Are there specific treatments for the metabolic syndrome?

The concept of the metabolic syndrome, although controversial, continues to gain acceptance. Whereas each risk factor of the metabolic syndrome (visceral obesity, atherogenetic dyslipidemia, elevated blood pressure, and dysglycemia) can be dealt with individually, the recommended initial therapeutic approach is to focus on reversing its root causes of atherogenetic diet, sedentary lifestyle, and overweight or obesity. No single diet is currently recommended for patients with the metabolic syndrome, although epidemiologic evidence suggests a lower prevalence of the metabolic syndrome associated with dietary patterns rich in fruit, vegetables, whole grains, dairy products, and unsaturated fats. We conducted a literature search to identify clinical trials specifically dealing with the resolution of the metabolic syndrome by lifestyle, drugs, or obesity surgery. Criteria used for study selection were English language, randomized trials with a placebo or control group (except for surgery), a follow-up lasting >= 6 mo, and a time frame of 5 y. We identified 3 studies based on lifestyle interventions, 5 studies based on drug therapy, and 3 studies based on laparoscopic weight-reduction surgery The striking resolution of the metabolic syndrome with weight-reduction surgery (93%) as compared with lifestyle (25%) and drugs (19%) strongly suggests that obesity is the driving force for the occurrence of this condition. Although there is no "all-inclusive" diet yet, it seems plausible that a Mediterranean-style diet has most of the desired attributes, including a lower content of refined carbohydrates, a high content of fiber, a moderate content of fat (mostly unsaturated), and a moderate-to-high content of vegetable proteins

Defining the role of insulin lispro in the management of postprandial hyperglycaemia in patients with type 2 diabetes mellitus

The role of postprandial hyperglycaemia in contributing to the risk of both micro- and macrovascular complications in patients with diabetes mellitus is being increasingly recognized. In type 2 diabetes, there is a progressive shift in the relative contributions of postprandial and fasting hyperglycaemia to the overall glycaemic control as the disease progresses. For patients with fairly good glycaemic control (glycosylated haemoglobin [HbA(1c)] <8.5%), postprandial hyperglycaemia makes a relatively greater contribution to the overall glycaemic load than fasting hyperglycaemia, but in patients with poorer control, the relative contribution of the two states to the overall glycaemic load is reversed. This finding, coupled with epidemiological evidence that elevated postprandial glucose concentration is an independent risk factor for cardiovascular disease (CVD), and is associated with a greater CVD risk than elevated fasting glucose, points to the need to monitor and target postprandial glucose, as well as fasting glucose and HbA(1c) levels, when optimizing insulin therapy for patients with type 2 diabetes. When insulin therapy becomes necessary in patients with type 2 diabetes who can no longer be controlled with oral anti hyperglycaemic therapy, use of short-acting insulin analogues with a rapid onset of action and capable of controlling postprandial glycaemic excursions when injected immediately before a meal, has advantages over regular human insulin in that they provide a more favourable time-action profile that mimics normal physiological insulin secretion. Among the available rapid-acting insulin analogues, insulin lispro has been shown to reduce postprandial glucose concentrations to a significantly greater degree than regular human insulin in patients with type 2 diabetes. Moreover, premixed combinations of insulin lispro with the longer acting analogue neutral insulin lispro prolamine suspension in 25% : 75% or 50% : 50% combinations are significantly more effective in lowering postprandial blood glucose concentrations than premixed regular human insulin plus neutral protamine Hagedorn (NPH) 30% : 70%. The premixed insulin lispro combinations offer the advantage of fewer daily injections than intensive insulin therapy, and the convenience of not having to mix insulin preparations manually. Although it has yet to be conclusively established that targeting postprandial hyperglycaemia reduces CVD risk, the potential benefits of improved postprandial and interprandial hyperglycaemia favour the use of newer insulin analogues, such as insulin lispro and insulin lispro mixes, over conventional insulin therapy, whenever insulin therapy becomes necessary in patients with type 2 diabetes

Vascular Effects of L -Arginine The Vascular Effects of L -Arginine in Humans The Role of Endogenous Insulin

Abstract This study aimed at evaluating whether increased availability of the natural precursor of nitric oxide, L -arginine, could influence systemic hemodynamic and rheologic parameters in humans and whether the effects of L -arginine are mediated by endogenous insulin. 10 healthy young subjects participated in the following studies: study I, infusion of L -arginine (1 g/min for 30 min); study II, infusion of L -arginine plus octreotide (25 g as i.v. bolus ϩ 0.5 g/min) to block endogenous insulin and glucagon secretion, plus replacement of basal insulin and glucagon; study III, infusion of L -arginine plus octreotide plus basal glucagon plus an insulin infusion designed to mimic the insulin response of study I. L -Arginine infusion significantly reduced systolic (11 Ϯ 3, mean Ϯ SE) and diastolic (8 Ϯ 2 mmHg, P Ͻ 0.001) blood pressure, platelet aggregation (20 Ϯ 4%), and blood viscosity (1.6 Ϯ 0.2 centipois, P Ͻ 0.01), and increased leg blood flow (97 Ϯ 16 ml/min), heart rate, and plasma catecholamine levels ( P Ͻ 0.01). In study II, plasma insulin levels remained suppressed at baseline; in this condition, the vascular responses to L -arginine were significantly reduced, except for plasma catecholamines which did not change significantly. In study III, the plasma insulin response to L -arginine was reestablished; this was associated with hemodynamic and rheologic changes following L -arginine not significantly different from those recorded in study I. These findings show that systemic infusion of L -arginine in healthy subjects induces vasodilation and inhibits platelet aggregation and blood viscosity. These effects are mediated, in part, by endogenous released insulin

Efficacy and safety of insulin-GLP-1 receptor agonists combination in type 2 diabetes mellitus: a systematic review

Introduction: Attaining optimal glycemic targets in patients with type 2 diabetes is often hard and compromised by the shortcomings of the several treatments. Areas covered: When glycemic levels are not adequately controlled, an association of GLP-1 receptor agonists and insulin therapy can be adopted. In order to assess the benefit/risk profile of this combination therapy, a literature search of randomized clinical trials was performed.Eighteen trials matched the inclusion criteria. In 10 studies, GLP-1 receptor agonists were added on to an existing regimen, whereas insulin added to an existing GLP-1 receptor agonists regimen occurred in 2 studies. Six studies compared GLP-1 receptor agonists with short acting insulin as a treatment strategy to intensify basal insulin therapy. Expert opinion: Clinical trials herein reviewed demonstrated the safety and the efficacy of combining GLP-1 receptor agonists with basal insulin, with most studies showing equal or slightly superior efficacy, as compared with the addition of prandial insulin, associated with weight loss and less hypoglycemia