A better way to a healthier community, Part 2.

By: Anne-Laura Cook, MD, FACP, MHCM Medical Director, Population Health Management & Primary Care Innovation Baptist Health Centers


Five Modifiable Risk Factors to Prevent or Control Chronic Disease:

• Tobacco Use

• Diabetes and Prediabetes

• High Cholesterol

• High Blood Pressure

• Excess Weight and Physical Inactivity


In September, I wrote about two risk factors, Tobacco Use and Diabetes/Prediabetes. In this post, we will discuss the other three:

High Blood Pressure
High Cholesterol

Heart disease is the number one killer of women and men in the United States, and high blood pressure and high cholesterol are major risk factors for heart attack and stroke. Surveys show that more than 44 percent of Alabamians who have had their blood cholesterol checked were told that is was too high. More than 40 percent of adult Alabamians have been told they have high blood pressure (Source: BRFSS 2013).

Most people know that lifestyle changes – improving your diet, exercising more, losing weight, stopping smoking – can improve your blood pressure and cholesterol levels. However, making these changes often feels like an extremely difficult task. In Baptist Health System’s Be Well program, we help individuals set and keep attainable goals – using small steps of change to increase motivation and achieve big picture success over time. Through motivational interviewing, we determine an individual’s desire to change, confidence about change and readiness to change. We then create a plan, including setting specific self-management goals. We then monitor progress towards and address barriers to achieving these goals.

Although lifestyle change is emphasized, medications are often necessary in order to properly treat high blood pressure and high cholesterol, but medication only helps if you take it. Multiple studies have shown that approximately 50 percent of patients diagnosed with a chronic illness (including high blood pressure and high cholesterol) do not take medications as prescribed. In our Be Well program, we are proactive in addressing barriers to medication adherence. Understanding that financial barriers are one of the most common causes of lack of adherence, we assess and explain the out-of-pocket costs of medication on each employer’s health plan prior to prescribing a medication. At each visit, patients are asked to assess their degree of medication adherence and are encouraged to talk about the reasons why they struggle to take medication as prescribed. Is it an annoying side effect they associate with a particular medication? Do they always forget their morning dose because their medication isn’t strategically placed to remind them to take it each day? We tackle these hindrances to care in partnership with our patients, creating a plan that works well for each individual.

Excess Weight and Physical Inactivity

It is no secret that Alabama has a weight problem. According to recent data, 33.5 percent of adults in Alabama are obese (Source: RWJF, The state of obesity, 2015). Perhaps because this health problem is so pervasive in our community, we have come to accept excess weight as normal. That’s a problem for our long-term physical and economic health. It is estimated that obesity-related conditions costs more than $190 billion a year in medical spending in the United States (Source: Cawley J, Meyerhoefer C. The medical costs of obesity. Journal of Health Economics. 31(1):219-230. 2012.).

We know this issue is challenging from a big picture perspective, and it is challenging for the individual, too. Staring down a 50+ pound weight loss goal (or more) often seems like an insurmountable task. This is where small steps of change can have the greatest impact. Instead of focusing on an ideal weight goal, focus on the first five pounds. Rather than eliminating temptations from your diet, focus on cutting back unhealthy items or substituting healthier choices for a few servings of the foods or drinks that you know provide you with more calories than you need.

When we need to lose weight, we often put most of our focus on improving our diet; however, increasing our activity can have the greatest impact on health. Making small changes such as taking the stairs, parking at the far end of the parking lot, or taking a 10-minute walk break every two hours during the work day can make a tremendous difference in your metabolism, revving up your body’s ability to efficiently process the food that you eat. Asking friends or colleagues to join you in your activity can also bolster your confidence since you are accountable to someone else. We frequently find it easy to let ourselves down; it is harder to disappoint someone else.


Baptist Health System wants to change the way you think about your health. We want to prepare you to take better care of yourself and help you prevent chronic illness. We want you to spend more time doing the things that matter to you – we want you to Be Well.

Do You Have The “Metabolic Syndrome”?

By: Sheela Lohiya, MD
Grandview Medical Group
Clinical Endocrinologist Board certified in Endocrinology, Diabetes and Metabolism


The metabolic syndrome (syndrome X, insulin resistance syndrome) consists of a constellation of metabolic abnormalities that confer increased risk of cardiovascular disease (CVD) and diabetes mellitus (DM). The major features of the metabolic syndrome include central obesity, hypertriglyceridemia, low high-density lipoprotein (HDL) cholesterol, hyperglycemia, and hypertension.

Risk Factors

Being overweight/obese, having a sedentary lifestyle, aging, having diabetes mellitus, CVD, lipodystrophy etc. confers risk.

Etiology

1) Insulin Resistance

This is caused by an incompletely understood defect in insulin action. The onset of insulin resistance is heralded by postprandial hyperinsulinemia, followed by fasting hyperinsulinemia and, ultimately, hyperglycemia.

2) Increased Waist Circumference

Waist circumference is an important component of the most recent and frequently applied diagnostic criteria for the metabolic syndrome. However, measuring waist circumference does not reliably distinguish increases in subcutaneous adipose tissue vs. visceral fat; this distinction requires CT or MRI.

3) Dyslipidemia

Hypertriglyceridemia is an excellent marker of the insulin-resistant condition. The other major lipoprotein disturbance in the metabolic syndrome is a reduction in HDL cholesterol.

4) Glucose Intolerance

The defects in insulin action lead to impaired suppression of glucose production by the liver and kidney and reduced glucose uptake and metabolism in insulin-sensitive tissues, i.e., muscle and adipose tissue. The metabolic syndrome is a fairly strong predictor of incident diabetes in many populations and that it predicts diabetes more strongly than it predicts coronary heart disease events.

5) Hypertension

The relationship between insulin resistance and hypertension is well established.

6) Proinflammatory Cytokines

Symptoms and Signs

The metabolic syndrome is typically not associated with symptoms! On physical examination, waist circumference may be expanded and blood pressure elevated. The presence of one or either of these signs should alert the clinician to search for other biochemical abnormalities that may be associated with the metabolic syndrome. Less frequently, lipoatrophy or acanthosis nigricans is found on examination.

Diagnosis

The diagnosis of the metabolic syndrome relies on satisfying the criteria listed in Table 1 by using tools at the bedside and in the laboratory. The medical history should include evaluation of symptoms for OSA in all patients and PCOS in premenopausal women. Family history will help determine risk for CVD and DM. Blood pressure and waist circumference measurements provide information necessary for the diagnosis.

Laboratory Tests

Fasting lipids and glucose are needed to determine if the metabolic syndrome is present. The measurement of additional biomarkers associated with insulin resistance can be individualized. Such tests might include apoB, high-sensitivity CRP, fibrinogen, uric acid, urinary microalbumin, and liver function tests. A sleep study should be performed if symptoms of OSA are present. If PCOS is suspected on the basis of clinical features and anovulation, testosterone, luteinizing hormone, and follicle-stimulating hormone should be measured.

Treatment: The Metabolic Syndrome

Lifestyle

Obesity is the driving force behind the metabolic syndrome. In general, recommendations for weight loss include a combination of caloric restriction, increased physical activity, and behavior modification.

Diet

A high-quality diet— i.e., enriched in fruits, vegetables, whole grains, lean poultry, and fish—should be encouraged to provide the maximum overall health benefit.

Physical Activity

Although increases in physical activity can lead to modest weight reduction, 60–90 min of daily activity is required to achieve this goal.

Obesity

In some patients with the metabolic syndrome, treatment options need to extend beyond lifestyle intervention. Weight-loss drugs come in two major classes: appetite suppressants and absorption inhibitors. Bariatric surgery is an option for patients with the metabolic syndrome who have a body mass index (BMI) >40 kg/m2 or >35 kg/m2 with comorbidities. Gastric bypass results in a dramatic weight reduction and improvement in the features of metabolic syndrome. A survival benefit has also been realized.

LDL Cholesterol

For patients with the metabolic syndrome without diabetes, the Framingham risk score may predict a 10-year CVD risk that exceeds 20%. In these subjects, LDL cholesterol should also be reduced to <100 mg/dL. With a 10-year risk of <20%, however, the targeted LDL cholesterol goal is <130 mg/dL. Also refer to the newly instituted ASCVD calculator!

++

++

Triglycerides

++

A fasting triglyceride value of <150 mg/dL is recommended. In general, the response of fasting triglycerides relates to the amount of weight reduction achieved. A weight reduction of >10% is necessary to lower fasting triglycerides.

++A fibrate (gemfibrozil or fenofibrate) is the drug of choice to lower fasting triglycerides and typically achieve a 35–50% reduction.

++Other drugs that lower triglycerides include statins, nicotinic acid, and high doses of omega-3 fatty acids.

++

HDL Cholesterol

++

Beyond weight reduction, there are very few lipid-modifying compounds that increase HDL cholesterol. Nicotinic acid is the only currently available drug with predictable HDL cholesterol-raising properties. The response is dose-related and can increase HDL cholesterol ~30% above baseline.

++

Blood Pressure

++

The direct relationship between blood pressure and all-cause mortality rate has been well established, including patients with hypertension (>140/90) versus prehypertension (>120/80 but <140/90) versus individuals with normal blood pressure (<120/80). In patients with the metabolic syndrome without diabetes, the best choice for the first antihypertensive should usually be an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker, as these two classes of drugs appear to reduce the incidence of new-onset Type 2 diabetes. In all patients with hypertension, a sodium-restricted diet enriched in fruits and vegetables and low-fat dairy products should be advocated. Home monitoring of blood pressure may assist in maintaining good blood pressure control.

++

Impaired Fasting Glucose

++

In patients with the metabolic syndrome and Type 2 diabetes, aggressive glycemic control may favorably modify fasting triglycerides and/or HDL cholesterol. Metformin has also been shown to reduce the incidence of diabetes, although the effect was less than that seen with lifestyle intervention.

++

Insulin Resistance

++

Several drug classes [biguanides, thiazolidinediones (TZDs)] increase insulin sensitivity. Because insulin resistance is the primary pathophysiologic mechanism for the metabolic syndrome, representative drugs in these classes reduce its prevalence.

 

So do you think you/someone you know may have the metabolic syndrome? If so, contact your primary care doctor/cardiologist/your friendly neighborhood endocrinologist!!

 

References:

1)      Metabolic Syndrome and Incident Diabetes: Diabetes Care. 2008 Sep; 31(9): 1898–1904.

2)      The Metabolic Syndrome: Harrison’s Endocrinology 3^rd edition 2013 Chapter 18 253-260.

 

 

Staying Sober During the Holidays

By: Terry and Sherry Pouncey, with ARCpoint Labs of Birmingham at Greystone


The holidays can be one of the most difficult times during the year to stay sober. For some, it’s the excess of food and drink and merriment. Attending parties and being surrounded by people eating and drinking to their heart’s content can make staying sober difficult, as no one wants to be left out of the party. And of course, there’s the stress of planning for the holidays, cooking the food, hosting a family gathering, and being forced to spend time with those family members that you may normally try to avoid. All that stress can make it tempting to use just one little drink to relax. Unfortunately, that one little drink tends to turn into two, and then three, and even more. These tips will help you stay strong and stay sober this holiday season.

Plan Non-Alcoholic Drinks Ahead of Time

If attending a holiday meal or other holiday party where most of the other adults will be drinking alcohol, make sure to bring your own non-alcoholic alternative beverage. Rather than just drinking water, consider bringing something that you enjoy drinking, whether that’s Diet Coke, non-alcoholic apple cider, or juice. Bring some sparkling grape juice for a more festive drink that you can even slip into a wine glass to feel more included in the holiday toast. Being prepared with a tasty alternative will give you something to sip on while others are downing glass after glass of wine.

Connect with a Support Group

As the holidays approach, it may be a good idea to connect with a sober support group, if you don’t already have one. Before entering any kind of high-risk situation, like a holiday party, attending a support meeting or talking with a sponsor or mentor will help give the support and resolve you’ll need to help you stay sober.

Recruit a Sober Buddy

Invite a sober friend to attend the Thanksgiving meal or holiday party with you, or ask a close family member to help you by remaining sober with you. Having someone by your side who you can trust to remain sober with you can be an enormous help. It’s much less tempting to drink if a friend is not drinking and that friend can also keep an eye on you to help keep you from slipping up.


ARCpoint Labs provides drug and alcohol testing to promote a sober and healthy workplace. Find the nearest ARCpoint Labslocation today.

Can Esophageal Cancer Be Prevented?

By: Brian A. Brunson, M.D., Gastroenterology Associates of North-Central Alabama, P.C.


Esophageal adenocarcinoma, or cancer of the lower portion of the esophagus, is one of fastest growing cancers in our country over the last several decades, with the number of new diagnoses growing six-fold from 1975-2001. It carries a poor prognosis, with a 17% five year survival once diagnosed. A condition known as Barrett’s Esophagus (BE) is the primary risk factor for the development of esophageal adenocarcinoma. Up to 1.3% of the general population is affected by BE, although this number is higher in patients seen in a typical gastroenterology practice (up to 5-10%). Barrett’s esophagus is thought to result from prolonged acid exposure in the esophagus, leading to replacement of the normal lining (squamous epithelium) with a specialized lining called intestinal metaplasia. Gastroesophageal reflux disease (GERD), therefore, is the primary disorder that puts a person at risk for BE. It’s most common symptom is heartburn which affects up to 10% of the population on a daily basis and up to 44% of the population on a monthly basis.

While there are no definitive recommendations for screening, most gastroenterologists will perform an upper endoscopy, or EGD, in patients over age 50 who have a history of GERD. This allows direct visualization of the lining of the esophagus and biopsies if there is suspicion for Barrett’s. Multiple studies have suggested that the risk is highest in males over the age of 55 who are overweight or obese. It is not clear, though, if we should screen patients with acid reflux who don’t meet those criteria, although this is still routinely done. Once Barrett’s Esophagus is confirmed by a pathologist, the gastroenterologist is then faced with the decision on how often to repeat the endoscopy to assess for progression towards cancer.

The progression of Barrett’s esophagus to cancer occurs in a stepwise fashion. Reflux of acid, bile, or other intestinal contents into the esophagus results in injury to the esophageal lining. This then leads to inflammation and, in some cases, transformation (metaplasia) into a specialized intestinal lining. In some patients, this will continue to progress to dysplasia, which is a change in the cells of the lining that is much more likely to lead to cancer. Many factors determine which patients develop this higher risk change, including ongoing inflammation and genetics. Treatment of the acid reflux with a class of medicines called proton pump inhibitors (PPIs) does decrease the risk of progression to cancer, but does not completely eliminate it. Therefore, once BE is diagnosed, patients are placed in a standardized protocol for follow up endoscopies and biopsies. After the initial diagnosis, a repeat endoscopy with biopsies is typically performed one year later. If no dysplasia is found at that time, then a surveillance exam is performed every 3 years. Unfortunately, studies have not shown surveillance to be very good at preventing cancer formation, particularly in patients who have dysplasia which is much more likely to turn into cancer.

Surgically removing the esophagus previously was the only true preventative option in patients at high risk for cancer. This surgery carries significant risks and typically requires a prolonged recovery and long-term dietary modifications. Thankfully new techniques to actually treat and eliminate Barrett’s Esophagus have been developed over the last decade. Initial therapies using a laser or a technique called photodynamic therapy brought mixed results and a high risk of complications such as stricture formation.

Newer therapies developed and tested over the last five years include radiofrequency ablation (or RFA) and cryotherapy ablation. Ablation is a technique where tissue is heated or frozen until it is no longer alive. RFA (or the “Halo” procedure) has become the most widely utilized technique in our country and can be performed by gastroenterologists or surgeons with a special interest and training in this field. This procedure is performed during a standard upper GI endoscopy. Special balloon catheters can be used to treat or “ablate” large circumferential segments of Barrett’s tissue. Smaller focal areas can be treated with a catheter with electrodes mounted onto the tip of the endoscope. Clinical trials have shown that RFA completely eliminates the dysplastic or pre-cancerous tissue in greater than 90% of patients at average followup of 2.5 to 3 years. A followup study showed this response persisted out to 5 years in 92% of patients. Depending on the length of the Barrett’s segment, it usually takes at least 2-3 treatment sessions to completely eliminate the abnormal area.

RFA is now recommended by all the major endoscopy and gastroenterology societies for the treatment of all patients with Barrett’s and high grade dysplasia, and in patients with low grade dysplasia confirmed by 2 expert pathologists. Some patients with long segments of Barrett’s tissue without dysplasia may also be candidates, especially young patients (under age 40) or those with a family history of esophageal cancer. The risks of the procedure are very low; less than 1% cumulative risk of developing esophageal strictures and less than 1/1000 risk of perforating the esophagus during the procedure.

In summary, heartburn and gastroesophageal reflux can put you at risk for Barrett’s Esophagus and esophageal cancer. Therefore it is recommended that all patients with symptoms of reflux be evaluated by a gastroenterologist to assess the risk of Barrett’s and need for endoscopy. New low risk, non-invasive and highly effective therapies have been developed to treat and eliminate the pre-cancerous Barrett’s tissue and prevent progression to esophageal cancer.

A Dose of Our Own Medicine – Exercise During the Holidays

By: Ricardo E. Colberg, M.D., Andrews Sports Medicine and Orthopaedic Center


As healthcare professionals, all of us know the importance of a healthy diet, staying physically active and getting a restful night’s sleep. On a daily basis, we treat many patients with chronic medical conditions that are a direct result of a sedentary lifestyle.

Even though we continually remind our patients about the need to make better lifestyle choices, we too are human and struggle with the same temptations. With the holidays, cooler months, and shorter days, the need to practice what we preach increases exponentially; otherwise, we become patients too. The American Heart Association recommends that we perform 30 minutes of exercise, five times a week, all year long. If you are having a hard time getting motivated to exercise during the winter months, here are your MUST READ reasons and recommendations.


“Why Should I Work Out?”

1. It is Easier to Keep Weight Off Than to Try Losing It

With the colder weather, our basal metabolic rate decreases, which means our bodies build fat easier. Staying physically active during the colder months keeps our metabolic rate elevated, allowing us to enjoy our holiday feasts without the guilt of packing on a few pounds. Considering that it takes one week to lose one pound of excess weight, it is easier to keep weight off than to gain weight during the winter and try losing it in the summer.

2. We are More Productive When We Work Out

With the colder mornings and later sunrise, we are all tempted to hit the snooze button more often. However, studies have shown that exercising in the morning increases your energy level and productivity throughout the whole day. There is also better compliance with the exercise program since it is the first activity of your day, so you are less likely to skip exercising due to running late with other commitments.

3. “Feel Good” Hormones are Produced When We Exercise

With the long, dark, and cold days of winter, we are more susceptible to seasonal affective disorder and depression. Staying physically active is a great way to produce endorphins, which are the "feel good" hormones in our bodies. This goes a long ways in keeping us energized throughout the day making those dark days of winter more enjoyable. Most importantly, it keeps us emotionally stable.

4. Exercise Stimulates the Production of Joint Fluid

Our joints tend to get stiffer during the winter due to the colder temperature causing peripheral vasoconstriction. Exercise stimulates increased blood flow to our extremities, which promotes the production of healthy joint fluid and helps preserve the joint’s full-range-of-motion. In the long run, this leads to decreasing the risk of developing osteoarthritis, specifically of the hips and knees.

5. Staying Active in the Winter Decreases Injuries in the Summer

Exercising during the winter keeps our bodies in shape, maintains our strength and flexibility, and keeps us ready for spring time. This decreases the risk of injuries when the warmer weather comes and we are more inclined to go outside and participate in sports and recreational activities.


“How Can I Stay Compliant?”

1. Schedule Workouts

Rather than leaving your workout up to chance, you can be proactive and schedule dedicated time to exercise, ideally in the morning.

2. Recruit an Accountability/Training Partner

While it may be hard to motivate yourself to get going on cold mornings, it is easier if you are not alone. Find a workout partner to stay motivated. You will be less likely to press the snooze button if there is someone else you are leaving hanging.

3. Exercise at Home and at Work

If you can't go to the gym during the holiday season, you can still get a great workout at home. There are many workout videos that you can play on your TV or tablet that do not require special equipment. In addition, make an effort to park at work farther from the building and to take the stairs more often. This forces you to exert your body more frequently during the day in order to maintain a higher basal metabolic rate.



Ricardo E. Colberg, M.D. is a sports medicine & non-surgical orthopaedic physician at the Birmingham & Pelham offices of Andrews Sports Medicine and Orthopaedic Center. Dr. Colberg has a special interest in treating acute and chronic musculoskeletal injuries, including bone, joint, ligament, muscle and tendon injuries. He performs various treatment modalities in the clinic that assist the patient in their recovery from the injury, among them diagnostic musculoskeletal sonography, ultrasound-guided injections, and platelet-rich plasma therapy. For more information, contact Andrews Sports Medicine and Orthopaedic Center at 205.939.3699 or visit AndrewsSportsMedicine.com

Access is Key in Patient Engagement

By: Tammie Lunceford, Healthcare Consultant at Warren Averett LLC.

Patient satisfaction is an ever growing aspect of medical service in the last few years. Physicians are acutely aware of competition in many forms; urgent care, Uber medicine, and telemedicine to mention a few. Even in rural areas, physicians complain that their patients will not call to schedule with them when they are sick because it is simply too easy to go the urgent care, close by. Recent radio advertisements reveal a telemedicine product designed to treat twenty common ailments without leaving home. Even if you need to see a healthcare provider face to face, Uber medicine will send someone to your home with the personal touch of the 1950’s. Busy patients simply want to receive treatment fast and spend their time on other aspects of life. Basically, patients want healthcare to be as easy as picking up their dry cleaning.

What does this mean for physicians in private practice? It means we can’t stop the way medicine is changing so we must make adjustments to keep the patient relationship strong. Unless you are a specialist known for your expertise, you may have to revise your schedule to accommodate immediate access. Consider a mid-level provider to accommodate walk-in or patients who call to be seen. Train your staff to meet the patient’s needs and to monitor no shows. How many patients who booked appointments today, also no showed today? If they could be seen more conveniently elsewhere, they went elsewhere! Another way to meet the needs of the patient is to stagger staff and providers during lunch so patients can be seen on their lunch hour. You can stagger the physician and the mid-level for early and late access. Be sure to market your changes so patients will know you are available.

I recently reviewed physician schedules to find new patients could only be seen during one appointment slot a day, one specific time of the day. We must adopt open access scheduling to meet the needs of busy professionals, working moms, etc. The only decision should be the number of patients your office can accommodate each day, then let the schedule fill. Your referring physicians will appreciate your flexibility. Your patients will recommend you to their friends.

Another Head on the Hydra Metabolic Syndrome and Low Back Pain

By: Matthew Smith M.D. with Alabama Pain Physicians

“Modernity’s double punishment is to both make us age prematurely and live longer.” - Nassim Nicholas Taleb, The Bed of Procrustes


The developed world is facing an insidious healthcare epidemic. Via a confluence of medical breakthroughs, primarily in neonatology and infectious disease, we have benefitted from a jump in life expectancy since the early 1900s. Yet, these advances have been deceptive. Our success in addressing some of the most immediately preventable causes of death have masked the fact that morbidity has been gradually increasing over the last century and a half, with a rapid increase over the last twenty years. Today, the average elderly male spends 7.7 years in increasing medical dependency before death and the average female over 10 years. Moreover, there is a steadily increasing progression of morbidity prior to these years of dependency.

The main reason why our society has been getting progressively sicker despite our medical advances is because of the widespread development of a constellation of interrelated diseases known as the metabolic syndrome. The metabolic syndrome is classically defined as a disease whose primary manifestations are a dysregulation of glucose and insulin metabolism, dyslipidemia, hypertension, and suboptimal excesses of visceral adipose tissue. It is well known that the metabolic syndrome is strongly associated with, and causative of, many instances of gout, polycystic ovary syndrome, myocardial infarction, stroke, and dementia. To borrow from Greek mythology, its disparate manifestations are like a many-headed hydra, with each head representing a different “disease” but with each head attached to the same body of pathology.

Yet this hydra has at least one more head. And while this head is less well known than the others, it is no less important. It is common knowledge that the metabolic syndrome causes gout, diabetes, and heart disease. It is less well known that the metabolic syndrome is also the cause of many cases of osteoarthritis, or the type of arthritis more traditionally thought to be only from “wear and tear.” The metabolic syndrome appears to not just cause arthritis in the weight bearing joints, where bad mechanics can play a role, but in the hands, elbows, and every other non-weight bearing joint of the appendicular skeleton. And there are now numerous studies showing that osteoarthritis of the spine (also known as spondylosis) is also often caused by the metabolic syndrome.

This new understanding of how a vast amount of arthritis and pain are caused is a game changer. We now know that the pain and debility associated with osteoarthritis has at least as much to do with physiology as it does with mechanics. Perhaps the most salient physiology linking the metabolic syndrome to arthritis involves the visceral adipose tissue (VAT). VAT is the “white” adipose tissue that is in the viscera, as opposed to the white adipose tissue under the skin. The main purpose of VAT was previously thought to be just to store extra fat. We now know that our previous understanding was not just incomplete but misleading. VAT is actually an important endocrine organ that has the capacity to produce inflammation and cause profound destructive systemic effects. VAT is one of the primary generators of such pro-inflammatory cytokines as interleuken-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha). VAT leads to a decrease in the anti-inflammatory cytokines IL-10 and adiponectin as well. It also causes an increase in phospholipase A2. Regarding the latter, note that corticosteroids, still one of the mainstays for injection therapy for numerous arthritides, works by inhibiting phospholipase A2. VAT is thus akin to the anti-corticosteroid injection. But this is not the end of the ways that the metabolic syndrome destroys joints and causes pain. The vascular diseases associated with the metabolic syndrome, including small vessel occlusion and venous stasis, predisposes individuals to subchondral bone ischemia and poor nutrient and gas exchange in the joint cartilage.

The problem of the metabolic syndrome from too much visceral adipose tissue is compounded by a general lack of muscle, or sarcopenia, that is also becoming ever more prevalent in our patient populations. Robust skeletal muscle mass is an excellent insulin sensitizer and acts as a “glucose sink”, stabilizing the metabolic abnormalities that are part and parcel with the metabolic syndrome. Skeletal muscle also acts on the periosteum on a cellular level, establishing a normalization of metabolic function and improving bone density, chondrocyte health, and other factors implicit to bone and joint health. A lack of adequate skeletal muscle is therefore not just bad mechanically, but it worsens the destructive potential of the metabolic syndrome physiologically. Thus we now know of many ways in which the metabolic syndrome wrecks havoc on bones, joints, and their surrounding tissue. Above are a few of these ways and this is by no means an exhaustive list.

The physiological causes of osteoarthritic pain from the metabolic syndrome are important as they explain why so many more people are now experiencing arthritic pain, particularly of the low back. Back pain has been with us since time immemorial. Even Otzi, the tattooed mummy unearthed in the Alps and thought to have lived about 6,500 years ago, had some spondylosis. Spondylosis is nothing new and, like wrinkles of the skin, seems to usually be a normal part of the aging process. And, like spondylosis, some degree of back pain has been with humans since the very beginning of our species. Back pain has classically been the second most common reason to visit the doctor, just after upper respiratory tract infections. Yet, while spondylosis and back pain are part of the human condition, the prevalence and severity of back pain has been increasing tremendously in recent years, in lockstep with the tremendous increases with the other manifestations of the metabolic syndrome.

In order to appreciate the magnitude of the problem, it is helpful to look at some of the numbers. Low back pain has a direct cost in the United States of 70 billion dollars annually, with an indirect cost of up to $130 billion. Nearly 150 million workdays in the United States are lost every year because of low back pain. The worldwide incidence of back pain is 5% a year, with recurrence in one year ranging from 24-80%, depending on which study is favored. And the problem continues to get worse. European studies have shown a quadrupling of low back pain workdays lost over the late twentieth century with similar trends in the United States.

And consider this in correlation with the astronomical rise in obesity over the last two decades. According to the CDC, in both 1994 and 2010, Alabama was the second most obese state in the union. Yet, if you took the percentage of Alabamians who were obese in 1994 and transferred them to 2010, Alabama would be the leanest state in the union. And things have only worsened over the last five years.

These findings are important for three reasons. The first reason is that it shows that arthritic pain is an incredibly important disease whose etiology now looks to be vastly more complicated than previously appreciated. The second reason is it shows that in many ways the Pain Physician is treating manifestations of the same pathology as Cardiologists, Endocrinologists, Nephrologists, and General Practitioners. The third reason is that it gives us guidance as to the optimal treatment of our patient’s chief complaints.

Since the primary way by which the metabolic syndrome leads to pain and osteoarthritis is physiological, this opens up opportunities to treat some of these conditions pharmacologically and interventionally. As mentioned earlier, this is already done somewhat with treatments such as corticosteroid injection therapy. Visceral adipose tissue produces phospholipase A2, which leads to the production of pro-inflammatory cytokines. Corticosteroids inhibit phospholipase A2. Likewise, the metabolic syndrome is associated with an increase in TNF-alpha. There is some preliminary evidence that TNF-alpha inhibitors may help with osteoarthritic pain. While TNF-alpha inhibitors have classically been associated with the treatment of autoimmune pathologies, it thus makes sense why these could work with the much more common osteoarthritides. Leptin, adiponectin, and other cytokines may also be targets for pharmacological intervention. Furthermore, as the metabolic syndrome is associated with a variety of hormonal and neurohormonal issues (hypogonadism, etc), we may be able to leverage our better understanding of this pathology to address these as well.

While pharmacological advances and procedural interventions are exciting, the most obvious guidance that this new knowledge gives us is the importance of addressing the root cause of the metabolic syndrome in general. The most important take away is that there is simply no substitute to a healthy lifestyle, including the diet and activity necessary to ensure that our patients are appropriately lean and well conditioned. Of course, the problem is this requires a tremendous amount of patient buy in. And it can be really difficult to get this buy in. But not all hope is lost. Smoking used to be vastly more prevalent than it is today. Yet due to a change in societal norms, including the advice of doctors, tobacco use has decreased dramatically. Hopefully, with enough time and perseverance, we can change the lifestyle factors that are the root cause of the metabolic syndrome and the increasing incidences of arthritic pain as well. In the meantime, perhaps we can also utilize our new and fuller understanding of the ultimate cause of many types of pain to design better interventions for those for whom lifestyle changes are not enough.


Further Reading:

Conaghan PG, Vanharanta H, Dieppe PA. Is progressive osteoarthritis an atheromatous vascular disease? Ann Rheum Dis, 2005, 64: 1539–1541.

Gandhi R, Woo KM, Zywiel MG, Rampersaud YR. Metabolic Syndrome Increases the Prevalence of Spine Osteoarthritis. Orthopaedic Surgery, 2014, 6: 23-27.

Goodson NJ, Smith BH, Hocking LJ, McGilchrist MM, Dominiczak AF, Morris A, Porteous DJ, Goebel A. Cardiovascular risk factors associated with the metabolic syndrome are more prevalent in people reporting chronic pain: Results from a cross-sectional general population study. Pain, 2013, http://dx.doi.org/10.1016/j.pain.2013.04.043

Alam I, Lewis K, Stephens JW, Baxter JN. Obesity, metabolic syndrome, and sleep apnoea: all pro-inflammatory states. Obesity Reviews, 2007, 8: 119-127.

Katz JD, Agrawal S, Velasquez M. Getting to the heart of the matter: osteoarthritis takes its place as part of the metabolic syndrome. Current Opinion in Rheumatology, 2010, 22:512-519.