Stress Reduction in the Non-Pharmacologic Treatment of Metabolic Syndrome

1. Stress Reduction in the Non-Pharmacologic Treatment of Metabolic Syndrome PAS 646 Master’s Project Sherry Kiernan February 22, 2007

2. Metabolic Syndrome • 3 out of 5 of the following risk factors • Abdominal Obesity • Increased Trig., LDL, Fasting Plasma Glucose • Decreased HDL • The cardiovascular risk associated with the syndrome increases exponentially with each additional factor1 • 25% of adults fulfill the requirements for MetS2

3. Current Non-Pharmacologic Treatment Options • There is no “accepted” pharmacological treatment plan1 • The recommended non-pharmacologic treatments are limited to Diet and Exercise • The challenge in recommending diet and exercise is that not all programs are equally effective for everyone (high rate of failure) • Usual recommendation is a diet low in fat, high in fiber and fruits/veggies and at least 30 minutes of exercise daily7

4. First Goal of Treatment • Clinically significant decreases in serum triglycerides, total cholesterol, and increases in HDL have been observed with even modest weight loss (10%)9 • Improvement in blood pressure and insulin resistance occurs as well9 • Weight Loss Should Be the Initial Goal of Treatment in MetS!

5. Abdominal Obesity • To find an effective treatment, it is important to understand the role of abdominal obesity in MetS • The “pear shape” of Gynoid obesity is not associated with developing MetS • The “apple shape” of Android or Abdominal obesity is one of the defining characteristics of MetS and may be the cause of developing all of the other risk factors • The main difference is the metabolism of adipocytes depending on where they are distributed

6. Role of Stress and Cortisol in Abdominal Obesity • Chronic Stress leads to HPA axis dysregulation of cortisol and plasma levels stay elevated • The more metabolically active abdominal adipocytes are more responsive to chronically elevated levels of cortisol • As a glucocorticoid, cortisol has many effects on glucose metabolism: • Opposition of insulin • Inhibition of protein synthesis in peripheral tissues • Activates lipoprotein lipase which causes an accumulation of lipids in abdominal adipocytes

7. The Stress Link • Chronic stress contributes to MetS when the stress is frequent and the ability to cope is impaired4,6 • The HPA Axis becomes unresponsive to the physiologic diurnal variation • Blood levels of cortisol never return to basal levels after a period of stress6 • Animal studies have proven that a daily trough lasting several hours is necessary to prevent negative effects of excess cortisol on peripheral tissues8

8. Relationship Between Stress, Cortisol, and MetS • MetS is not just about weight loss - it is a complex syndrome with many causal factors • There is a strong relationship between chronically increased levels of cortisol due to stress and accumulation of fat in the abdominal region • Stress is an integral part of every day life for most people • Diet and Exercise may not be sufficient to correct the HPA axis dysfunction • Incorporating a stress-reducing therapy into the treatment of MetS may help to break the cycle of dysregulation and assist patients in losing the abdominal fat that is contributing to the syndrome

9. What Are the Stress-Reducing Options? • Massage Therapy • Music Therapy • Yoga • Qigong • Transcendental Meditation (Just to name a few…)

10. How do we measure Stress? • The intimate relationship between plasma cortisol levels, stress, and MetS suggests that measuring changes in cortisol production would be a consistent way of evaluating the efficacy of each therapy • Changes in plasma, salivary, or urinary cortisol levels can be measured

11. What Were the Findings? • Trials using Massage Therapy, Music Therapy, Yoga, Qigong, and TM all had positive findings for lowering cortisol levels • Most of the studies had other positive findings such as lowered blood pressure or better insulin utilization further supporting the benefits for Met S patients

12. Transcendental Meditation May Decrease Healthcare Costs • Numerous studies have shown the benefits of TM for lowering stress and improving the risk factors associated with MetS15 • What makes TM unique is that the cost-benefit of using TM for health improvement has actually been studied16 • 5 years of insurance claims by 2000 practitioners of TM were analyzed • They had 87% fewer inpatient admissions and outpatient visits for cardiovascular disease • The non-cardiovascular disease related visits did not change so there was no aversion to traditional medicine

13. Advantages and Disadvantages to each type of Relaxation Therapy

14. Conclusion • Alleviating chronic stress helps to normalize cortisol levels • Restoring balance decreases deleterious effects of cortisol excess on peripheral tissues • May help to lose the abdominal obesity - improves all aspects of the syndrome • Adding a relaxation method to diet and exercise may be the key to treatment success in Metabolic Syndrome – Only more research will tell

15. Sources • 1. Hadley, RD. Treatment options for metabolic syndrome. The Clinical Advisor. 2005 Nov;45-55. • 2. Levy D. Epidemiology of obesity and its cardiovascular consequences. Audio-Digest Special Topics. 2006 May;10(2). • 3. Nesto R. Metabolic syndrome and obesity. Audio-Digest Special Topics. 2006 Jun;10(3). • 4. Gans, RO. The metabolic syndrome, depression, and cardiovascular disease: interrelated conditions that share pathophysiologic mechanisms. Med Clin N Am. 2006;90:573-91. • 5. Hjemdahl, P. Stress and the metabolic syndrome: an interesting but enigmatic association. Circulation. 2002;106:2634. • 6. Bjorntorp P. Do stress reactions cause abdominal obesity and comorbidities? Obes Rev. 2001;2:73-86.

16. Sources • 7. Kushner R. Modest weight loss and cardiometabolic risk. Audio-Digest Special Topics. 2006 May;10(2). • 8. Jacobson L. Hypothalamic-pituitary-adrenocortical axis regulation. Endocrinol Metab Clin N Am. 2005;34:271-92. • 9. Borgman M, McErlean E. What is the metabolic syndrome? Prediabetes and cardiovascular risk. J Cardiovasc Nurs. 2006;21(4):285-90. • 10. Field T, Hernandez-Reif M, Diego M, Schanberg S, Kuhn C. Cortisol decreases and serotonin and dopamine increase following massage therapy. Int J Neurosci. 2005;115:1397-1413.

17. Sources • 11. Miluk-Kolasa B, Obminski Z, Stupnicki R, Golec L. Effects of music treatment on salivary cortisol in patients exposed to pre-surgical stress. Exp Clin Endocrinol. 1994;102(2):118-20. • 12. Innes KE, Bourguignon C, Taylor AG. Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with yoga: a systematic review. J Am Board Fam Pract. 2005;18:491-519. • 13. Lee MS, Lee MS, Kim HJ. Qigong reduced blood pressure and catecholamine levels of patients with essential hypertension. Int J Neurosci. 2003;113:1691-1701.

18. Sources • 14. Lee MS, Rim YH, Kang CW. Effects of external Qi-therapy on emotions, electroencephalograms, and plasma cortisol. Int J Neurosci. 2004;114:1493-1502. • 15. Paul-Labrador M, Polk D, Dwyer JH, Velasquez I, Nidich S, Rainforth M, et al. Effects of randomized controlled trial of transcendental meditation on components of the metabolic syndrome in subjects with coronary heart disease. Arch Intern Med. 2006;166:1218-1224. • 16. Waltonb KG, Schneider RH, Nidich S. Review of controlled research on the transcendental meditation program and cardiovascular disease. Cardiol in Review. 2004:12:262-6.