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Wednesday, January 22, 2003The enemy isn't a box of Krispy Kreme donuts. The enemy isn't a bag of Cheetos. The enemy isn't even super-sized french fries. The enemy is their own bodies, which unknown to them are producing far too much insulin, sending the wrong messages to their brains. It's a condition called Syndrome X and it affects almost 70 million (one in four) Americans. But if it isn’t the Krsipy Kreme donuts, the Cheetos, or the super-sized french fries, how do you explain the success of the treatment? Koehler has lost 55 pounds since she was diagnosed in April and went on a high-protein, low-carbohydrate diet. She's now able to wake up at 7:30 or 8 each morning, instead of her old rising time of 10:30 or 11. She runs errands, instead of staying homebound. She can stay up until midnight, instead of collapsing after her last piano lesson at 8 or 9. ``What you have to understand is that I'm not doing this to lose weight, I'm doing this to have a life,'' she said. That’s right folks, the treatment is to eat less. Reading this story reminded me of the professor I had in medical school who explained that we treat alcoholism as a disease now rather than a personal choice because alcoholics responded better to the disease model than to the moral model. Tell them it’s in the genes, that it’s a disease, and for some reason, they’re more motivated to change. They aren’t fighting themselves anymore, they’re fighting something “other”. That’s got to be why giving some people a diagnosis of “Syndrome X” helps them approach losing weight better. They still have to do the same things - exercise more and eat less - but they’re doing it to conquer a disease now. Instead of grappling with their willpower, they’re grappling with a diseased metabolism. There very well may be a physiological and metabolic basis for “Syndrome X,” or as it’s also known, insulin resistance syndrome, but, contrary to the assertions of the newspaper article, there’s no easy way to diagnose it: Unlike the diagnosis of overt diabetes, the biochemical diagnosis of insulin resistance syndrome is fraught with difficulties. The most accurate way to measure insulin resistance is the euglycemic insulin clamp technique, in which insulin is infused to maintain a constant plasma insulin level. Glucose is then infused and, as the plasma level falls because of the action of insulin, more glucose is added to maintain a steady level. The amount of glucose infused over time provides a measure of insulin resistance. This and similar methods are useful for research but are otherwise impractical. Use of fasting insulin levels has received some attention. Fasting insulin levels correlate well with the degree of insulin resistance. Unfortunately, measurement of fasting insulin is not widespread. Standard methods for performing the test have yet to be adopted, and criteria for normal and abnormal values have not been established. (You can read more about insulin levels here.) Because it's so difficult to accurately measure insulin levels, making the diagnosis of insulin resistance relies on soft clinical findings like symptoms and signs: The lack of practical, inexpensive, reliable serum tests means that the diagnosis of insulin resistance can, at best, be made on the basis of strong clinical suspicion. This is reasonable because the goal is to identify a condition whose treatment is neither risky nor expensive because it involves sensible lifestyle modifications and careful monitoring for the component diseases of the syndrome. At least, that was true until now. Now, some doctors, such as the one profiled in the newspaper article, are beginning to advocate the use of drugs to treat the syndrome: Once diagnosed, Syndrome X patients are put on a high-protein, low-carbohydrate diet, along with medications -- metformin (Glucophage) to increase the body's sensitivity to insulin and wellbutrin (Zyban) to help curb carbohydrate cravings. Generic metformin can cost from $33 to $55 a month, and its potential side effects, though rare, include anemia and a dangerous build up of lactic acid. Those are risks that are worth taking when it’s being used to treat a real disease such as diabetes, but is it worth it to lose weight? (Not coincidentally, one of its more common side effects is decreased appetite.) The generic version of Wellbutrin and Zyban (bupropion) costs from $49 to $66 a month. Potential side effects include seizures and irregular heart rhythms (also rare). Again, not coincidentally, one of the more common side effects is loss of appetite. These drugs may help people lose weight, but we should be cautious about advocating their life-long use for the treatment of a syndrome which owes its existence largely to theory. Advocate diet, advocate exercise, but save the drugs for real diseases. Needless to say, I declined to test my patient’s insulin levels or to put her on the drugs. I discussed diet and exercise with her, but she was clearly non-plussed. I should introduce her to my other patient who was given the diagnosis of Syndrome X by an endocrinologist at a tertiary care center. She went on both the drugs, but never has accepted the “eat less, exercise more” part, and has failed miserably. She still blames her body. Her endocrinologist has given up on her. Whenever I see her, she spends most of her appointment complaining that no one can (or will) help her. But until she realizes that the problem lies with her own choices, not the failure of medical science, no one ever will be able to help her. posted by Sydney on 1/22/2003 08:10:00 AM 0 comments 0 Comments: |
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