The Choice of a Metabolic Syndrome Generation: Soft Drink Consumption Associated With Increased Metabolic Risk
July 25, 2007 — Drinking more than one soft drink daily is associated with a higher risk of developing adverse metabolic traits, as well as developing the metabolic syndrome, a new study has shown. Interestingly, it doesn't matter if the soda consumed is the diet variety, those with zero calories, as investigators showed these also increased the burden of metabolic risk in middle-aged adults.
"That was one of the more striking aspects of this study," lead investigator Dr Ramachandran Vasan (Boston University School of Medicine, MA) told heartwire. "It actually doesn't matter if the soft drink is regular or diet. There was an association of increased risk of developing the metabolic syndrome with both types of drinks."
Discussing the findings, which are published online July 23, 2007 in Circulation, Vasan said that the consumption of soft drinks has doubled to tripled between 1977 and 2001. During this same time period, soft-drink sizes have also increased to staggering proportions. With evidence that soft-drink consumption is linked with weight gain and obesity as well as an increased risk of diabetes, the investigators questioned whether soft-drink consumption in adults, in amounts that are seemingly innocuous, like one per day, posed any metabolic hazard.
The investigators, led by Dr Ravi Dhingra (Harvard Medical School, Boston, MA), related the incidence of metabolic syndrome and its components to soft-drink consumption in more than 6000 individuals participating in the Framingham Heart Study. Information on daily consumption of soft drinks was collected via a physician-administered questionnaire, with information on the type of soft drink — diet or regular — collected in later questionnaires. Metabolic syndrome was defined as the presence of three or more of following risk factors: excess waist circumference, high blood pressure, elevated triglycerides, low high-density lipoprotein (HDL)-cholesterol levels, and high fasting glucose levels.
In a cross-sectional analysis of the data, investigators report that those consuming more than one soft drink daily had a 48% higher prevalence of metabolic syndrome than those who drank less than one soft drink per day. In a longitudinal analysis of more than 6000 subjects free from metabolic syndrome at baseline, drinking more than one soft drink daily was associated with a 44% greater risk of developing metabolic syndrome and with developing four out of five components of metabolic syndrome. There was a trend toward an increased risk of developing high blood pressure, but this association did not reach statistical significance.
Odds Ratio of Developing Components of the Metabolic Syndrome and Metabolic Syndrome in Adults Consuming = 1 Soft Drink Daily
Component of the metabolic syndrome
In a smaller sample of participants who had data available regarding the type of soft drink consumed, researchers observed that that those who consumed one or more drinks of diet or regular soda per day had a 50% to 60% increased risk of developing new-onset metabolic syndrome.
Odds Ratio of Developing the Metabolic Syndrome in Adults Consuming = 1 Soft Drink (Diet or Regular) Daily
Component of the metabolic syndrome
Despite the fact that diet soda has zero calories, the findings are not entirely surprising, said Vasan, as diet soft drinks have been previously linked with poor health outcomes in children, such as weight gain and high blood pressure. In terms of theories explaining the association between soft-drink consumption and the metabolic syndrome risk, Vasan said there are no definitive answers yet.
"Individuals who drink soda tend to have a greater intake of calories, they consume more saturated and trans fats, they consume less fiber and dairy products and have a more sedentary lifestyle," he said. "We adjusted for a number of these variables, but even after the adjustment, there was a significant association that was evident. It makes the case that maybe you can't fully adjust for lifestyle factors, and it might be a lifestyle/dietary background thing driving this."
In addition, Vasan said diet soda might also induce a conditioning response in which the soft drinks promote a dietary preference for sweeter foods. Also, because diet soda is liquid, this has the effect of individuals eating more at the next meal, mainly because liquids are not as satiating. And finally, the brown caramel in soda has been linked with tissue damage and inflammation, which might contribute to the increased risk. All of these theories, however, are debated in literature.
"Clearly, these findings are sufficiently intriguing that scientists now have to help us understand better why we see this association," said Vasan. "We are not inferring causality from this analysis. It is just an association, so we need to turn to the scientists who are better positioned to help us understand the association more."
Clinical Context
Increased soft drink consumption has been associated with an increased risk for obesity and diabetes among children and adolescents, but educational programs may reduce the number of children choosing soft drinks. In a study of 644 children aged between 7 and 11 years by James and colleagues, the use of an educational program reduced the consumption of soft drinks by 0.6 glasses per day immediately compared with an increase of 0.2 glasses per day in a control group. The results, which were published in the May 22, 2004, issue of BMJ, also demonstrated that the rate of overweight and obesity increased in the control group by 7.5% during 1 year, compared with a respective decrease of 0.2% among children who received the educational program.
The potential harms of soft drink consumption among adults are less clear. The current analysis of the Framingham Offspring study cohort seeks to determine the relationship between drinking sodas and incidence of the metabolic syndrome.
Study Highlights
5124 participants comprised the main study cohort, and they were queried regarding lifestyle habits, including soft drink consumption, approximately every 4 years between 1987 and 2001. Participants who completed at least 2 consecutive examinations were included in the current analysis, whereas those with metabolic syndrome at baseline were excluded.
The main study outcome was the relationship between the frequency of soft drink consumption and incident metabolic syndrome. Metabolic syndrome was defined by the presence of at least 3 of the following factors: waist circumference of at least 35 inches in women or 40 inches in men, fasting blood glucose level of at least 100 mg/dL or treatment of diabetes, blood pressure of at least 135/85 mm Hg or treatment of hypertension, serum triglyceride levels of at least 150 mg/dL or treatment with niacin or fibrates, and HDL cholesterol level less than 40 mg/dL in men or less than 50 mg/dL in women.
The main study outcome was adjusted for other factors, including age, sex, body mass index, diet, blood pressure, serum lipid and glucose values, physical activity, smoking status, and alcohol use.
Slightly more than half the study cohort were women, and the mean age was 52.9 years. Approximately 35% of subjects reported consuming at least 1 soft drink per day.
Rates of incident metabolic syndrome were 18.7% and 22.6% among subjects who drank less than 1 soda per day and subjects who drank at least 1 soda per day, respectively. The adjusted odds ratio (OR) of incident metabolic syndrome associated with higher soft drink consumption was 1.44.
Differentiating sodas into those that were low-calorie or contained caffeine did not significantly alter the main study outcome.
Compared with drinking less than 1 soda per day, drinking at least 1 soft drink per day significantly increased the risks for obesity (OR, 1.31), increased waist circumference (OR, 1.30), impaired fasting glucose (OR, 1.25), hypertriglyceridemia (OR, 1.25), and reduced HDL cholesterol levels (OR, 1.32).
Pearls for Practice
An educational program has been demonstrated to reduce soft drink consumption and the risk for overweight or obesity among children.
The current study shows that regular consumption of either diet or regular soda increases the risk of developing the metabolic syndrome and its individual components among middle-aged adults.
Endocannabinoids -- the Brain's Own Marijuana -- May Be Linked to the Metabolic Syndrome
Posted 10/09/2006
George T. Griffing, MD
The metabolic syndrome is a cluster of cardiovascular risk factors, including abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, and insulin resistance, associated with a prothrombotic and proinflammatory state. It is a major health problem in the United States and elsewhere, but we still don't understand its etiology.
Recent studies suggest that endocannabinoids, which are the brain's own marijuana, may be an etiologic factor linked to the metabolic syndrome.[1]
New data show that the human brain makes its own "chemical marijuana" in the form of 2 compounds: anandamide, a Sanskrit word meaning "bliss," and 2-AG (2-arachidonoylglycerol).[2]
These endocannabinoids are unique since they are synthesized on demand and work in a reverse direction, from postsynaptic neurons where they are synthesized to presynaptic neurons where they bind to receptors.
Two specific endocannabinoid receptors have been identified. These receptors are in high concentrations in the brain, liver, muscle, gut, and adipose tissue. Generally, these receptors appear to be located in areas of the body responsible for modulating energy balance, feeding behavior, hepatic lipogenesis, and glucose homeostasis.[3]
Endocannabinoid stimulation favors metabolic processes that lead to weight gain, lipogenesis, insulin resistance, dyslipidemia, and impaired glucose tolerance, and overactivity of this system has been found in human obesity and in animal models of genetic and diet-induced obesity.
Treatment with a specific endocannabinoid inhibitor, rimonobant, in clinical trials in human obesity has not only reduced excess body weight, but also lowered blood pressure in hypertensive patients, improved insulin sensitivity, corrected dyslipidemia, and decreased the prevalence of metabolic syndrome.[4]
It is remarkable that marijuana components, which have been used for centuries by man, have led to the unfolding story of the effects of endocannabinoids and a possible answer to the metabolic syndrome.
That's my opinion. I'm Dr. George Griffing, Professor of Medicine at St. Louis University and Editor-in-Chief of Internal Medicine for eMedicine.
References
Pagotto U, Marsicano G, Cota D, Lutz B, Pasquali R. The emerging role of the endocannabinoid system in endocrine regulation and energy balance. Endocr Rev. 2006;27:73-100. Abstract
Devane WE, Hanus L, Breuer A, et al. Isonation and structure of a brain constituent that binds to the cannabinoid receptor. Science. 1992:258:1946-1949. Abstract
Di Marzo V, Matias I. Endocannabinoid control of food intake and energy balance. Nat Neurosci. 2005;8:585-589. Abstract
Pi-Sunyer FX, Aronne LJ, Heshmati HM, Devin J, Rosenstock J; RIO-North America Study Group. Effect of rimonabant, a cannabinoid-1 receptor blocker, on weight and cardiometabolic risk factors in overweight or obese patients: RIO-North America: a randomized controlled trial. JAMA. 2006;295:761-775. Abstract
George T. Griffing, MD, Professor of Internal Medicine, Saint Louis University, St. Louis, Missouri; Editor-in-Chief of Internal Medicine for eMedicine.com
Metabolic syndrome is defined by the NCEP ATP III as the presence of at least three of the following disorders:
- fasting hyperglycemia of more than 110 mg/dL,
- hypertriglyceridemia of more than 150 mg/dL,
- HDL cholesterol level of
- less than 40 mg/dL in men
- less than 50 mg/dL in women,
- blood pressure higher than 130/85 mm Hg,
- waist circumference of
- more than102 cm in men (40 inches)
- more than 88 cm in women. (36 inches)
simple explanation of metabolic syndrome
- diabetes or prediabetes,
- abdominal obesity,
- unfavorable lipid profile
- hypertension,
New Definition of the Metabolic Syndrome: A Newsmaker Interview With Sir George Alberti, MA, DPhil, BMBCh
Laurie Barclay, MD Medscape Medical News 2005. © 2005 Medscape
May 5, 2005 — Editor's Note: On April 14, the International Diabetes Federation (IDF) issued a global consensus statement presenting a new worldwide definition of the metabolic syndrome to facilitate early detection and more intensive management, in hopes of reducing the long-term risk of cardiovascular disease (CVD) and diabetes. The IDF panel included experts from six continents who specialize in diabetes, cardiology, lipidology, public health, epidemiology, genetics, metabolism, and nutrition.
The metabolic syndrome, which includes
- diabetes or prediabetes,
- abdominal obesity,
- unfavorable lipid profile
- hypertension,
triples the risk of myocardial infarction or stroke and doubles mortality from these conditions. It also increases the risk of developing type 2 diabetes, if not already present, fivefold. Recent data from Australia and the U.S. suggest that up to one quarter of the adult population may have the metabolic syndrome.
To learn more about the clinical and research implications of the new definition, Medscape's Laurie Barclay interviewed Sir George Alberti, past president of the IDF and cochairman of the consensus group, and professor of medicine at the University of Newcastle upon Tyne, U.K.
Medscape: What was the impetus behind redefining the metabolic syndrome?
Prof. Alberti: Over the past six years, several definitions of the metabolic syndrome have been proposed starting with the World Health Organization (WHO) in 1999. They all differ, and this has caused confusion, particularly when attempting to compare data from different studies. It was also uncertain which, if any, of the definitions best picked out those at risk of CVD and diabetes. We therefore felt that it would be helpful to attempt to produce a unifying definition which would be easy to use worldwide and would serve as the basis for furthering our knowledge of the syndrome.
Medscape: How does the new definition of the metabolic syndrome differ from existing definitions?
Prof. Alberti: The new definition is to some extent an amalgam of the three previous major definitions by WHO, European Group for the Study of Insulin Resistance (EGIR), and Adult Treatment Panel III (ATP III). It is closest to ATP III in that it includes the same variables: central obesity, triglycerides, HDL-cholesterol, hypertension and fasting hyperglycemia. It differs in that central obesity is an essential component. Also waist girth is set at a lower level than in ATP III and is ethnicity-specific. The cutoff points for blood pressure and lipids are the same, however, whilst fasting hyperglycemia is set at the new American Diabetes Association (ADA)-suggested level for impaired fasting glucose (IFG). It does not include any measure of insulin resistance, and hyperglycemia is not an obligatory component, which sets it apart from WHO and EGIR.
Medscape: Please summarize the key points of these guidelines.
Prof. Alberti: The new diagnostic criteria are central obesity, defined as waist equal to or more than 94 cm for males and 80 cm for females in Europids, and ethnic-specific levels in Chinese, Japanese and South Asians; together with two of the following: raised triglycerides of at least 1.7 mmol/L or 150 mg/dL; low HDL-cholesterol, defined as less than 1.04 mmol/L (40 mg/dL) in males and less than 1.29 mmol/L (50 mg/dL) in females; raised blood pressure of at least 130/85 mm Hg; and fasting hyperglycemia, defined as glucose equal to or greater than 5.6 mmol/L (100mg/dL) or previous diagnosis of diabetes or impaired glucose tolerance.
Medscape: How will the new definition facilitate early detection and more intensive management?
Prof. Alberti: The new definition is receiving a lot of attention, thereby raising awareness of the syndrome itself. By using new criteria and cutpoints we feel that we have made it a more useful tool for worldwide use. The measurements involved should be available in most places and hence aid its use. It can be used as a routine screening test or in those deemed to be at risk. It should serve to focus attention on those at particularly high risk of CVD and diabetes, allowing intensification of lifestyle advice as well as therapeutic intervention for individual components of the syndrome. We need, however, to publicize the syndrome further as a useful tool for picking out those at greatest need of CVD prevention measures.
Medscape: How likely are the new guidelines to be accepted and widely implemented?
Prof. Alberti: There is a good likelihood that the guidelines will be accepted in most parts of the world. They will be promoted by IDF, which is a worldwide organization, and will we hope be considered shortly by WHO. There is some [doubt] as to their take-up in the U.S., as ATP III is firmly embedded there. However ATP III is currently being reconsidered by the American Heart Association, and we have also requested that any studies carried out in the U.S. using ATP III guidelines should also report their results using the new IDF criteria.
Medscape: How will the new definition facilitate research?
Prof. Alberti: The new criteria will allow direct comparisons between studies carried out in different parts of the world, which may well yield valuable etiological clues. We hope that new longitudinal outcome studies will be conducted on a worldwide basis using the criteria, which will tell us the most important components of the syndrome for predicting CVD outcomes, and will be used to refine the criteria and cutoff points used. We would also hope that such studies will incorporate many of the new factors which have been suggested as possible components of the syndrome, such as C-reactive protein, cytokines, adiponectin, etc.
Medscape: What are the potential public health benefits of adopting this new definition?
Prof. Alberti: CVD and diabetes continue to ravage the developed world, and are now beginning to devastate the developing world as well. This will destroy many health economies let alone causing untold human suffering. The new criteria are already seen as user-friendly and will, we are sure, be used worldwide to identify people at risk. Appropriate preventive measures can be targeted at individuals while primary prevention strategies are implemented on a global basis. The latter will, however, take decades to take effect, so that the high-risk strategy, facilitated by popularization of the new criteria and knowledge of the syndrome itself, is essential in the short and intermediate term.
Reviewed by Gary D. Vogin, MD
metabolic syndrome responsible for 40% of all prescription drug costs, study says
By Linda A. Johnson
TRENTON, N.J. -- Americans with metabolic syndrome -- a condition marked by big waistlines, diabetes, high blood pressure and cholesterol problems -- account for $4 of every $10 spent on prescription drugs for adults, according to a study.
The report by Medco Health Solutions Inc., a huge prescription benefit manager, shows that adult use of medication for the syndrome jumped 36 percent between 2002 and 2004.
Annual prescription costs for people 20 and older with metabolic syndrome averaged $4,116 last year, 4.2 times the average amount spent on drugs for that age group, according to New Jersey-based Medco, which released the data exclusively to The Associated Press.
Medco reached its findings by studying prescription records from a random sample of 2 million clients.
Dr. Robert Epstein, Medco's chief medical officer, calls metabolic syndrome one of the country's top five health problems.
The syndrome -- once called Syndrome X -- was first recognized about 40 years ago, but the term "metabolic syndrome" did not come into wide use until the last decade. The first international symposium on the syndrome was held three weeks ago in Berlin.
Metabolic syndrome is caused by the body's inability to use insulin efficiently, and the hallmark of the condition is excessive abdominal fat. Patients also have two or more related conditions, including high blood pressure, low levels of good cholesterol, high levels of blood fats called trigyclerides, and high blood sugar. Many have diabetes or will eventually.
People with metabolic syndrome as twice as likely to suffer a heart attack or stroke and more than three times as likely to die early from those causes.
According to various U.S. estimates, at least one in four adults and roughly one in eight children have metabolic syndrome, with overeating and inactivity being key causes.
The prevalence in people over 40 jumped more than 60 percent over the past decade, federal health surveys show.
Dr. Stuart Weiss, director of the Diabetes Education Center at New York University, said naming the syndrome has brought more aggressive treatment for some patients and prevented cases of diabetes and heart disease.
New guidelines from the International Diabetes Federation are being reviewed by health agencies around the world to standardize the criteria for diagnosing the condition and help family doctors spot the syndrome and start treatment early.
"There aren't enough heart specialists and diabetes specialists to handle all the cases worldwide," said Dr. Paul Zimmet, co-chairman of the guidelines committee.
Medco is launching a service this summer to alert clients taking drugs for multiple components that they should be checked for the syndrome.
A look at trends in metabolic syndrome
Surging Syndrome: New figures show that $4 of every $10 spent on prescriptions for American adults is going toward treating metabolic syndrome.
What It Is: A disorder in which the body no longer uses insulin efficiently. People with metabolic syndrome are fat around the middle and have two or more related conditions, such as high blood pressure, high blood sugar and abnormal cholesterol levels.
The Danger: Metabolic syndrome sharply raises the risk of dying of a heart attack or stroke.
What's Next: Medical groups are pushing for family doctors to be more aggressive in testing patients for metabolic syndrome and starting treatment early.
Waist Size Associated With the Metabolic Syndrome in Children
CHICAGO, IL -- August 1, 2005 -- Waist circumference is associated with insulin resistance in children and may offer a simple way to identify children with risk factors for cardiovascular disease and type 2 diabetes, according to a study in the August issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals. The prevalence of childhood obesity has doubled in the past two decades, accompanied by an epidemic of type 2 diabetes mellitus (T2DM) and potentially devastating cardiovascular disease (CVD) consequences, according to background information in the article. Some studies suggest that in adults, measurement of waist circumference (WC), an indicator of intra-abdominal fat, is a better indication of CVD risk than body mass index (BMI), a measure of overall obesity. Waist circumference is one component of the metabolic syndrome, a combination of health conditions, including type 2 diabetes, high blood pressure and high levels of lipids (fat) in the blood, that place a person at high risk for heart disease. Valeria Hirschler, M.D., of the Durand Hospital of Buenos Aires, Argentina, and colleagues measured the waist circumference of children aged six to 13 years and compared waist circumference to measurements of components of the metabolic syndrome, including obesity (BMI), insulin resistance, lipid profile (fats in the blood, including cholesterol and triglyceride levels) and blood pressure. Of the 84 children evaluated (44 girls), 28 were overweight, 40 were obese and 16 were normal weight. Statistical analysis showed that waist circumference was an independent predictor for elevated blood pressure, insulin resistance and elevated high-density lipoprotein cholesterol level. "In our study, there was a significant correlation between WC and all the components of the metabolic syndrome," the authors report. "Visceral obesity may be an important risk factor for insulin resistance syndrome in children," the authors conclude. "Waist circumference serves as a readily available means to estimate abdominal obesity in the office setting. Normative data specific for ethnic group need to be collected. The present study showed that children with abdominal obesity, as determined by WC, have increased metabolic risk factors for CVD and T2DM." (Arch Pediatr Adolesc Med. 2005; 159:740-744. Available pre-embargo to the media at www.jamamedia.org.) SOURCE: JAMA/Archives Media Relations Department
