Chronic and Acute
5 Insulin Resistance and the
Insulin Resistance and the Metabolic Syndrome
Risk Factors, Prevention, and Management of the Metabolic Syndrome
The Role of Hyperinsulinemia in the Metabolic Syndrome
Causes and Management of Gout
Causes and Management of the Polycystic Ovary Syndrome
Medication Issues with Insulin Resistance
The Role of the Nurse or Other Health Care Professional in Prevention and Management of
the Metabolic Syndrome
After completing this chapter, you should be able to:
■ Describe the metabolic syndrome.
■ Identify individuals at risk for the metabolic syndrome.
■ Recognize an appropriate lifestyle plan for preventing and managing insulin resistance.
■ Explain the application of the Dietary Guidelines in managing insulin resistance.
Terms to Identify
Acanthosis nigricans Glucagon Lipoprotein lipase
Androgens Glycemic index Metabolic obesity
Atherosclerosis Gout Nonalcoholic fatty liver
C-peptide Hirsutism disease
C-reactive protein (CRP) Hyperglycemia Oral glucose tolerance test
Central obesity Hyperinsulinemia (OGTT)
Cutaneous papilloma Hypoglycemia Polycystic Ovary Syndrome
Dyslipidemia Impaired fasting glucose
Endometrial hyperplasia Impaired glucose tolerance
Ferritin Insulin resistance
152 SECTION 2 Chronic and Acute Illness
It has been over 10 years since the metabolic syndrome received ofﬁcial recognition.
It was considered a theory before then. The metabolic syndrome, also known as the
insulin resistance syndrome, was initially called Syndrome X.
Insulin resistance describes a condition in which the body cells resist the action
of insulin, leading to poor use of blood glucose at the cellular level. Various causes
have been suggested, from hormonal and enzymatic factors to issues of
inflammation and problems with cellular structures. It is now well recognized that
lifestyle and diet exert their influence on individuals with a genetic tendency
toward insulin resistance. Obesity and lack of physical activity are known to
worsen the genetic predisposition to insulin resistance.
The metabolic syndrome is often discussed in terms of the common gene theory
because it is commonly found. An estimated 40% of U.S. adults between the ages of
40 and 74 have prediabetes (see later section). The rate of insulin resistance in some
populations is as high as 60%. Insulin resistance is also associated with the common
gene theory because it is the underlying cause of many chronic health problems.
About one third of persons with insulin resistance go on to develop type 2
diabetes. Most individuals with type 2 diabetes still have hyperinsulinemia.
However, the amount of insulin produced is not adequate to overcome the
resistance at the cellular level. The result is high blood glucose levels or diabetes
mellitus (see Chapter 8). The World Health Organization (WHO) has estimated that
there will be around 300 million persons with diabetes by 2025. It is anticipated that
Asia will be at the forefront because of a genetic tendency for insulin resistance
along with changing lifestyles.
Obesity is now an epidemic throughout the world and is found with the health
problems of the metabolic syndrome, including type 2 diabetes, hypertension, and
hyperlipidemia (see Chapter 7). The medical community faces an emerging epidemic
of type 2 diabetes in children and adolescents as the obesity epidemic continues
(Miller and Silverstein, 2005). It is further predicted there will be an epidemic of
early cardiovascular morbidity and mortality in years to come unless the epidemic
of obesity is stemmed (Pontiroli, 2004).
This chapter provides an overview of the metabolic syndrome. Other chapters
in Section Two expand on the speciﬁc health problems associated with this
syndrome, including central obesity, coronary heart disease, and diabetes, with the
resulting adverse effects on the kidneys. Research is expanding on other health
conditions associated with the metabolic syndrome, such as certain forms of cancer.
As this section points out, the health problems associated with insulin resistance are
realized only through environmental factors, with diet playing a large role.
WHAT IS THE METABOLIC SYNDROME?
The National Cholesterol Education Program’s Adult Treatment Panel III deﬁnition
uses easily measured clinical ﬁndings of increased abdominal circumference,
elevated triglycerides, low levels of high-density–lipoprotein cholesterol (HDL-C),
elevated fasting blood glucose, and/or elevated blood pressure. Three of these
ﬁve are required for diagnosis of the syndrome. Gout (a condition related to high
levels of uric acid; see later in this chapter) is often found with the metabolic
syndrome as well.
Insulin Resistance and the Metabolic Syndrome CHAPTER 5 153
There are different deﬁnitions of the criteria to use in making the diagnosis of
the metabolic syndrome. The American Association of Clinical Endocrinologists
has identiﬁed the following risk factors:
■ Obesity or overweight body mass index (BMI) >25 (especially with central
obesity or metabolic obesity—carrying weight in the abdomen or having a
high waist-to-hip ratio; see Chapter 6)
■ Elevated triglycerides: 150 mg/dL (1.69 mmol/L)
■ Low HDL cholesterol
Men <40 mg/dL (1.04 mmol/L)
Women <50 mg/dL (1.29 mmol/L)
■ Elevated blood pressure ≥130/85 mm Hg
■ 2-Hour postglucose challenge >140 mg/dL (199 mg/dL; prediabetes)
■ Fasting glucose between 110 and 126 mg/dL (6.15 and 7.05 mmol/L; prediabetes)
■ Other risk factors:
Family history of type 2 diabetes, hypertension, or cardiovascular disease (CVD)
Polycystic ovary syndrome (PCOS): a clinical diagnosis based on high levels of
male hormones, male pattern hair growth, and ovarian cysts (see later in
Ethnic groups having high risk for type 2 diabetes or CVD
Diagnosis depends on clinical judgment based on risk factors.
One condition found with the metabolic syndrome includes atherosclerosis (a
buildup of plaque in the arteries and blood vessels; see Chapter 7). Although there
are a variety of causes of atherosclerosis, an association with diabetes is well
known. Because atherosclerosis generally is noted before the diagnosis of diabetes,
it is believed that excess insulin related to insulin resistance promotes the plaque
buildup. An increased tendency to form clots is also found with the metabolic
syndrome and type 2 diabetes and can cause a variety of circulatory problems.
Therefore persons with the metabolic syndrome are at increased risk of heart disease.
Certain cancers have been associated with the metabolic syndrome. Known
cancers related to the metabolic syndrome include cancers of the breast, pancreas,
liver, and colon and uterine (endometrial) cancer. An epidemic pattern of colon
cancer and type 2 diabetes among Japanese persons has been noted. However, rates
for colon cancer among Japanese in the United States are even higher than among
those living in Japan. It is believed that the rise of colon cancer reflects the
westernization of food intake (Kuriki et al., 2004). Newer research has linked
prostate and ovarian cancers with the metabolic syndrome (see Chapter 10).
Other health problems that have recently been connected with the metabolic
syndrome and insulin resistance include Nonalcoholic fatty liver disease—a
condition of fat buildup in the liver (Brea et al., 2005) and hypothyroidism (Dessein
et al., 2004).
WHAT MEASUREMENTS CAN HELP DIAGNOSE INSULIN RESISTANCE?
A fasting blood glucose between 100 and 125 mg/dL is referred to as impaired
fasting glucose and is indicative of prediabetes. Another test that can help diagnose
prediabetes is the 2-hour oral glucose tolerance test (OGTT) (blood glucose test
154 SECTION 2 Chronic and Acute Illness
performed 2 hours after a 75-g carbohydrate drink). An OGTT blood glucose level
of 140 to 199 mg/dL is referred to as impaired glucose tolerance and is indicative
of insulin resistance and prediabetes.
As hyperinsulinemia is found with insulin resistance, measurements of insulin
levels can help conﬁrm the diagnosis of the metabolic syndrome. Insulin is measured
using different techniques. One is the ratio of fasting glucose levels to fasting insulin
levels. It has been found that a fasting glucose-to-insulin ratio less than 7 may serve
as an early identiﬁcation of children at risk for complications of insulin resistance
(Silfen et al., 2001). One indirect measure of insulin production is C-peptide.
Another lab value increasingly taken into account is the level of C-reactive
protein (CRP) (a type of protein found with inflammation). Low-grade chronic
inflammation reflected by increased CRP can identify those at risk for type 2 diabetes
and coronary heart disease. Over one third of children and adolescents with the
metabolic syndrome have been found to have high levels of CRP (Ford et al., 2005).
Overweight children and adolescents with a BMI over the 85th percentile (see
Chapters 6 and 12) have been found to have elevated CRP and fasting insulin levels
(Kelly et al., 2004). Women with PCOS (see section later in this chapter) are often
insulin resistant with increased risk for type 2 diabetes and coronary heart disease.
Women with PCOS have shown signiﬁcantly elevated CRP concentrations (Kelly
et al., 2001).
Research is linking high levels of ferritin (a substance that holds iron in the
blood) with insulin resistance. High iron stores have been linked to the metabolic
syndrome (Jehn et al., 2004). The association between heme iron and diabetes risk
may be a result of a relationship between hepatic iron overload and insulin
resistance (Piperno et al., 2004). High hemoglobin levels are associated with excess
weight, hypertension, hyperlipidemia (see Chapter 7), and hyperinsulinemia (Choi
et al., 2003). Heme-iron intake from red meat sources has been positively associated
with the risk of type 2 diabetes (Jiang et al., 2004).
Body weight measurement is another means of assessment. Individuals in the
upper normal weight range (BMI over 23) and mildly overweight range (BMI over
25) are at increased risk for having the metabolic syndrome, and screening is
advised to help prevent diabetes and cardiovascular disease (St-Onge et al., 2004).
What Do We Know about Risks for Insulin Resistance?
Historically, thinking has generally focused on the development of obesity as the
cause of insulin resistance and the listed health conditions. This is reflected in
warnings that obesity can cause diabetes. However, research continues to indicate
that insulin resistance has a strong genetic link. Thus, not everyone with obesity
will develop diabetes.
Persons who have inherited a genetic predisposition to insulin resistance
probably have ancestors who survived repeated bouts of famine. It is likely that
several thousands of years ago, before there were restaurants, corner grocery stores,
refrigeration, and transportation, many of our ancestors faced continual cycles of
famine. Those who were able to survive likely had the ability to be thrifty with food
kilocalories. In fact, insulin resistance is often referred to as the thrifty gene theory
(being thrifty in calorie expenditure; see Chapter 6 for management of obesity
related to insulin resistance).
Insulin Resistance and the Metabolic Syndrome CHAPTER 5 155
Many of us have the genetic legacy of those survivors of famine, in that persons
who inherit the thrifty gene gain body fat easily in times of plenty. They also tend to
have a difﬁcult time losing weight, whether through self-imposed dieting or
environmental factors that reduce the food supply. This would have been a survival
advantage before a stable food intake could be relied on, but in current times it can
result in obesity, type 2 diabetes, and other health problems found with the metabolic
The Pima Indians of Arizona are the classic example of why it is believed
genetic predisposition and environmental conditions allow for the development of
the metabolic syndrome. The Pima Indians in the Southwest United States have the
highest reported occurrence of obesity and non–insulin-dependent diabetes
mellitus in the world. This situation developed only about 100 years ago with the
abrupt changes in lifestyle accompanying the rerouting of the Gila River to provide
irrigation waters for California. As these Pimas could no longer grow their own
foods and their activity levels went down, their lifestyles and dietary intake
drastically changed. This has resulted in an epidemic of obesity and diabetes.
However, this is in contrast to the low rates of obesity and diabetes among the
Pimas living in Mexico (Valencia et al., 2005). The lower rate of diabetes among the
Mexican Pimas is attributed to their higher physical activity levels and maintenance
of a more traditional diet that emphasizes high-ﬁber foods and low reliance on
meat and processed foods.
There is some evidence that the risk of the metabolic syndrome may be set in
utero. Large babies who were exposed prenatally to their mother’s gestational
diabetes or obesity have been noted to be at increased risk for developing the
metabolic syndrome in later childhood (Boney et al., 2005). Excess kilocalorie intake
during pregnancy is suspected to predispose the infant to later development of the
metabolic syndrome (Armitage et al., 2005). Therefore counseling women during
pregnancy to avoid excess weight gain and having screening for gestational
diabetes with appropriate management may help reduce the rate of diabetes for
future generations. See Chapter 11 for pregnancy guidelines.
What Population Groups Are Known to Have High Levels of Insulin Resistance?
Genetically, certain population groups are known to have high rates of insulin
resistance. Native Americans, in general, have a high prevalence of type 2 diabetes.
South Paciﬁc Islanders are also at high risk for insulin resistance. Other known
groups with high rates of the insulin resistance syndrome include persons with
Spanish (i.e., Hispanic and Latino) and South Asian heritage. In Mexico there is an
epidemic of obesity, type 2 diabetes, and cardiovascular disease linked with the
metabolic syndrome (Sanchez-Castillo et al., 2004). Asian populations may become
more susceptible to the metabolic syndrome as a Western diet and lifestyle are
adopted. WHO Expert Consultation has advised a BMI (see Chapter 6) of 22 to 25
among the Asian population to reduce the adverse health outcomes of the
metabolic syndrome (Rakugi and Ogihara, 2005). Persons with African heritage
have a high rate of insulin resistance. Among African-American children a higher
rate of type 2 diabetes, along with hyperinsulinemia, obesity, acanthosis nigricans
(a skin condition with dark patches related to diabetes—see Figure 5-1 and Chapter
8), and family history of diabetes has been noted as compared to their Caucasian
156 SECTION 2 Chronic and Acute Illness
Figure 5-1 Acanthosis nigricans causes dark patches to
occur on the skin, often in the underarm area as
shown, or on the neck; cutaneous papillomas or “skin
tags” are also commonly found with insulin resistance
counterparts (Arslanian, 2002). Cutaneous papillomas or skin tags are also found
with insulin resistance and type 2 diabetes (Figure 5-1).
There is a general trend for higher rates of insulin resistance among persons
with heritage from regions nearer the equator, such as the Paciﬁc Islanders. There
are exceptions to this because insulin resistance is known to occur in all ethnic
groups. Finland is one northern country with a relatively high rate of diabetes
(Ilanne-Parikka et al., 2004). Among an Irish population the prevalence of glucose
intolerance and type 2 diabetes was noted to be almost 15% (Smith et al., 2003). In a
study of French families, the metabolic syndrome was found to increase with age
(Maumus et al., 2005).
Native Hawaiians have been advocating a return to more traditional diets and lifestyles. This
is a result, in part, of the recognition of high numbers of chronic illnesses including diabetes,
obesity, hypertension, heart disease, and cancer. Family is very important to native
Hawaiians, along with respect for one’s ancestors. As part of this, traditional foods are
viewed with respect. Arguments or negative comments about traditional foods, such as poi,
are frowned on as being disrespectful to ancestors. Attempts to improve the health of native
Insulin Resistance and the Metabolic Syndrome CHAPTER 5 157
Hawaiians is best done from a family perspective, rather than an individual one, and should
include exercise, cooking, and eating together. ■
How Can the Metabolic Syndrome Be Prevented or Managed?
Genetically, a family history of type 2 diabetes and the other health conditions
found with the metabolic syndrome increase one’s own risk of developing
diabetes. However, even though there may be an increased genetic risk, there are
ways to minimize this. Physically active, nonsmoking persons of normal weight
with moderately low intake of carbohydrate and alcohol have been found to have a
lower risk of developing the metabolic syndrome (Zhu et al., 2004). Lifestyle
changes have shown prevention of diabetes by over 40% among persons with
prediabetes (Orchard et al., 2005). One study found that individuals who increased
their level of physical activity were about 65% less likely to develop diabetes
(Laaksonen et al., 2005). The nutritional factors to lower risk for developing the
health conditions found with insulin resistance are summarized as follows:
■ Aim for meals with lower glycemic index and glycemic load (McKeown et al.,
■ Include at least 20 g of dietary ﬁber daily, with emphasis on soluble ﬁber (Davy
and Melby, 2003).
■ Aim for six meals daily to lower insulin release (Farshchi et al., 2005).
■ Reduce intake of sweetened beverages to control kilocalories (Schulze et al.,
2004; Yoo et al., 2004).
■ Avoid excess intake of high-fructose corn syrup as found in commercially
sweetened products to control triglyceride levels (Basciano et al., 2005).
■ Include magnesium-rich foods to reduce inflammation (McCarty, 2005).
■ Increase foods rich in vitamin C and beta carotene to lower CRP levels
(Fredrikson et al., 2004).
■ Include folate and vitamin B12 to improve insulin resistance (Setola et al., 2004).
■ Emphasize nuts and olive oil versus a low-fat diet, but within a controlled
kilocalorie intake (Esposito et al., 2004).
■ Limit intake of saturated fats and trans fats (Musso et al., 2005; Schulze and Hu,
■ Increase the amount of omega-3 fats to lower blood pressure, serum insulin,
and triglycerides (Aguilera et al., 2004; Hulbert et al., 2005).
■ Aim for weight loss as needed, physical activity, and a diet moderate in fat and
carbohydrate, with emphasis on monounsaturated fats and omega-3 fatty acids
to control triglyceride and blood glucose levels (Carson, 2003).
■ For those who already drink, include moderate amounts (Carnethon et al.,
2004; Djousse et al., 2004).
What Is the Role of Magnesium in Controlling Insulin Resistance?
Insulin resistance may be promoted by magnesium deﬁciency because of adverse
changes to metabolic enzymes (Higashiura and Shimamoto, 2005). As reviewed in
Chapter 3, magnesium is related to the production of 300 metabolic enzymes.
Hyperinsulinemia, as generally found with insulin resistance, promotes excess
loss of magnesium. Severe magnesium deﬁciency has been shown to cause a
clinical inflammatory syndrome that can be controlled with increasing intake of
158 SECTION 2 Chronic and Acute Illness
magnesium. Magnesium deﬁciency contributes to conditions found with the
metabolic syndrome, including hyperlipidemia, and hypertension related to
cardiovascular disease and cancer (Rayssiguier and Mazur, 2005). Magnesium is
found in dark green, leafy vegetables, as it is part of the chlorophyll molecule, and
is also found in high amounts in legumes, the germ portion of whole grains, nuts,
milk and milk products, and ﬁsh.
FALLACY: A person with a strong family history of diabetes is doomed to develop this
FACT: Studies show that groups at risk of developing diabetes can help prevent or delay the
development of type 2 diabetes if there is regular physical activity, maintenance of a healthy
weight, and emphasis on foods high in ﬁber and low in saturated fat. ■
WHAT IS THE ROLE OF HYPERINSULINEMIA IN THE INSULIN
A person with a genetic predisposition to insulin resistance tends to have an altered
insulin response. With insulin resistance there is often a delayed production of
meal-related insulin. This can result in a transient state of hyperglycemia (high
levels of blood glucose). When the body does respond to the hyperglycemia, it is
often with excess insulin production over a prolonged period. Persons with insulin
resistance have been noted to produce up to 10 times the amount of insulin to
control blood glucose levels as compared with other insulin-sensitive individuals.
This hyperinsulinemia can result in symptoms of hypoglycemia (low levels of
blood glucose; see Chapter 8) if meals are delayed.
The symptoms of reactive hypoglycemia are common among persons with
insulin resistance, but medically the condition is rarely diagnosed. The blood
glucose criteria for diagnosis of reactive hypoglycemia are more stringent than for
persons with diabetes on medication. Physicians generally will not make the
diagnosis unless blood glucose levels are below 50 mg/dL. Symptoms of hypo-
glycemia, however, may occur years before the onset of diabetes and are likely
because of hyperinsulinemia and excess release of counterregulatory hormones (see
Counterregulatory hormones correct hypoglycemia by causing the liver to
release its stored sugar, called glycogen. The symptoms that occur because of these
hormones, however, can be unpleasant. Altered glucagon (a counterregulatory
hormone that is the ﬁrst one produced in response to low levels of blood glucose)
secretion has been noted in reactive hypoglycemia. Glucagon in excess leads to
feelings of nausea. Glucagon release is inhibited with hyperinsulinemia. It may be
for this reason that persons with insulin resistance experience the symptoms of
hypoglycemia as the body needs to release other counterregulatory hormones such
as adrenalin (epinephrine). Adrenalin causes an increased heart rate and physical
tremors, which is an unpleasant and potentially frightening experience if the
person has not associated it with the need to eat a carbohydrate source.
The symptoms of hypoglycemia do affect the quality of life. However, most
persons with hypoglycemia symptoms are not in an immediate health emergency.
Insulin Resistance and the Metabolic Syndrome CHAPTER 5 159
Severe hypoglycemia requiring medical assistance is usually limited to persons taking
insulin or insulin-stimulating medications such as the sulfonylurea medications (see
Hyperinsulinemia is found with central obesity. It is still, however, a bit of a
chicken-and-egg question. Which came ﬁrst? Hyperinsulinemia and central obesity
are known to worsen insulin resistance. However, it may be that the genetic
predisposition to insulin resistance is what ﬁrst sets up excess production of insulin
in relation to carbohydrate intake. Some health care professionals suggest that
hyperinsulinemia encourages the gain of abdominal weight in the ﬁrst place. This is
the basis of the low-carbohydrate diets (see Chapter 6).
Within a group of obese children, 40% were found to have hyperinsulinemia,
and over 10% had impaired glucose tolerance as based on an OGTT. About one
third of obese children had dyslipidemia (disordered fats in the blood; generally
referring to elevated triglycerides and low levels of HDL-C) and hypertension.
The metabolic syndrome was found in 30% of children under 12 years of age
(Viner et al., 2005).
With regard to dyslipidemia (see Chapter 7), it has been clearly shown that the
enzyme lipoprotein lipase (an enzyme that helps the breakdown of triglycerides) is
altered in the presence of hyperinsulinemia. This results in reduced breakdown of
triglycerides, leading to high serum triglyceride levels. Thus elevated triglyceride
levels in the blood are generally associated with hyperinsulinemia, especially if
the person also has central obesity. This occurs even in childhood, with triglyceride
levels correlating with insulin levels in children (Reinehr et al., 2005). Reduction in
hyperinsulinemia generally improves dyslipidemia. One study showed that an
intake of 250 mg EPA/DHA omega-3 fats for only 6 weeks signiﬁcantly decreased
both fasting and postprandial triglyceride levels (Brady et al., 2004).
Hypertension is now a well-recognized aspect of insulin resistance and the
metabolic syndrome. There are still unanswered questions regarding the speciﬁc
mechanism related to hypertension and the underlying cause of insulin resistance.
The role of hyperinsulinemia is being suggested as the link, as a result of altered
vasodilation. Therefore advice to follow a low-glycemic index diet may contribute
to management of hypertension (Kopp, 2005). A person with central obesity and
hypertension likely has insulin resistance (Figure 5-2).
Hyperinsulinemia is now believed to be related to early heart disease, because
of the incidence of heart disease occurring before the diagnosis of diabetes. It is well
known that diabetes is associated with increased risk of atherosclerosis (see
Type 2 diabetes is described as a relative insufﬁciency of insulin production.
Hyperinsulinemia is usually present with type 2 diabetes; there just is not enough
insulin for the demand or to overcome severe insulin resistance at the cellular level.
However, hyperinsulinemia can worsen insulin resistance, making it more difﬁcult
for the body to regulate blood glucose levels.
Certain cancers are found with the metabolic syndrome. Middle-aged men
with the metabolic syndrome were found to be more likely to develop prostate cancer
(Laukkanen et al., 2004). Excess weight in women is found with hyperinsulinemia,
low HDL-C, increased levels of estrogen, and breast cancer (Furberg et al., 2005). See
Chapter 10 for more on the role of hyperinsulinemia in the development of cancer.
160 SECTION 2 Chronic and Acute Illness
Figure 5-2 Hypertension is commonly found with excess abdominal weight.
WHAT IS GOUT, AND WHAT ARE ITS RISK FACTORS AND
Gout is the medical condition related to high levels of uric acid. The buildup of uric
acid causes crystals to form. Uric acid crystals can cause severe pain in various
joints in which the crystals tend to collect. Commonly the big toe is involved, but
other joints may be affected. Damage to the kidneys is known to occur with uric
acid deposition in this organ. The incidence of gout is increasing, especially with
older adults, with men having this condition three to four times more frequently
than women (Wallace et al., 2004).
A high level of uric acid is associated with insulin resistance (Cohn et al., 2005).
Historically, higher uric acid levels are believed to have been helpful to maintain
adequate blood pressure levels when intake of sodium was too low. As the
Westernized diet has become increasingly prevalent, there has been an increase in
both hypertension and gout (Johnson et al., 2005).
Traditional medical nutritional therapy for gout has been aimed at lowering
intake of purines as found in legumes and other protein-based foods. Generally the
use of medications such as allopurinol and colchicines is the primary intervention.
With the newer recognition of gout as part of the metabolic syndrome, the goals of
medical nutrition therapy (MNT) for managing insulin resistance may be more
effective. Moderate amounts of legumes may be tolerated and help meet the goal
Insulin Resistance and the Metabolic Syndrome CHAPTER 5 161
for increased intake of ﬁber and magnesium. Slow weight loss, avoidance of excess
alcohol, and good fluid intake can be of help. Data from the Third National Health
and Nutrition Examination Survey were analyzed and showed that total protein
intake was not related to the serum uric acid levels. However, meat and seafood
intake appears to increase levels, whereas milk and yogurt consumption was
related to lower levels (Choi et al., 2005).
WHAT IS THE POLYCYSTIC OVARY SYNDROME, AND WHAT IS ITS
PCOS can be related to hyperinsulinemia. There are different causes of PCOS.
When PCOS is found in conjunction with central obesity and other risk factors for
insulin resistance, hyperinsulinemia is the most likely cause. In the presence of
excess levels of insulin, male-type hormones, called androgens, may be formed.
This results in the masculinization of some women, leading to hirsutism (excessive
male-type body hair), ovarian cysts, and irregular menstrual cycles.
In one outpatient adolescent clinic 5% were diagnosed with PCOS including
excess androgen levels, hirsutism, acanthosis nigricans (a skin condition; see Figure
5-1), and obesity (Omar et al., 2004). Of women with unwanted hair growth, it was
found that about half had excess androgen levels and PCOS. Women with
hirsutism are advised to have ovulatory function assessed even if the menstrual
cycle is normal (Souter et al., 2004).
Women with PCOS are at high risk for impaired glucose tolerance and type 2
diabetes. This is especially true of minority women. A 2-hour OGTT for screening
women with PCOS at high risk for diabetes, rather than fasting glucose levels
alone, can better identify health risk. An increased potential for endometrial
hyperplasia (thickening of the endometrial layer of the uterus) and cancer is
associated with anovulation (Richardson, 2003). This underscores the need for
prompt identiﬁcation and treatment of PCOS.
Women with PCOS generally beneﬁt with the same goals of MNT to control
insulin resistance as described earlier in the chapter. One area of concern, however,
is normalizing food intake. A higher prevalence of bulimia nervosa (see Chapter 12)
and greater cravings for sweets has been noted with PCOS. This may be related to
impaired release of the satiety factor, cholecystokinin (Hirschberg et al., 2004). As
discussed previously, an increased intake of unsaturated fats is a positive goal in
the management of the metabolic syndrome and can help increase cholecystokinin
levels. Individuals who follow very-low–kilocalorie diets may also have episodes
of binge eating and crave sweets. Small, frequent meals with low glycemic index
can be very helpful in controlling PCOS.
FALLACY: Children instinctively know how to make food choices to stay healthy.
FACT: Children need the guidance of adults in selecting foods. The insulin resistance
syndrome includes many chronic diseases, such as obesity, heart disease, and high blood
pressure, that can start in childhood as a result of poor food choices. Using the MyPyramid
to teach children to eat more high-ﬁber plant foods, such as vegetables, fruits, and legumes
(beans), is appropriate. ■
162 SECTION 2 Chronic and Acute Illness
WHAT ARE MEDICATION CONCERNS IN MANAGING INSULIN
There are multiple factors that can influence risk for the metabolic syndrome. It has
been noted that persons with schizophrenia who take the medications clozapine or
olanzapine are at increased risk for insulin resistance and should be monitored
(Henderson et al., 2005). Medications that are known to cause weight gain, such as
some antipsychotics, need to be used cautiously in persons at risk for the metabolic
Medications that serve a positive role include insulin sensitizers such as
metformin, sold under the brand name of Glucophage. For PCOS, antiandrogen
medications in combination with estrogen can restore regular menstrual cycles and
reduce acne and hirsutism found with this syndrome (Homburg, 2005).
Other medications exist to control insulin resistance, and more are expected to
be developed. The insulin-sensitizing medication rosiglitazone was studied with
severely insulin-resistant obese women who had PCOS. It was found that this
medication improved insulin resistance and glucose tolerance, decreased ovarian
androgen production, normalized insulin levels, and helped restore spontaneous
ovulation (Sepilian and Nagamani, 2005).
WHAT IS THE ROLE OF THE NURSE OR OTHER HEALTH PROFESSIONAL
IN THE PREVENTION AND MANAGEMENT OF THE INSULIN RESISTANCE
The nurse or other health professional should be aware of the common occurrence
and risk factors of the metabolic syndrome. The nurse can help identify at-risk
individuals through review of family history and health correlates of insulin
resistance. Prompt identiﬁcation can help to prevent early heart disease and diabetes.
The nurse or other health care professional can provide lifestyle guidance. This
might entail encouraging low-sugar beverages, such as seltzer water or iced tea, or
recommending that a pitcher of water with lemon slices be kept in the refrigerator
to increase its appeal. To encourage intake of vegetables and ﬁber, use of
mayonnaise-based dressings or using olive oil to sauté vegetables can be suggested.
To lower glycemic index of meals, it can be advised to “Eat fruit; don’t drink it.” It
should be clariﬁed, however, that 4 oz of juice (15 g of carbohydrates) is generally
well tolerated; advice might be to drink juice the “European way” (mixed with
seltzer water). Reviewing food labels for ﬁber content is a practical strategy that can
empower individuals to reduce their risk of the metabolic syndrome. Increased
physical activity should be promoted; walking, dancing, or other forms of exercise
can be encouraged. For individuals with mobility issues, even chair exercises can be
of help. Adolescents might be encouraged to play basketball or skip rope to help
stem the epidemic of obesity and diabetes in our youth.
1. If you are working with an individual who has central obesity and hypertension,
is this individual at risk of diabetes? What laboratory values can help determine
Insulin Resistance and the Metabolic Syndrome CHAPTER 5 163
2. Ask students to raise their hands if they have experienced symptoms of
hypoglycemia, such as feeling weak, shaky, or irritable, that are resolved with
3. Have students volunteer, as desired, their family history of insulin resistance
correlates. Estimate the percentage of students in class who are at risk for the
4. Assess the following menu for the questions that follow:
BREAKFAST LUNCH DINNER
Banana Hot dog on roll Cheeseburger
Corn flakes Mustard and relish French fries
Whole milk Chocolate chip cookies Coleslaw
Sugar Coke Milkshake
Toast, butter, and jelly
Judge these meals based on a typical adult’s needs according to the new MyPyramid.
Identify the foods or beverages high in sugar and saturated fat.
What suggestions would you make to change this menu to lower the risk of developing
the metabolic syndrome?
Royce had been on a very-low–fat diet since his open heart surgery 2 years before.
He was now being advised by the nurse practitioner that he had prediabetes and
should include more fat and ﬁber with moderate amounts of carbohydrate. It was a
bit confusing, but it seemed to make sense. He had said he would be delighted to
put real olive oil on his salads, instead of the fat-free dressings he had been using.
He certainly loved nuts and was willing to try natural peanut butter on his toast. He
had been getting hungry right after breakfast when he just used jam. And being
advised to eat sardines was particularly easy; that took him back to his childhood
when he sat on his grandfather Sean’s lap while the two of them ate sardines
together. The advice to eat beans wasn’t new to him, either. He’d been eating his
grandmother’s baked beans for years, and even now his wife’s cooking included
beans. He and Nellie loved pinto beans and collards, and her mother had taught
them to like adzuki beans, along with her specialty of succotash. Thinking about all
this food made him hungry. He didn’t like to cook, so he got out the can of kidney
beans and prepared to add the vinegar and pinch of sugar. He loved eating cold
beans from the can. Then he was going for a walk, he told himself. He was
motivated, since he’d learned he had prediabetes. And he was very thankful for being
able to walk, since his car accident had put him in the hospital a number of years
back. Yes, life was okay.
Critical Thinking Applications
1. What laboratory value(s) must Royce have to diagnose prediabetes?
2. What is known about the prevention of diabetes? How does this relate to the
advice given by the nurse practitioner?
3. What factors in Royce’s diet help meet the nutritional guidelines to manage the
metabolic syndrome and help prevent diabetes?
164 SECTION 2 Chronic and Acute Illness
4. Why would the nurse practitioner advise eating more monounsaturated fats
and fewer carbohydrates?
5. What is in sardines, and how might they help Royce?
6. If Royce needs 2000 kcal, how many grams of carbohydrate would be advised?
How many grams of fat?
7. In doing a diet history, what foods and nutrients are important to assess?
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