A practical approach to the metabolic syndrome: review of current concepts and management

Innovative strategies to predict and prevent the risk for malnutrition in child, adolescent, and young adult cancer survivors

Children, adolescents, and young adult cancer survivors (CAYAs) constitute a growing population requiring a customized approach to mitigate the incidence of severe complications throughout their lifetimes. During cancer treatment, CAYAs cancer survivors undergo significant disruptions in their nutritional status, elevating the risks of mortality, morbidity, and cardiovascular events. The assessment of nutritional status during cancer treatment involves anthropometric and dietary evaluations, emphasizing the necessity for regular assessments and the timely identification of risk factors. Proactive nutritional interventions, addressing both undernutrition and overnutrition, should be tailored to specific age groups and incorporate a family-centered approach. Despite encouraging interventions, a notable evidence gap persists. The goal of this review is to comprehensively examine the existing evidence on potential nutritional interventions for CAYAs cancer survivors. We explore the evidence so far collected on the nutritional intervention strategies elaborated for CAYAs cancer survivors that should target both undernutrition and overnutrition, being age-specific and involving a family-based approach. Furthermore, we suggest harnessing artificial intelligence (AI) to anticipate and prevent malnutrition in CAYAs cancer survivors, contributing to the identification of novel risk factors and promoting proactive, personalized healthcare.

Osteoporosis in Childhood Cancer Survivors: Physiopathology, Prevention, Therapy and Future Perspectives

The improvement of chemotherapy, radiotherapy, and surgical interventions, together with hematopoietic stem cell transplantation, increased childhood cancer survival rate in the last decades, reaching 80% in Europe. Nevertheless, anti-cancer treatments are mainly responsible for the onset of long-term side effects in childhood cancer survivors (CCS), including alterations of the endocrine system function and activity. In particular, the most frequent dysfunction in CCS is a metabolic bone disorder characterized by low bone mineral density (BMD) with increased skeletal fragility. BMD loss is also a consequence of a sedentary lifestyle, malnutrition, and cancer itself could affect BMD, thus inducing osteopenia and osteoporosis. In this paper, we provide an overview of possible causes of bone impairment in CCS in order to propose management strategies for early identification and treatment of skeletal fragility in this population.

Metabolic and inflammatory functions of cannabinoid receptor type 1 are differentially modulated by adiponectin

BACKGROUND

Antagonists of cannabinoid type 1 receptor (CB1) have been shown to promote body weight loss and improve insulin sensitivity. Cannabinoids decrease adiponectin, and CB1 blocker increase adiponectin. However, the mediators of CB1 actions are not well defined.

AIM

To investigate whether the beneficial effects of CB1 inhibition are, at least in part, mediated by adiponectin.

METHODS

We compared metabolic and inflammatory phenotypes of wild-type (WT) mice, CB1-null (CB1 -/-) and CB1/adiponectin double-knockout (DKO) mice. We assessed the insulin sensitivity using insulin tolerance test and glucose tolerance test, and inflammation using flow cytometry analysis of macrophages.

RESULTS

CB1 -/- mice exhibited significantly reduced body weight and fat mass when compared to WT mice. While no significance was found in total daily food intake and locomotor activity, CB1 -/- mice showed increased energy expenditure, enhanced thermogenesis in brown adipose tissue (BAT), and improved insulin sensitivity compared to WT mice. DKO showed no difference in body weight, adiposity, nor insulin sensitivity; only showed a modestly elevated thermogenesis in BAT compared to CB1 -/- mice. The metabolic phenotype of DKO is largely similar to CB1 -/- mice, suggesting that adiponectin is not a key mediator of the metabolic effects of CB1. Interestingly, CB1 -/- mice showed reduced pro-inflammatory macrophage polarization in both peritoneal macrophages and adipose tissue macrophages compared to WT mice; in contrast, DKO mice exhibited increased pro-inflammatory macrophage polarization in these macrophages compared to CB1 -/- mice, suggesting that adiponectin is an important mediator of the inflammatory effect of CB1.

CONCLUSION

Our findings reveal that CB1 functions through both adiponectin-dependent and adiponectin-independent mechanisms: CB1 regulates energy metabolism in an adiponectin-independent manner, and inflammation in an adiponectin-dependent manner. The differential effects of adiponectin on CB1-mediated metabolic and inflammatory functions should be taken into consideration in CB1 antagonist utilization.

Nutritional interventions for survivors of childhood cancer

BACKGROUND

Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health-promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health-protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases.

OBJECTIVES

The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost-effectiveness of the intervention

SEARCH METHODS

We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers - the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) - reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long-Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We used the GRADE criteria to assess the quality of each trial.

MAIN RESULTS

Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow-up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies.There was no clear evidence of a difference in calcium intake at one month between those who received the single, half-day, group-based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) -258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self-efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one-month follow-up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self-reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face-to-face, group-based, health behaviour session.There was no clear evidence of a difference in bone density Z-scores measured with a dual-energy X-ray absorptiometry (DEXA) scan at 36 months follow-up (MD -0.05, 95% CI -0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12-month (median difference -0.17, P = 0.99) and 24-month follow-up (median difference -0.04, P = 0.54).A single multi-component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow-ups brought about a 0.17 lower score on the four-point Likert scale of self-reported junk food intake compared with the control group (MD -0.17, 95% CI -0.33 to -0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self-reported use of nutrition as a health protective behaviour (MD -0.05, 95% CI -0.24 to 0.14; P = 0.60, low quality evidence).

AUTHORS' CONCLUSIONS

Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population.

Metabolic syndrome and neurotrophins: effects of metformin and non-steroidal antiinflammatory drug treatment

OBJECTIVE

Metabolic syndrome (MS) presents with central obesity, impaired glucose metabolism, dyslipidemia and hypertension. Our aim was to examine the effect of metformin treatment either alone or in combination with non-steroidal anti-inflammatory drugs (NSAID) on plasma levels of nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) in patients with early stage MS (MS-es) and generalized MS (MS-ge).

MATERIALS AND METHODS

The study compared 35 female patients with MS-es (mean age of 43.39±1.54 years) and 40 patients with MS-ge (mean age of 45.69±2.18 years) to 10 age-matched controls each. Patients with MS-es were administered 850 mg metformin twice daily. The patients with MS-ge were divided into two groups of 20 patients per group. One group received metformin alone, while the other group received metformin in combination with 500 mg aspirin and 150 mg Diclac daily. Plasma NGF and BDNF levels were measured by ELISA. Statistical data analysis was performed using ANOVA.

RESULTS

Plasma NGF and BDNF levels were significantly higher in MS-es patients and lower in MS-ge patients than in controls. NGF levels were decreased in both groups after treatment with metformin. NGF levels were significantly higher in MS-ge patients on combined therapy than in those on metformin only.

CONCLUSION

The combination of metformin and NSAID treatment is more effective than metformin alone on NGF and BDNF production as well as on metabolism-related anthropometric and laboratory features. This represents a pathogenetic therapeutic mechanism in MS due to its strong anti-inflammatory effect and improves MS-ge symptoms.

A meta-analysis of body mass index of adolescent and adult survivors of pediatric acute lymphoblastic leukemia

PURPOSE

We conducted a meta-analysis of existing studies to examine body mass index (BMI) of adolescent and adult survivors of pediatric acute lymphoblastic leukemia (ALL) compared to individuals without cancer.

METHODS

Studies were identified and reviewed using specific inclusion criteria. The effect size was odds ratio (OR) of the prevalence of overweight/obese BMI (≥ 25 kg/m(2)) in ALL survivors versus comparison groups. Study data were coded and validated. Fixed-effects (FE) and random-effects (RE) estimates of the effect size were estimated.

RESULTS

A total of 9 studies met our inclusion criteria. Survivors were more likely to be overweight/obese compared to comparison groups (FE OR = 1.12, 95% CI 1.06-1.18 and RE OR = 1.28, 95% CI 1.07-1.53). When limited to studies from North American samples, female survivors were overweight/obese more often than the comparison groups (FE OR = 1.30, 95% CI 1.19-1.43).

CONCLUSIONS

Adolescent and adult survivors of pediatric ALL, especially female survivors, may be at a higher risk of being overweight/obese compared to individuals without cancer. However, few studies provided detailed information on patient and treatment factors (e.g., cranial radiation) that can impact BMI. Standardized reporting of study content is vital for providing robust information on the risk of developing late effects among cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Adolescent and adult survivors of pediatric ALL require additional weight management resources such as targeted counseling for physical activity and dietician support both early in treatment and after the end of their therapy. Female survivors may need additional guidance to develop healthy eating practices and to participate in exercise programs.

Effect of Diamel in patients with metabolic syndrome: a randomized double-blind placebo-controlled study

BACKGROUND

The aim of the present study was to determine whether the administration of Diamel, marketed as a food supplement by Catalysis Laboratories (Madrid, Spain) could improve any of the components of metabolic syndrome (MS), as well as insulin resistance and sensitivity.

METHODS

In all, 100 patients with MS (19-70 years of age) who satisfied the World Health Organization criteria for MS were included in the study. Participants were randomly assigned to receive either oral Diamel or a placebo (while maintaining a diet appropriate to their weight and physical activity) at a dose of two capsules before each of the three main meals each day for 1 year. Anthropometric indices, blood pressure, fasting plasma glucose, lipid profile, insulin, creatinine, and uric acid (UA) were determined. Insulin resistance (IR) was assessed and three indirect indices were used to calculate insulin sensitivity (IS).

RESULTS

Compared with placebo, Diamel improved fasting insulin concentrations, IS, and IR and reduced UA concentrations from 6 months until the end of treatment (P < 0.05 for all). In addition, after 12 months treatment with Diamel, significant changes from baseline were seen for mean fasting insulin (P < 0.05), UA (P < 0.05), IR (P < 0.001), and IS (P < 0.001), whereas no such changes were seen in the placebo-treated group. Improvements were noted in body mass index, IR, and IS in both groups.

CONCLUSIONS

Long-term Diamel treatment, combined with lifestyle changes, was beneficial for IR and IS, and reduced serum UA levels in patients with MS.

Management of dyslipidemias in the presence of the metabolic syndrome or type 2 diabetes

In the metabolic syndrome and type 2 diabetes, excess energy intake on the background of genetic predisposition and lifestyle factors leads to the dysregulation of fatty acid metabolism and acquired insulin resistance. These initial metabolic defects are reflected to both lipoprotein and glucose metabolism and contribute to increased risk for cardiovascular disease. However, even after controlling for the traditional cardiovascular risk factors, subjects with the metabolic syndrome and type 2 diabetes remain at high residual cardiovascular risk despite of low/normal LDL-cholesterol concentration. For 2 decades, statin therapy has been the cornerstone of treatment of dyslipidemia in these disorders. In the metabolic syndrome and type 2 diabetes, only statin treatment has demonstrated consistently a significant reduction in cardiovascular and all cause mortality in clinical trials. Lately, increased incidence of diabetes especially in the high-risk populations using statins has raised the debate whether statins are indicated for primary prevention especially in the metabolic syndrome. Guidelines recommend intensified lifestyle intervention to those in high risk groups on statin therapy to reduce the residual risk. Despite of the proven efficacy on plasma lipids, fibrate, or niacin as monotherapy, or in combination with statins has failed in reducing cardiovascular mortality. This underlies the fact that improvement in dyslipidemia or other biomarkers is not equal to the reduction in cardiovascular events. However, fibrates in combination with statins seem to be beneficial to reduce CVD events in subjects with low HDL-cholesterol (< 0.9-1.1 mmol/L) and elevated triglycerides (> 2.3 mmol/L), but the data are derived from subgroup analysis of clinical trials. The position of niacin and ezetimibe and omega-3 fatty acids in treatment of dyslipidemia in the metabolic syndrome and type 2 diabetes is even less clear and remains to be established in future clinical trials.

The whey fermentation product malleable protein matrix decreases TAG concentrations in patients with the metabolic syndrome: a randomised placebo-controlled trial

Animal and human studies suggest that a malleable protein matrix (MPM) from whey decreases plasma lipid concentrations and may positively influence other components of the metabolic syndrome such as glucose metabolism and blood pressure (BP). The primary objective of this double-blind, multi-centre trial was to investigate the effects of a low-fat yoghurt supplemented with whey MPM on fasting TAG concentrations in patients with the metabolic syndrome. A total of 197 patients were randomised to receive MPM or a matching placebo yoghurt identical in protein content (15 g/d). Patients were treated during 3 months with two daily servings of 150 g yoghurt each to compare changes from baseline in efficacy variables. MPM treatment resulted in a significantly larger reduction of TAG concentrations in comparison to placebo (relative change -16%, P=0·004). The difference was even more pronounced in subjects with elevated fasting TAG (≥200 mg/dl) at baseline (-18%, P=0·005). The relative treatment difference in fasting plasma glucose was -7·1 mg/dl (P=0·089). This effect was also more pronounced in subjects with impaired fasting glucose at baseline (-11 mg/dl, P=0·03). In patients with hypertension, the relative treatment difference in systolic BP reached -5·9 mmHg (P=0·054). The relative treatment difference in body weight was -1·7 kg (P=0·015). The most common adverse events were gastrointestinal in nature. Conclusions from the present study are that consumption of a low-fat yoghurt supplemented with whey MPM twice a day over 3 months significantly reduces fasting TAG concentrations in patients with the metabolic syndrome and improves multiple other cardiovascular risk factors.

Ezetimibe therapy: mechanism of action and clinical update

The lowering of low-density lipoprotein cholesterol (LDL-C) is the primary target of therapy in the primary and secondary prevention of cardiovascular events. Although statin therapy is the mainstay for LDL-C lowering, a significant percentage of patients prescribed these agents either do not achieve targets with statin therapy alone or have partial or complete intolerance to them. For such patients, the use of adjuvant therapy capable of providing incremental LDL-C reduction is advised. One such agent is ezetimibe, a cholesterol absorption inhibitor that targets uptake at the jejunal enterocyte brush border. Its primary target of action is the cholesterol transport protein Nieman Pick C1 like 1 protein. Ezetimibe is an effective LDL-C lowering agent and is safe and well tolerated. In response to significant controversy surrounding the use and therapeutic effectiveness of this drug, we provide an update on the biochemical mechanism of action for ezetimibe, its safety and efficacy, as well as the results of recent randomized studies that support its use in a variety of clinical scenarios.

Metabolic Syndrome versus Framingham Risk Score for Association of Self-Reported Coronary Heart Disease: The 2005 Korean Health and Nutrition Examination Survey

BACKGROUND

Several studies in Western populations have indicated that metabolic syndrome (MetS) is inferior to the Framingham risk score (FRS) in predicting coronary heart disease (CHD). However there has been no study about the predictability of MetS vs. FRS for CHD in Korea.

METHODS

Among the 43,145 persons from the third Korea National Health and Nutrition Examination Survey in 2005, laboratory test and nutritional survey data from 5,271 persons were examined. Participants were also asked to recall a physician's diagnosis of CHD.

RESULTS

The median age was 46 (range, 20 to 78) in men (n=2,257) and 44 (range, 20 to 78) years in women (n=3,014). Prevalence of self-reported CHD was 1.7% in men and 2.1% in women. Receiver operating characteristic curves and their respective area under the curve (AUC) were used to compare the ability of the FRS and the number of components of MetS to predict self-reported CHD in each sex. In men, AUC of FRS was significantly larger than that of MetS (0.767 [0.708 to 0.819] vs. 0.677 [0.541 to 0.713], P<0.01). In women, AUC of FRS was comparable to that of MetS (0.777 [0.728 to 0.826] vs. 0.733 [0.673 to 0.795]), and was not significant.

CONCLUSION

The data suggested that FRS was more closely associated with CHD compared to MetS in Korean men.

Moderate-to-high-intensity training and a hypocaloric Mediterranean diet enhance endothelial progenitor cells and fitness in subjects with the metabolic syndrome

A reduction in EPC (endothelial progenitor cell) number could explain the development and progression of atherosclerosis in the MetS (metabolic syndrome). Although much research in recent years has focused on the Mediterranean dietary pattern and the MetS, the effect of this diet with/without moderate-to-high-intensity endurance training on EPCs levels and CrF (cardiorespiratory fitness) remains unclear. In the present study, the objective was to assess the effect of a Mediterranean diet hypocaloric model with and without moderate-to-high-intensity endurance training on EPC number and CrF of MetS patients. Thus 45 MetS patients (50–66 years) were randomized to a 12-week intervention with the hypocaloric MeD (Mediterranean diet) or the MeDE (MeD plus moderate-to-high-intensity endurance training). Training included two weekly supervised sessions [80% MaxHR (maximum heart rate); leg and arm pedalling] and one at-home session (65–75% MaxHR; walking controlled by heart rate monitors). Changes in: (i) EPC number [CD34+KDR+ (kinase insert domain-containing receptor)], (ii) CrF variables and (iii) MetS components and IRH (ischaemic reactive hyperaemia) were determined at the end of the study. A total of 40 subjects completed all 12 weeks of the study, with 20 in each group. The MeDE led to a greater increase in EPC numbers and CrF than did the MeD intervention (P≤0.001). In addition, a positive correlation was observed between the increase in EPCs and fitness in the MeDE group (r=0.72; r2=0.52; P≤0.001). Body weight loss, insulin sensitivity, TAGs (triacylglycerols) and blood pressure showed a greater decrease in the MeDE than MeD groups. Furthermore, IRH was only improved after the MeDE intervention. In conclusion, compliance with moderate-to-high-intensity endurance training enhances the positive effects of a model of MeD on the regenerative capacity of endothelium and on the fitness of MetS patients.