PI Brief Update

Metabolic Syndrome Controversies - Dr Mark Burgin

14/02/25. Dr Mark Burgin discusses why one of the most common and serious medical conditions is rarely diagnosed and prevention and treatment remains limited.

Metabolic syndrome impacts over 25% of the population and yet is largely unknown. Although everyone is familiar with the consequences of the condition (high blood pressure, cholesterol, diabetes) few sufferers are told of their diagnosis. Doctors have largely avoided using this diagnosis and are reluctant to discuss the condition.

The problem has arisen due to there being two competing theories explaining metabolic syndrome. The evidence is currently limited to support the toxic food theory of the metabolic syndrome although it has been popularised by some doctors in videos. Most people who have metabolic syndrome are unaware of their condition because of this controversy.

Doctors find it difficult to discuss controversies because it creates uncertainty in their patients. They also fear criticism from colleagues and the need to be seen as maintaining a professional image. With the metabolic syndrome these factors appear to be causing doctors to avoid mentioning the issue completely. The polarisation of beliefs could be due in part to the strength of the food and pharmaceutical industries.

Standard version

The standard description of metabolic syndrome focuses on a cluster of conditions that often occur together, increasing the risk of heart disease, stroke, and type 2 diabetes.

Key Features of Metabolic Syndrome:

• Visceral fat: Excess body fat around the organs leads to an imbalance in the production and function of adipokines, such as increased leptin and decreased adiponectin and this can cause increased activity of the sympathetic nervous system.
• Insulin Resistance: The insulin signalling pathways in various cell types (liver, muscle and fat) are impaired by metabolic changes and cytokines causing increased blood glucose and increased activity of the renin-angiotensin-aldosterone system (RAAS).
• Dyslipidaemia: Hight fat diet causes abnormal blood lipid levels, including high triglycerides and LDL and low "good" cholesterol (HDL).
• Blood vessel changes: Endothelial dysfunction from increased oxidative stress and inflammation causing impaired vasodilation, increased vascular resistance and deposits of LDL cholesterol as atherosclerotic plaques.

The standard version states that each of the consequences should be treated as a separate condition even though they are interlinked. The use of statins, anti-diabetic, anti-hypertensives, anti-obesity, gout medications and so on has been extraordinarily effective.

Toxic diet version

• The liver's metabolic function becomes impaired when overwhelmed by excessive inputs of hepatotoxic substances, such as trans fats, fructose, alcohol, and some synthetic additives. This overload disrupts crucial liver processes, leading to the accumulation of lipids and other metabolites within the liver. Consequently, the liver releases these metabolites into the bloodstream (ceramide, LDL cholesterol, uric acid) or bile (altered bile acid metabolism) and secretes inflammatory cytokines, causing the systemic changes characteristic of metabolic syndrome (adipokine imbalance, cellular insulin signalling pathways and the RAAS system).

The toxic diet theory suggests that the combination of multiple toxins overloads the liver. The correct treatment is reducing the combination of all these different chemicals. This would allow the liver to return to balance and correctly deal with the waste products. This in turn would allow the muscles and fat cells to return to balance and each of the consequences would reverse.

Communicating controversy

Medical understanding is always incomplete and there will always be a difference of opinion. Doctors often will avoid discussing the controversy either by stating one or other view as fact or simply avoiding the discussion completely. The failure to diagnose metabolic syndrome and communicate the consequences with patients is causing harm through poor engagement.

Patients who are told that they have blood pressure or high cholesterol will be sceptical as they feel well. They cannot understand how they could have got this disease and are understandably unhappy that they must take medication for the rest of their lives. Risk factors are generally managed poorly with the so-called law of halves (half are diagnosed, half of those are treated, half of the treated are to target).

There is substantial evidence that good communication can improve the patient engagement. Patients feel that they have a choice, that they understand why they are having problems and that they may have other issues. Metabolic syndrome affects many systems so a patient with blood pressure knows that they are more likely to have diabetes.

Conclusions

Doctors do not need to have the answer to the controversy in theories about metabolic syndrome to provide information to their patients. The failure to make a diagnosis of the condition is a breach whatever theory is eventually successful. Doctors must explain that sufferers will require a large combination of medications to prevent the complications. Patients will otherwise be resistant to medical advice which they see as over medicalising and giving them side effects for no benefit.

Patients will commonly contact lawyers when they develop serious complications often many years after the initial presentation. The date of knowledge is usually the date of the medical report which first diagnoses the missed metabolic syndrome. Few patients refuse treatment once they are aware of the diagnosis so any poor compliance is partly due to the GP. Some lawyers prefer to refer the GP to the GMC first as this can save the cost of litigation and makes repetition of the problem less likely.

There are two highly effective treatments for metabolic syndrome GLP-1 ‘fat’ injections and weight loss surgery. The latter has been available for decades but rationed so most patients who could have benefited have not had the treatment unless they went privately. GLP-1 treatments are being used inappropriately by those without metabolic syndrome and not by those with the condition. Each group could have a legal case for compensation if they suffer complications due to not knowing their diagnosis.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 websites drmarkburgin.co.uk and gecko-alligator-babx.squarespace.com

Disability Analysis: A Practical Guide by Mark Burgin | 18 Oct 2024

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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