Vexed by Syndrome X

Joseph Dell’Alba says he wasn’t looking for “eternal life.” But the 76-year-old, semiretired businessman was looking for a better way to deal with his heart disease. For almost two decades he had been bouncing in and out of the hospital for bypass surgery, angioplasty and medication. Dell’Alba had gotten to the point where it was a struggle to walk the 200 feet to his mailbox in rural Pennsylvania.

Fed up and discouraged by conventional treatment, last May Dell’Alba tried a new nutrition-oriented doctor who told him that the root of his problems was his high insulin levels. With no history of diabetes in his family, Dell’Alba was shocked that he now had a new thing to worry about along with his elevated triglycerides, high blood pressure and blocked arteries.

But Dell’Alba religiously stayed away from pasta and fruit, loaded up on olive oil, cod liver oil, fish, lean meat and nonstarchy vegetables, and took lots of supplements. Less than a year into his regimen, Dell’Alba’s insulin levels have plummeted along with his blood pressure, triglycerides and weight.

Dell’Alba suffers from the scary-sounding condition Syndrome X, also known by the more prosaic term insulin resistance syndrome, a well-documented metabolic disorder that some experts say is a too-often-forgotten key in the treatment of a range of disorders, especially heart disease and stroke.

When diabetics are diagnosed, they quickly learn about their bodies’ glucose metabolism problems and that they are at greater risk for heart disease. But Stanford University’s Dr. Gerald Reaven, author of the recent book “Syndrome X: Overcoming the Silent Killer That Can Give You a Heart Attack,” estimates that 25% of the nondiabetic population in this country also has glucose metabolism problems, though most don’t know it. They are, however, at risk for the panoply of conditions that characterize Syndrome X, including high triglycerides, high blood pressure and low levels of HDL (“good”) cholesterol.

Doctors routinely screen and treat patients for those heart risk conditions. But they often do not recognize and treat these patients’ faulty glucose metabolism. That is a mistake, says Boulder, Colo.-based Dr. Ron Rosedale, who is Dell’Alba’s physician. When you treat the risk factors without dealing with the glucose metabolism problems underlying those symptoms, he says, “it’s like pulling out the dandelions by the leaves and not by the roots. It’ll come back.”

The root of Syndrome X is insulin resistance--that is, difficulty utilizing insulin, and “hyperinsulinemia,” or high levels of insulin. Type 2, or adult-onset, diabetics also suffer from insulin resistance, but they have lost the ability to regulate their blood sugar levels.

Those suffering from Syndrome X have workhorse pancreases that pump out extra insulin to compensate for the body’s sluggish ability to process it. That extra insulin forces the blood sugar down, but at a price, says Reaven. “Excess insulin in the bloodstream prompts the damage associated with Syndrome X,” Reaven says. In addition, Syndrome X sufferers are at risk for developing diabetes when their overworked pancreases give out. Yet they often fall through the diagnostic cracks because doctors typically screen for elevated glucose levels that characterize diabetes, but not for insulin resistance and the high insulin levels that characterize Syndrome X.

It was Reaven who in 1988 first identified the link between a number of heart disease risk factors and insulin resistance coupled with compensatory hyperinsulinemia. He suggested the name “Syndrome X” to stress the still unknown nature of the condition. The heart attack risk factors that he linked to insulin resistance at the time were high blood pressure, high triglycerides and low HDL cholesterol levels. Since then the list of risk factors linked to Syndrome X has grown to include abnormal (smaller and denser) LDL cholesterol particles, slow clearing of blood fats after meals and decreased ability to break up clots. Not all patients exhibit all of those abnormalities and the luckier ones, with milder cases, may exhibit only a few.

*

There are now a number of studies corroborating Reaven’s work. The long-term Quebec Cardiovascular study, for example, found that men with the Syndrome X symptoms of high insulin levels, small dense LDL particles and another lipid abnormality, elevated apolipoprotein B, were 20 times more likely to develop heart disease than those without those conditions.

Yet in clinical practice, many doctors still look at their heart patients through what Reaven terms “cholesterol-colored glasses.” The focus is still on lowering LDL levels and overall cholesterol levels with drugs and a diet low in saturated fat. Those are laudatory goals, says Reaven, but they are not an adequate treatment plan for Syndrome X patients who may, for example, have normal LDL cholesterol levels. Says Reaven, “Trying to explain heart disease by one factor, the cholesterol count, does not give an adequate picture of all known risks.”

In addition to heart disease, researchers have also found an intriguing link between some of the symptoms of Syndrome X and cancer. A recent University of Toronto study found that women with breast cancer and high levels of insulin were eight times more likely to develop a recurrence and die of the disease than were women who had normal insulin levels. Researchers at the State University at Buffalo found that women with Syndrome X symptoms were 10 times more likely to die of colon cancer than women who didn’t have those symptoms. Concludes University at Buffalo professor Dr. Paola Muti: “The most common cancers in our population have somehow very similar determinants, and these determinants are very much related to glucose metabolism.”

Of course, these studies do not show that Syndrome X causes cancer. But the cancer and heart studies do suggest that lowering insulin levels and decreasing insulin resistance could be a smart preventive health measure. For that reason an increasing though still small number of doctors advocate routine screening for hyperinsulinemia. Rosedale orders up lots of lab tests for his patients, including ones that check cholesterol levels, but none with more zeal than a test for insulin levels: “It is by far the single most important laboratory criterion of health,” says Rosedale.

Reaven, on the other hand, doesn’t recommend widespread screening for insulin levels because he says the measurements are difficult to make and results vary from lab to lab. He advocates screening for insulin resistance indirectly by checking for elevated blood pressure, triglycerides and low HDL: “If those are normal, the chances of your being insulin resistant are very low.”

Even more controversial than how to screen for Syndrome X is what kind of diet to prescribe to treat it. Reaven and others believe that high-carbohydrate diets make Syndrome X worse by continuously spiking insulin levels. They advocate cutting down on carbohydrates and replacing them with “good” fats such as fish oil, olive oil and cod liver oil. The American Heart Assn.’s new dietary guidelines for the first time cite specific recommendations for those with Syndrome X, warning patients away from very low-fat, high-carbohydrate diets and suggesting they instead eat more “good” fats.

Some bestselling low-carbohydrate diet gurus recommend even lower levels of carbohydrates and higher levels of fat, including saturated fat, than does the AHA. Reaven and others attack diets that promote such foods as cheeseburgers and bacon. The Atkins diet, for example, created by cardiologist Dr. Robert Atkins, restricts carbohydrates but lets dieters eat lots of meat and eggs.

Colette Heimowitz, director of education at Atkins Health and Medical Information Services, counters that when carbohydrates are restricted, “the rules change.” According to Heimowitz, patients do not suffer ill effects from high saturated fat in their diet as long as they avoid most carbohydrates.

At the other end of the spectrum, cardiologist Dr. Dean Ornish says his low-fat, high-carbohydrate diet is the only one backed up by rigorous studies that prove that it can reverse heart disease. Ornish says his diet works even for those suffering from Syndrome X because the focus is on fiber-laden complex carbohydrates that are absorbed slowly, thus preventing insulin spikes. Syndrome X sufferers do need to be especially vigilant about avoiding sugar, white flour and alcohol, but they have no reason to avoid fiber-rich, complex carbohydrates, according to Ornish. Ornish fears that the new focus on Syndrome X will “dissuade people from making changes we have proven can help them.” In fact, he adds, hearing about unsubstantiated diet cures for Syndrome X “makes me want to tear my hair out.”

While some experts in the throes of the passionate debate over what Syndrome X patients should eat tear out their hair, others stress that diet is only part of the treatment picture. Dr. Scott Grundy, director of the Center for Human Nutrition at the University of Texas Southwestern Medical Center, who is leading an international study on the genetics of Syndrome X, comes down on the side of those who advocate fewer carbohydrates for Syndrome X patients. But he cautions that diet is “only one factor” and not the most important one affecting the syndrome. “The more important factors are genetics, obesity and physical activity.”

While there’s little you can do about lousy genes, experts on all sides of the diet debate agree with Grundy that exercise and losing weight are proven methods of improving insulin resistance and thus worthy goals for Syndrome X sufferers. Not all Syndrome X patients are obese or even overweight, and not all obese Americans have Syndrome X. But, says Reaven, “if you’re overweight and sedentary and have bad genes, you’re likely going to be insulin resistant” and thus be at risk for Syndrome X.

*

Given this country’s epidemic obesity rates and declining fitness levels, there is no sign that the at-risk population is going to start losing weight and exercising regularly any time soon. That has researchers worrying about a parallel epidemic of insulin resistance that puts even more people, including children, at risk for Syndrome X. One ominous University of North Carolina at Chapel Hill study last year found that children with three Syndrome X characteristics--high insulin levels, high blood pressure and elevated triglycerides or low levels of HDL--were 53 times more likely to be obese than those without such risk factors.

It is easy to advise obese children and adults to cut back on calories and exercise more, but Heimowitz for one recommends compassion and specially tailored diets for those whose genetics work against their efforts at lowering their weight and thus decreasing their insulin resistance. “It is usually our insulin-resistant patients who have tried every diet and nothing helps. It’s heart-wrenching. They’re starving all the time. They’re obsessed with food. They can’t control their portions.”

Some argue that the genetically unfortunate need extra help from supplements as well as an improved diet. A new book co-authored by Dr. Burton Berkson, “Syndrome X: The Complete Nutritional Program to Prevent and Reverse Insulin Resistance,” recommends vitamins C and E, the herb silymarin and cinnamon sprinkled on food to improve insulin sensitivity.

But the hottest anti-Syndrome X supplement is alpha lipoic acid (ALA), a vitamin-like nutrient found in many foods. Dr. Robert Sherwin, president of the American Diabetes Assn., is awaiting the results of ongoing clinical trials before he recommends ALA to his patients. But Berkson, who has been interested in ALA since the 1970s--when the Food and Drug Administration gave him the investigational drug permit for intravenous ALA therapy--says it lowers glucose and insulin levels, reduces insulin resistance and has been used for years to treat diabetic complications.

Dell’Alba takes ALA twice a day and appreciates nontraditional doctors who reach for supplements if possible before drugs. Dell’Alba has lost 40 pounds, eats a third of what he once did and no longer feels the need to constantly snack, now that he follows a low carbohydrate, high “good” fats diet. Though Dell’Alba still takes a reduced dosage of one blood pressure medication, he says it is diet, exercise and supplements that have changed his life, though they are subjects he heard almost nothing about from the traditional doctors who treated him for heart disease. Neither did he hear anything from them about Syndrome X, a diagnosis that at first seemed like one more burden, but now, he believes, explains his once debilitating health problems and offers the key to improving them.