Priscilla S. Sarinas, MD; Daniel S. Dube, MD
Potential Financial Conflicts of Interest: None disclosed.
Sarinas P., Dube D.; The Diabetes Prevention Program and the Metabolic Syndrome. Ann Intern Med. 2005;143:544-545. doi: 10.7326/0003-4819-143-7-200510040-00021
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Published: Ann Intern Med. 2005;143(7):544-545.
TO THE EDITOR:
With respect to the study by Orchard and colleagues (1), several other studies have also suggested that sleep-related breathing disorder is independently associated with insulin resistance, endothelial dysfunction, and hypertension (2). Furthermore, impaired glucose tolerance seems to be related to the severity of oxygen desaturation associated with sleep-related breathing disorder independently of age, sex, body mass index, and waist circumference, and may be mediated by elevated release of epinephrine (2, 3). These abnormalities are corrected with positive-pressure ventilation (4). Thus, sleep is a “missing link” that should be included as a variable of syndrome X (5). Notwithstanding the omission of sleep as an important variable, the demonstration that exercise and diet are superior to metformin in the resolution of the metabolic syndrome is counter to the orthodox strategies adopted in treatment of syndromes such as diabetes or hypertension that are clinically considered to have “well-defined” abnormalities. In vitro evidence suggests that hypertension and insulin resistance are very complex disorders with multiple metabolic derangements whose measurement is poorly served by the contemporary indices used to gauge them, such as blood sugar or blood pressure. It seems logical that intrinsic biochemical counteractive measures provoked by exercise or balanced nutritional homeostasis would better counteract the abnormalities thought to be operational in these syndromes. The absence of these syndromes in agrarian societies supports the conclusion that syndromes of insulin resistance, obesity, and acquired hyperlipidemia reflect the modern distortion of the organism–environmental equilibrium attained throughout human evolution, in which energy use was balanced with physiologic demands for survival. Thus, exercise, control of caloric use, and sleep may coax intrinsic biophysiologic machinery to balance use of protein and energy. In consonance with the findings of Orchard and colleagues' important study, we support an integrated and multifaceted approach to the treatment of the metabolic syndromes. This study has extensive ramifications with regard to managing insulin resistance, hypertension, and obesity and requires careful scrutiny.
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