioten-sin II that in turn trigger the cascade of events. Progression to atherosclerotic disease and left ventricular hypertrophy leads to plaque destabili-zation in the face of uncontrolled risk factors, with acute coronary syndrome and myocardial infarction as the sequelae 50 . Loss of cardiac muscle eventually leads to remodeling of the left ventricle progressing relentlessly to heart failure and end-stage cardiomyopathy (Fig. 2).

Interaction between angiotensin endothelium and insulin resistance

Insulin resistance is associated with metabolic syndrome, which increases the risk of adverse cardiovascular outcomes. There is definitive evidence that insulin resistance and endothelial dysfunction progress in parallel. As insulin resistance progresses to clinical metabolic syndrome, impaired glucose tolerance, and development of diabetes, there is a parallel track that leads from endothelial dysfunction to inflammation, with increased oxi-dative stress leading to overt atherosclerotic disease. Insulin resistance has been shown to interact with this parallel track of endothelial dysfunction through the accumulation of free fatty acids, proinflammatory adipokines, and TNF alpha 59 . In addition, increased oxidative stress, oxidation of LDL, the reduction of HDL, and the development of hypertension, hyperuricemia, and hy-perglycemia contribute to the mechanisms of underlying endothelial dysfunction in insulin resistance 51 .

Communitybased studies of lifestyle change

Over two years, subjects attending the intervention church had no weight gain (compared with +3.1 kg on average in the control group), a decreased waist circumference, and increased knowledge about diabetes and nutrition. Self-reported intake of high-fat foods was lower after the intervention, and the majority of respondents felt it had been useful to them. The intervention church continued the physical activity and nutrition program on a self-sustained basis. It appears that this type of intervention had some success in preventing weight gain (though it did not achieve weight loss).

Cardiometabolic risk syndrome

IR is thought to play a central role in the development of a cluster of interrelated metabolic abnormalities that predispose to the development of coronary heart disease (CHD) and occur together more often than would be predicted by chance. Over the years, this clustering of risk factors has been referred to by such terms as the Insulin Resistance Syndrome, Syndrome X, Metabolic Syndrome, and the Cardiometabolic Risk Syndrome. The commonly acknowledged features include increased adiposity, dyslipidemia, glucose intolerance, and hypertension, although more recent evidence indicates that other abnormalities are also associated with this syndrome, including hyperuricemia, low-grade inflammation, and a prothrombotic state (6). The focus of this chapter will be the pathogenesis and management of the characteristic dyslipidemia associated with insulin-resistant states.

Clinical studies of renin angiotensin aldosterone system inhibition and outcomes of insulin resistance

Improving insulin sensitivity 118-124 . Several factors make the results of these trials using ACE inhibitors or ARBs less robust overall. Different choice of experimental models, target molecules, doses, and route of administration may all have contributed to the conflicting results. In addition, the measure of insulin resistance itself is fraught with problems because of its sensitivity, specificity, positive and negative predictive values, reproducibility, discrimination, and calibration. The parameters used in evaluating glucose homeostasis are not always equivalent or comparable. Clearly, there is a need to improve the modeling technique by using refined methods of quantifying insulin resistance to predict more accurately the likelihood of developing diabetes and cardiovascular disease 125 . At present, metabolic syndrome variables may well be the best predictors for evaluating the likelihood of coronary artery disease.

Comprehensive Risk Reduction of Cardiovascular Risk Factors in the Diabetic Patient An Integrated Approach

The excess CV mortality and morbidity in the diabetic population seems to reflect the strong association of diabetes with insulin resistance and with well-established coronary risk factors. During the past 2 decades, significant advances have been made in elucidating the pathophysiologic determinants and consequences of the metabolic perturbations in the diabetic state. The disease is characterized by insulin resistance and is commonly associated with the metabolic syndrome. Sensitivity to insulin is variable in the population at large. Cellular insulin resistance develops as the result of a complex interplay of genetic and environmental factors. Hyperinsulinemia occurs as an adaptive response to the increasing insulin resistance. Type 2 diabetes develops when insulin-resistant individuals cannot maintain the degree of excess insulin secretion needed to overcome insulin resistance. There are two aspects to the type 2 diabetic state hyperglycemia and hyper-insulinemia. Insulin...

Trials examining glycemic management techniques

Approaches, and more specifically insulin sensitizers, provide benefits beyond glucose lowering in managing CV risk. The possibility first was suggested based on the notion that insulin resistance is linked epidemiologically with components of the metabolic syndrome including dyslipidemia, dysglycemia, hypertension, a procoagulant state, vascular inflammation, endothe-lial dysfunction, and premature vascular disease 13,14 . Several small and medium-sized studies have supported the idea that insulin-sensitizing approaches could be superior to approaches that supplement deficient insulin secretion, suggesting improvements in markers of CV risk during treatment with metformin and thiazolidinediones when compared with other therapies. Furthermore, in the UKPDS, among overweight subjects, those randomly assigned to initial therapy with metformin (but not to insulin or sulfonylurea) demonstrated a reduction in diabetes mellitus-related deaths and MI compared with those treated with...

Body Weight And Food Intake

Normal hypocretin levels, corroborates this finding and suggests that hypocretin deficiency per se promotes body weight gain (27). Hypocretin-deficient narcoleptics were significantly heavier than age- and sex-matched controls, and the percentage of obese patients (BMI 30 kg m2) was significantly higher in the narcoleptic group. The differences were not explained by differences in medication use. Although the study was cross-sectional, the data suggest that weight gain mainly occurs during the early phase of the disease. A new and striking finding was that the waist circumference of the narcoleptic patients was within the range that is clearly associated with increased risk of cardiovascular disease and diabetes mellitus.

Management of CVD Risk Factors Behavioral Risk Factors

Metabolic Syndrome The European Guidelines use the definition of metabolic syndrome as defined in the NCEP ATP III Guidelines. Although the guidelines suggest that patients with metabolic syndrome are usually at high risk of CVD, no specific guidelines exist beyond those described by the SCORE assessment guidelines.

Is lifestyle modification adequate to prevent onset of diabetes

Metabolic syndrome carries with it the underlying pathophysiologic feature of insulin resistance with tissue resistance to insulin action, compensatory hyperinsulinemia, and excessive circulating free fatty acids 78,79 . In addition, cardiovascular risk factors of low HDL and high triglyceride levels, hypertension, and lack of physical activity have all been shown to be predictors of non-insulin-dependent diabetes 80 . The relationships between metabolic syndrome and cardiovascular mortality as well as chronic complications of type 2 diabetes have been well described 81,82 . Several studies have shown impaired glucose tolerance to be a predictor of progression to type 2 diabetes 8385 . In addition, in one study, adiponectin was an independent predictor of type 2 diabetes 86 . It follows, then, that aggressive intervention in patients with impaired glucose tolerance or metabolic syndrome would translate to diabetes prevention. In addition to the Da Qing study, the Finnish diabetes...

Risk Factors For Cpvd

Weight, height, waist, and BMI, defined as weight in kg divided by height squared in meters squared, were positively associated with TCS, and DFD in men and VV, TCS, and SFD in women. Weight, waist circumference, the waist hip ratio, and body mass index are all measures of adiposity. A number of studies have found an association of obesity with venous disease. Gourgou et al.10 found a relationship in both men and women with VV. Our finding of increased waist circumference in men with TCS was consistent with findings that both obesity and male gender were associated with CVI and with the finding that weight was an independent risk factor for CVI in multivariate analysis (reviewed in Reference 8). In contrast, Coughlin et al. and Fowkes et al. both found that obesity was not a factor in venous insufficiency among women.11,12 Fowkes et al. extended this finding to men as well.12 Other studies also have found no association between obesity and venous disease.9 However, the Edinburgh group...

Significance and treatment of individual risk factors

Dyslipidemia associated with the metabolic syndrome is characterized by increased conversion of HDL-C from large, buoyant HDL2-C particles to more dense HDL3-C particles and conversion of large, buoyant LDL-C particles to small, dense LDL particles. A decrease in plasma levels of cardioprotective HDL2-C accompanied by increase in atherogenic small, dense LDL is associated with a higher risk of coronary artery disease. Stratification of risk factors for coronary artery disease in type 2 diabetes shows that LDL-C and HDL-C levels are the best predictors of coronary heart disease (Table 2). In the diabetic population, Hypertension is seen in about 60 to 80 of individuals with type 2 diabetes. As with the metabolic syndrome, hypertension often predates the manifestation of overt diabetes. There is

The Role of Intensive Glycemic Control in the Management of Patients who have Acute Myocardial Infarction

An alternative explanation for the relationship between glucose levels that are measured upon hospital admission and prognosis is the link between insulin resistance, the metabolic syndrome, and cardiovascular (CV) disease. Metabolic syndrome is characterized by insulin resistance and the association with traditional (the deadly quartet'' of obesity, hypertension, glucose intolerance, atherogenic dyslipidemia) and novel (endothelial dysfunction, proinflamma-tory state, hypercoagulability) risk factors for the development of CV disease and DM 17,18 . The metabolic syndrome is present in approximately 30 of middle-aged men 17 and is associated with a threefold to fourfold increase in CV mortality as compared with controls, even when patients who had known CV disease and DM were excluded from analysis 18 . Patients who have insulin resistance and frank DM also may have a host of associated conditions (Box 1) that may contribute to a poor CV prognosis.

Current state of affairs and future directions

The best approach for the problem of diabetes mellitus and associated CV disease is to prevent or delay the onset of diabetes mellitus. A truly comprehensive approach to reducing the risks posed by diabetes should explore the possibility of preventing or delaying the onset of diabetes. From a public health perspective, this approach, with the potential of wide application, might be the most cost effective strategy. Of course, the assumption is that prevention of diabetes will also lead to prevention of atherosclerosis, and this assumption is yet to be substantiated by prospective trials. To demonstrate this association, individuals at risk must be identified early in the course of development of the disease. For this reason the Western Working Group, NCEP, ADA, and other major groups have emphasized the importance of the metabolic syndrome as a potential prediabetic state 9,22,47 . Although data are lacking regarding the benefit of intervention in patients with the metabolic syndrome,...

Risk factors for diabetes

The increase in prevalence of type 2 diabetes is paralleled by the rising rate of obesity and metabolic syndrome. As body mass index (BMI) increases, the risk of developing type 2 diabetes increases correspondingly. The prevalence of type 2 diabetes is three to seven times higher in obese patients and is 20 times higher in those with a BMI greater 35 kg m2 than in those with a BMI between 18.5 and 24.9 kg m2 7-8 . This increased prevalence, however, may vary among ethnic groups. Obesity is a component of metabolic syndrome. The National Cholesterol Education Program Adult Treatment Panel (NECP-ATP III) defines metabolic syndrome using the objective clinical criteria given in Table 1 9 . Metabolic syndrome is defined as the presence of any three of the risk factors. The clustering of risk factors associated with this syndrome predicts development of manifest diabetes and cardiovascular disease. Hence, prevention of type 2 diabetes should aim to treat and prevent components of Clinical...

Diagnosis

Treatment and Outcome Most people with DISH do not have symptoms and do not need any treatment. Those with spinal stiffness need to understand what the problem is and use occasional painkillers as needed. A very few may need surgical removal of a spur or decompression of the spine or nerve root. injection of a small amount of corticosteroids around a painful heel spur may be very helpful. Those who are overweight should lose weight and exercise more, but it has not been shown that this will beneficially affect the DISH. More importantly, in these patients the diagnosis of DISH may prove the trigger for them and their physician to recognize that they have the metabolic syndrome. These patients often have high insulin levels, insulin resistance, obesity, hypertension, gout, and high lipid levels as well as a high risk of coronary artery disease.

Obesity

You should also keep an eye on your waist measurement, which is an indication of your body-fat level. As people grow older, for example, their waist size often increases, though the scale tells them they weigh the same as they did the previous year. That's because people tend to lose muscle mass as they age, but if they gain enough fat, they maintain the same weight.

Combination Therapy

Specific topics addressed in the 2003 Guidelines include the management of patients that are at high risk of CAD and are already at target for LDL-C (100 mg dL), the management of patients who have combined dyslipidemia and low HDL-C levels, and the non-invasive assessment of CVD and other risk factors. Factors such as metabolic syndrome, apolipoprotein B, lipoprotein (a), homocysteine, and C-reactive protein are discussed as they relate to their influence on risk assessment.

Apolipoprotein B

The Canadian Guidelines discuss the advantages of measuring apolipoprotein B especially in patients with moderate hypertriglyceridemia and metabolic syndrome. Advantages also include being able to measure a non-fasting blood sample. According to Genest, (5) Canadian population values for apolipoprotein B have been established, apolipoprotein B measurement has been standardized, and most Canadian laboratories have the equipment and expertise to measure it. In the Canadian population, an apolipoprotein B level of 0.9 g L is around the 20th percentile, 1.05 g L the 50th percentile, and 1.2 g L the 75th percentile. Clinical Identification of the Metabolic Syndrome Clinical Identification of the Metabolic Syndrome Abdominal obesity

Box

By the end of the intervention, the two active groups were virtually indistinguishable, because the one without a preplanned spiritual component had created its own. Both of the groups with the active intervention experienced significant improvements, compared with the self-help group, in weight, waist circumference, blood pressure, dietary energy, and total fat and sodium intakes. The input and participation of the community in planning and implementation and a supportive social environment resulted in behavioral changes that led to improved health. Four years after the project began, eight of the nine churches with an active intervention, plus the church that hosted the pilot intervention, continue the weekly support and education sessions an example of sustained, institutionalized change (Yanek et al., 2001).

Fire Up Your Core

Fire Up Your Core

If you weaken the center of any freestanding structure it becomes unstable. Eventually, everyday wear-and-tear takes its toll, causing the structure to buckle under pressure. This is exactly what happens when the core muscles are weak – it compromises your body’s ability to support the frame properly. In recent years, there has been a lot of buzz about the importance of a strong core – and there is a valid reason for this. The core is where all of the powerful movements in the body originate – so it can essentially be thought of as your “center of power.”

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