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Evaluating metabolic syndrome in a medical

physiology laboratory
Bruce Martin, John B. Watkins, III and J. W. Ramsey

Advan Physiol Educ 28:195-198, 2004. doi:10.1152/advan.00017.2004
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Pizza and pasta help students learn metabolism
R. M. Passos, A. B. Se, V. L. Wolff, Y. K. M. Nobrega and M. Hermes-Lima
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Advances in Physiology Education is dedicated to the improvement of teaching and learning physiology, both in specialized
courses and in the broader context of general biology education. It is published four times a year in March, June, September and
December by the American Physiological Society, 9650 Rockville Pike, Bethesda MD 20814-3991. Copyright © 2005 by the
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Biochemistry .. Triglycerides
Medicine .. Fitness (Physical Activity)
Medicine .. Cholesterol
Medicine .. Metabolic Syndrome X
Medicine .. Exercise
Medicine .. Obesity

Finally. A second one-third of the class is asked to follow a Step I diet of the National Cholesterol Education Program (NCEP). . The final one-third of the class must comply with the NCEP Step II diet. which is the exercise described in this study. are made by students on each other. Student-selected lunch. Bruce. is a major and increasingly prevalent disorder in the developed world. physical activity estimates. Consent was obtained after the completion and assignment of grades in this course. or constrained to the National Cholesterol Education Program Step I or Step II diets. Rm 200. and abdominal obesity (14)] are readily determined. Bloomington. Ramsey. this laboratory is well suited to a teaching strategy designed to directly involve students. Watkins III. the National Heart. Indiana Univ. student-measured blood pressure records are obtained and are later included in this laboratory. triglyceride. Venous blood collection and analysis. 9.Adv Physiol Educ 28: 195–198. Martin. doi:10. To address this issue. Class members were randomized to groups allowed ad libitum meal composition. During weeks four and five. hypertension. IN 47405 (E-mail: martin1@indiana. Ca2⫹. and J. in physicians more secure in their nutritional knowledge (9). together with a lunch that required complete nutritional analysis. METHODS Informed consent. blood pressure. high-density lipoprotein cholesterol. All measurements.org on August 12. including blood draws. a cluster of factors linked to obesity that contribute to risk for atherosclerosis and Type 2 diabetes. John B. The two primary risk factors for development of the metabolic syndrome apart from genetic factors are overweight/ obesity and physical inactivity. creatinine. Thirty-five students signed informed consent forms to allow their data. students learn to draw venous blood samples from each other. W. accepted in final form 23 August 2004. The exercise takes place on one afternoon of a 14-week physiology laboratory and problem-based learning component of the first-year medical and graduate student curriculum. highdensity lipoprotein (HDL) cholesterol. 2004. Adv Physiol Educ 28: 195–198. may affect 20–25% of the adults in the United States. Na⫹. Evaluating metabolic syndrome in a medical physiology laboratory. John B. dietary fiber. understanding the physiological and nutritional aspects of the metabolic syndrome is of fundamental importance for their future medical practice (4). cholesterol.00017. Jordan Hall. We incorporated nutritional analysis in part because ⬎50% of graduating medical students in the United States describe their medical education coverage of nutrition as inadequate (7). These basic 1043-4046/04 $5. Cl⫺. The data returned from Bloomington Hospital were given to students the next week (week six). to illustrate nutritional factors involved in causation and treatment of the metabolic syndrome.edu). HDL cholesterol. Participants agreed to allow their data to be included in published mean group data. and atherogenic dyslipidemia (4. and glucose. Fasting blood samples from weeks four and five are analyzed at Bloomington Hospital for a lipids panel (cholesterol. Teaching in the Laboratory Evaluating metabolic syndrome in a medical physiology laboratory Bruce Martin.1152/advan. 2004.2004. insulin resistance. malnutrition THE METABOLIC SYNDROME. A third party eliminated the data from those individuals who did not consent. goals that enhance student interest and motivation (16).00 Copyright © 2004 The American Physiological Society 195 Downloaded from ajpadvan. One-third of the students are allowed any food choices whose total caloric content does not exceed the allowable lunch total. We designed a laboratory that also addressed each of the latter two factors by including assessment of physical activity and body fatness. During week two of this block. On the morning before this afternoon laboratory. and triglycerides). These procedures were reviewed and approved by the Bloomington campus Institutional Review Board of Indiana University. and carbohydrate content) was discussed in the context of blood cholesterol. meal selection and analysis. K⫹. central obesity) were measured by students on each other either previously or during this exercise. This laboratory allows a comprehensive analysis of the physiological and nutritional factors involved in the development of the metabolic syndrome. low-density lipoprotein cholesterol. and Blood Institute of the National Institutes of Health has initiated the Nutrition Academic Award program to develop strategies for implementation and integration of nutritional education into the medical curricula (11). W. and determinations of body fatness. The design of this laboratory allows new nutritional information to be readily integrated into existing curricula (13. as obtained in a class laboratory exercise in medical physiology. while under the supervision of a registered nurse and a trained phlebotomist (5). In contrast to the ad libitum food choices given to this first group. We designed a medical physiology laboratory to evaluate and discuss the physiological and nutritional principles involved in the metabolic syndrome. a meal was provided during the laboratory.physiology. Their lunch caloric content is then restricted to a maximum of one-third of estimated daily caloric expenditure. 15). Lung. and then presented the investigators with the remaining data without identifiers. The class consisted of first-year medical students and graduate students. blood pressure. Watkins III. meal composition is further constrained in the remainder of the class. and a basic metabolic panel [including blood urea nitrogen. obesity. with no individual data or identifiers to be used. which limits saturated fat to ⬍7% of total calories and cholesterol to ⬍200 mg/day (⬍70 mg for this meal) (14). to be included in this publication. bicarbonate (measured as total CO2). glucose. electrolytes.00017. This condition is suitable for study in a first-year medical physiology laboratory since the five variables used for diagnosis [fasting blood triglyceride. In addition. and J. 2006 Martin. This design creates personal as well as professional ties to the material. and glucose levels. cholesterol. Indiana 47405 Submitted 1 June 2004. doi:10. The diet should also contain ⬎55% carbohydrate calories and ⬎15% of dietary calories as protein (14). Ramsey Medical Sciences Program..— The metabolic syndrome.2004. Improved nutritional training results Address for reprint requests and other correspondence: B. and albumin].1152/advan. students are given a standard equation for estimation of daily caloric expenditure (1). 14). and data analysis began only after obtaining consent. The five criteria used to diagnose this syndrome (fasting blood triglycerides. and glucose levels. total protein. The composition of the diet (including saturated fat. Indiana University School of Medicine. The Step I diet limits saturated fat to ⬍10% of total calories and cholesterol to ⬍300 mg/day (⬍100 mg for this meal). a condition characterized by central obesity. Bloomington. For medical students.

and insulin resistance (4. g Na⫹ content. and the class mean results from the five noninvasive indexes of body fatness and malnutrition are shown in Table 4. was determined from arm circumference and triceps skinfold and compared with data from National Health and Nutrition Examination Surveys (12). Meal composition Kilocalories Fat calories. n ⫽ 35 subjects. are shown in Table 1. risk factors for insulin resistance. Four other simple. and ⬎35 inches (88 cm) in females (3). Step I. For many young adults this is their first exposure to a therapeutic diet. Second. 9. % total Kcal Cholesterol. Table 2. the National Heart. 680⫾200 29⫾11 10⫾4 24⫾11 82⫾37 1. 2006 The mean lipid levels in the class of 35. area. ⱕ50 mg/dl (females). Because McDonald’s USA provides the most extensive nutritional information in the Bloomington. HDL. It also shows saturated fat and cholesterol contents of self- DISCUSSION . % total Kcal Cholesterol. midarm muscle area. n ⫽ 35 subjects. The primary causes of and treatments for the metabolic syndrome include dietary and nutritional factors. Lung. Third.org on August 12. including central obesity. and vitamins A and C. Evaluation of the features of the metabolic syndrome leads directly to consideration of the triglycerideand cholesterol-lowering diets followed by the students. Diet composition. noninvasive estimates of body fatness or malnutrition were used. Students used McDonald’s USA Nutrition Facts for Popular Menu Items as obtained on the internet (6) for calculation of lunch nutritional content. and Treatment of High Blood Cholesterol in Adults (14). hypertension. mg/dl LDL cholesterol. Body fatness and malnutrition estimates. • Blood HDL cholesterol ⱕ40 mg/dl (males). After lunch has been eaten in the laboratory. dietary fiber (g). they were chosen as vendor. and Step II groups. cholesterol transport and regulation. and is said to afflict as many as 20–25% of the adults in this country (4. 15). and Blood Institute of the National Institutes of Health issued its Third Report of the Expert Panel on Detection. Discussion of diet composition. Lung. known as the TLC diet (14). mg Values are means ⫾ SD. mg Step 2 diet Saturated fat. atherogenic dyslipidemia. 8). calcium. g Carbohydrate. high-density lipoprotein. saturated fat (g). This list includes total calories and calories from fat. Evaluation. The National Heart. • Fasting glucose ⱖ110 mg/dl. central obesity. mg/dl HDL cholesterol. recommendations persist in the updated NCEP version of the Step II diet. or hyperglycemia make this area fertile soil indeed for conversation with medical students. serum. % total Kcal Cholesterol. analysis of the selected lunch items is carried out using nutrition facts provided by the retailer. mg Dietary fiber. During the afternoon exercise. First. and Blood Institute has recently amended and expanded its definition of the former Step II diet. mg/dl Cholesterol.physiology. obtained from analysis of fasting venous blood samples. In 2002. mg Step 1 diet Saturated fat. Blood lipid levels Variable Recommended Level or Metabolic Syndrome Diagnostic Criterion (14) Class Mean Triglycerides. Females ⬍50 Recommended ⬍130 99⫾52 166⫾34 48⫾12 99⫾33 Values are means ⫾ SD. The metabolic syndrome is increasing in incidence in the US. low-density lipoprotein. This report defines the metabolic syndrome as the presence of three or more of the following (14): Because each of these criteria is readily evaluated. serum. Table 2 lists mean meal composition from the entire class. g Ad libitum diet Saturated fat. was determined and the criteria for diagnosis of the metabolic syndrome were defined as ⬎40 inches (102 cm) in males. body mass index was calculated as {weight (kg)/[height (m)]2} (2. this laboratory allows a complete analysis and discussion of a condition that is epidemic across much of the developed world. triceps skinfold was compared with standards obtained from the combined National Health and Nutrition Examination Surveys of 1971–1974 and 1976–1980 (12). mg Cholesterol. 14). selected diets of persons assigned to the ad libitum. making this issue an ideal site for a nutrition-physiology connection in medical education (13. This diet is now known as the Therapeutic Lifestyle Changes Advances in Physiology Education • VOL 28 • DECEMBER 2004 Downloaded from ajpadvan. hypertension. used to detect the presence of malnutrition. LDL. as estimated from abdominal circumference. Our experience has been that students enjoy being randomized into the three diets and then searching the menu to meet the given dietary requirements. Fourth. and protein (g). ⬎35 inches (females)]. IN. carbohydrate (g). body weight was compared with reference weights for various heights as derived from mortality experience data. sodium (mg). Mean results from the basic metabolic panel are listed in Table 3. % total Kcal Protein. and expressed as a percentage of the weight-for-height median values (12).037⫾333 74⫾34 4⫾2 14⫾2 103⫾45 8⫾2 88⫾41 6⫾3 34⫾5 The metabolic syndrome (or “syndrome X”) consists of a constellation of factors. cholesterol (mg). serum. ⱖ150 mg/dl.Teaching in the Laboratory 196 EVALUATING THE METABOLIC SYNDROME Table 1. and iron as the percentage of recommended daily value. These clustered factors contribute substantially to risk for both Type 2 diabetes and atherosclerotic cardiovascular disease (9). Evaluating criteria for presence of metabolic syndrome. RESULTS • Central obesity [waist circumference ⬎40 inches (males). mg/dl Diagnostic criterion: ⬎150 Recommended: ⬍200 Diagnostic criteria: Males ⬍40. % total Kcal Saturated fat calories. 14). • Blood pressure ⱖ130/85 mmHg. and potential medications used for treatment of hyperlipidemia. serum. • Fasting blood triglycerides. total.

protein. total plasma. by having them draw each other’s blood and then interpret their own results. mEq/l [HCO⫺ 3 ]. This study of obesity and its origins and risks often begins with students remarking on the small size of the allowed lunch in kcal–the simple calculation of estimated daily caloric expenditure is often a first careful exploration into basic issues of energy balance for these students. Estimates of fatness and malnutrition Variable Normal Range or Metabolic Syndrome Diagnostic Criterion (14) Class Mean Waist.0 70–105 77⫾14 6. plasma. for example. and advocate replacement of animal proteins with soy protein in some situations. interest. albumin.2 8. Females ⬎35 Overweight: 25–30. and here a meal prepared in a metabolic kitchen could provide a broader array of foods low in Na⫹ content. designed to comply with all TLC diet guidelines. Body fatness and malnutrition estimates.4–10.0⫾2. mg/dl Normal Range Class Mean 136–146 143. and protein breakdown products Variable [Na⫹] plasma.3 78⫾23 101⫾14 89⫾23 Values are means ⫾ SD. and fails to distinguish soluble from insoluble fiber.2 9. By having them estimate their daily caloric expenditure. n ⫽ 35 subjects. and personal investment is essential to any successful teaching laboratory (16). mEq/l [Ca2⫹]. mg/dl Protein.physiology. we generate consid- Table 4. Another alternative would be to prepare a lunch. total. and triceps skinfold (12) helps students understand various methods for and problems with noninvasive determination of fatness. weight for height compared with the midpoint of an acceptable range (12). inches Body mass index. A more meaningful 197 . %median Mid-arm muscle area. Stimulating student involvement. Although our chosen vendor does not provide potassium levels in the nutritional tables provided. The low coefficient of variation (SD/mean) for plasma levels of Na⫹ and Cl⫺.3.6–1. the nutritional information provided by McDonald’s USA lists only total fiber.3 3.7⫾3. simple. is a useful starting point for a dialogue about extracellular fluid Na⫹ regulation and its complex relationship to Na⫹ intake. In addition. Obese: ⬎30 Malnutrition: ⬍50. Engaging student interest and personal ties to material. glucose. although its full explication belongs in a laboratory devoted to renal function. Other possible points for emphasis. Many major restaurant chains provide this nutritional information. One of these recommendations is that persons increase viscous (soluble) fiber intake to 10–25 g/day. Blood levels of electrolytes. plasma.5–5. during anorexia nervosa. we chose not to emphasize Ca2⫹ intake and Ca2⫹ plasma regulation.1 0.3 23–29 26. by allowing them to choose their own lunch in full view of its nutritional content. Similarly.3 8. further information could be added from standard nutritional tables.1⫾0. McDonald’s USA is not a preferred source for a wide range of foods low in Na⫹. and limiting cholesterol to ⬍200 mg/day) several other recommendations can be considered. mg/dl [K⫹] plasma. mg/dl Urea nitrogen. protein content. We chose to supplement measures of waist circumference with four other rapid. and by randomizing them into clinically relevant therapeutic diets. %standard Weight.5–5. plasma. We do this in part by simply using the students themselves as subjects. [HCO⫺ 3 ] is measured as total CO2. weight (kg)/[height (m)]2 Triceps skinfold. The physiological responses to malnutrition are readily expanded to include assessment of meal caloric content. The midarm muscle area (12) is used to estimate the possible presence of malnutrition. The recent dietary guidelines also suggest an intake of 2 g per day of plant stanols/sterols.5 3. and this is easily done during an actual class exercise.0⫾2.org on August 12.4 Males 0.Teaching in the Laboratory EVALUATING THE METABOLIC SYNDROME Table 3.4 98–106 103. vitamin C. the blood levels of urea nitrogen and creatinine can also properly be included in this overarching review of protein anabolism and catabolism during malnutrition.3⫾0. Females 0.1 4. mEq/l [Cl⫺] plasma. blood. blood. 8). This number far exceeds that contained in the lunches chosen by our students (Table 2). mEq/l Glucose. Most clinical laboratory panels also include bicarbonate and anion gap readings.0⫾0. recommend enough exercise each day to expend at least 200 kcal (14). analysis would separate data from males and females. in a metabolic kitchen. noninvasive estimates of body fatness or malnutrition. The TLC diet includes several additional lifestyle and dietary changes that can be mentioned and discussed during this portion of the laboratory.5⫾0. but Ca2⫹ intake levels are directly available from the restaurant and easily could be included in class discussion. and dialogue can readily be generated that helps integrate these readings into the broader understanding of extracelluar fluid and acid-base regulation. n ⫽ 35.2 7–18 14⫾3 Values are means ⫾ SD.2⫾2. and the levels of total protein. We also chose to de-emphasize the vendor-provided nutritional information regarding vitamin A.9⫾0. g/dl Creatinine. Contrasting the results obtained from body mass index (2. We have found that all of these dietary and lifestyle issues are made highly relevant and engaging in this laboratory. 2006 (TLC) diet (14). To more directly address the issue of soluble fiber and its important role in the lowering of blood cholesterol. but these also represent possible areas for exploration. and urea nitrogen in the blood. g/dl Albumin. Our results show only the whole-class means.7–1. and iron content. In addition to those issues directly commented on thus far (the need for adjustment of total caloric intake to maintain a desirable body weight. as may occur.4–8. which include both males and females.0 4. the maintenance of saturated fat intake ⬍7% of dietary calories. Finally. blood. these could be calculated and then contrasted with the numbers seen in the normal plasma range. Obesity: ⬎150 Normal range: ⬇ 85–115 Malnutrition: ⬍70 32⫾4 22. as contrasted with the very wide range of individual levels of Na⫹ intake. Advances in Physiology Education • VOL 28 • DECEMBER 2004 Downloaded from ajpadvan. %standard Diagnostic criteria: Males ⬎40.

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