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Aurelian Udristioiu¹, Manole Cojocaru² ¹Clinical Laboratory, Department of Hematology, Emergency County Hospital Targu Jiu & UCB University, Romania, E-mail: aurelianu2007@yahoo.com ²Titu Maiorescu University, Faculty of Medicine, Physiology Department, Bucharest, Romania; E-mail: mancojocaru@yahoo.com Corresponding author Aurelian Udristioiu Abstract Objective: The aim of this study was to determine the effectiveness of a standard physical exercise protocol in terms of returning patients with signs of metabolic syndrome (MS) to a normal metabolic status. Methods: Patients showing signs of MS (45 adult females and 35 adult males, 20-50 years old) without any disability applied a combined treatment consisting of a hypocaloric diet (<2,500 kcal/day) and a program of physical exercise using a fitness bicycle. Results: Prior to the exercise program and without any treatment, 23% showed a healthy lipid metabolism, 28% presented high LDL and low HDL, 14% showed an atherosclerotic index and LDL/HDL >3.5 for males and >2.5 for females, 5% exhibited values predictive of coronary risk (CHOL/HDL >5), and the remaining 30% had dyslipid syndrome types 2-4, with high cholesterol and triglyceride levels. After 3 months of standard physical effort, 64 patients (80%) exhibited normalized biochemical results and a normal health status. Of the patients who failed to respond to this standard physical exercise regimen, 16 (20%) might require drug-based treatment in addition to exercise and dieting. Conclusions: The diet/exercise combination presented in this study was effective for treatment of MS. Keywords: Metabolic Syndrome, Qualitative Index HOMA, Waist-to-hip Ratio, Metabolic Equivalents, Body Mass Index.

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Methods Patients who presented at general practitioners with clinical and paraclinical signs of MS, had no other disability and had not received specialized treatment for this syndrome, and who, based on the advice of their physicians, presented with medical letters to the Department of Endocrinology of the Ambulatory County Hospital Targu Jiu, were considered for inclusion in this study. The patients had been advised by a specialist physician to volunteer for combined treatment consisting of a hypocaloric diet (<2,500 kcal/day) and a program of physical exercise on a fitness bicycle. The fitness bicycle used (Pegas-Pedalux 3, Factory City Brasov, Romania) allowed the investigator to record the intensity of physical effort. During the physical exercise, the average heart rate (HR) was 110-136 bpm. Some patients with advanced obesity (30%) did not agree to participate in the standard exercise regimen; they were not included in the study. In this experiment were following biochemical parameters with signs of MS: 1.Blood glucose >120 mg/dl, as a sign of insulin resistance in non-diabetic obese persons, 2.HOMA Qualitative Index (the relationship between liver fat and fasting serum insulin concentrations) >2, indicating liver fat and insulin resistance. Liver fat was measured by tomography [5]. 3. Liver enzymes: aspartate aminotransferase (AST), alanine aminotransferase (ALT) gamma glutamyl transpeptidase (GGT), alkaline phosphatase (ALP) levels 20-40 units above normal as a sign of fatty liver, and an AST/ALT ratio <1 in non-alcoholic fatty liver and serum cholinesterase > 9000 U/L, as signs of liver dysfunction [6]. 4. Elevated uric acid [7], interleukin-18, C-reactive protein [8], and adipokines [9, 10, 11], and a lipid profile characterized by elevated plasma cholesterol and triglycerides (TGs), increases in cholesterol only (pure or isolated hypercholesterolemia), increases in TGs only (pure or isolated hypertriglyceridemia or a low high-density lipoprotein level, which contributes to the development of atherosclerosis) [12]. Formerly, ideal weight (IW) was calculated using the Lorenz formula, which was developed in 1929 and exists as two versions, one for males and the other for females. Body weight must be known before its application: For females, IW (kg) = H (cm) – 100 – [H (cm) – 150] / 2; for males, IW (kg) = H (cm) – 100 – [H (cm) – 150] / 4. More recently, ideal weight has been recommended to be calculated as a function of height in centimeters (H) and age (A). Using the new formula (Bull’s algorithm, also known as the EMBED Equation 3 method): for males, IW = 50 + 0.75(H – 150) + [(A– 20) / 4], and for females, IW  0.9. The schedule of physical exercise was accompanied by a daily dietary energy intake reduction of 400 kcal [Table 1]. Male, age Cal/kg Calories Female, age Cal/kg Calories 25 46 3200 25 40 2500 45 40 3000 45 39 2200 65 38.5 2550 65 38 1800 Table 1. Calories per day with respect to age and weight with normal physical activity Note: Inclusion criteria of MS, based on clinical signs of metabolic risk factors can be prevented if the persons do not register: 1. Obesity with a BMI >26 for females and >30 for males, calculated as [weight (kg)]/[height (m2)]. 2. Waist circumference >90 cm for females and >85 cm for males, measured half-way between the xyphoide appendix and the navel. 3. Waist-to-hip ratio (WHR) >0.95 for females and >0.85 for males, calculated as waist circumference/hip circumference (measured between the two trochanters). The target heart rate (THR), which determined the intensity of the exercise, was generally recommended based on the resting heart rate (HR at rest) and the heart rate during physical effort (HRP), which had to be 60–80% of the values characteristic of aerobic metabolism. The THR ranges were calculated using the Karvonen approach, as follows: THR = (HRP × 50%) + HRR. For a value of 60% of aerobic metabolism, the THR is ((180 − 70) ×0.60) + 70 = 136 bpm [13]. Metabolic equivalents (METs) are useful when walking exercises are recommended by physicians. By definition, a MET is the energy or level of oxygen used at rest (1 MET = 3.5 VO2 mL/kg/min). However, recent studies indicate that the average resting MET level in subjects with coronary heart disease is 23–36% less than the standard value of 3.5 mL/kg/min [14]. Patients showing signs of MS (45 females and 35 males, aged 20-50 years), were assessed using a biochemical analyzer (Hitachi 912, Roche Diagnostics USA); the principal biochemical parameters for lipid metabolism: total cholesterol (CHOL), triglycerides (TGs), HDL-CO, and LDL- CO were evaluated. This assessment was performed both before and after the physical exercise /diet treatment. The total energy expended, Q (kcal), was calculated by the theoretical equation Q (kcal) = oxygen consumption (VO2)  isocalorific coefficient (4.83 kcal) = [(5.8  W) + (151 +10.1  P)  4.83], where W represents the patient’s weight (kg) and P is the power of pedaling on the stationary bicycle (Watts/sec) (15). The lipid energetic consumption, QL (kcal) was estimated using the equation Q1 = VO2 – [17.35  4.83  total muscle mass of body (MSC)]. For efficient exercise, lipid energy consumption exceeds 7 kcal/min, when MSC = 20% from W. The energy consumption per minute for jogging was calculated as E (kcal) = 0.8  v + 0.5, where v is the jogging speed (3.5-6.5 km/h). In a parallel study, a control group consisting of 75 young healthy individuals (45 males and 30 females, mean age 21.8 years) who were members of a sporting club (Tennis Club of Bucharest) were assessed using the same type of ergonomic bicycle. The maximum effort capacity (VO2max) and calorie consumption (Q) of the healthy individuals, in comparison with the patients in the cohort study, were determined using an identical physical effort schedule (Table 2). No., Sex Mean age Mean weight (kg) VO2 /min Heart rate (BPM) Respiratory rate/min Index O2/pulse Respiratory eq. kcal / min Watts 15 Males 29 65 3.1 120-130 35 18.7 21.4 13.6 212 10 Males 25 63 2.7 144-150 40 17.1 24.2 12.6 196 20 Males 17 61 2.2 140-150 45 14.1 30.3 10.4 179 12 Females 23 52 2.1 140-150 50 13.3 32.5 9.7 147 18 Females 20 50 2.0 150-160 60 9.5 38.1 8.3 122 5 Females 17 48 1.9 150-160 60 8.8 38.8 7.8 114 Table 2. Energy expenditure during aerobic–anaerobic exercises performed by athletes on the fitness bicycle Legend: VO2 = oxygen consumption, L/min, Index oxygen pulse = VO2 2/heart beat (>18.7 for ideal performance), Respiratory equivalent = expiratory volume/ VO2 (≤28±3 for ideal performance), Expiratory volume = current volume  heart rate., Current volume = 37% of body weight (kg). Results Before participating in the standard exercise program, based solely on the biochemical tests, 23% of the patients showed a healthy lipid metabolism, 28% presented high LDL (mean 189 mg/dL, SD 2.13) and low HDL (mean 30 mg/dL, SD 2.66), indicating onset of the atherosclerotic process, another 14% showed an atherosclerotic index and LDL/HDL > 3.5 for males, and >2.5 for females, a further 5% showed predictive coronary risk (CO/HDL >5), and the remaining 30% were patients with dyslipid syndrome types 2-4, in conjunction with high cholesterol (360 mg/dL, SD 2.26) and triglyceride (mean 255 mg/dL, SD 3.10) levels. Two 5- to 6-km jogging sessions per week led to the use of an additional 200-300 kcal/session. Energy consumption during exercise according to age was calculated using a mean value, 10 kcal/min After 3 months of following the exercise regimen, 64 (80%) patients obtained a normal BMI and a good WHR [Table 3], a normal health status (normal HOMA Qualitative Index <2), and normalized biochemical results: total cholesterol (mean 169.5 mg/dL, SD 2.13, p = 0.005, reference interval = 114-225 mg/dL), triglycerides (mean 99 mg/dL, SD 2.92, p = 0.04, reference interval = 53-145 mg/dL), HDL (mean 63 mg/dL, SD 2.60, reference interval = 36-60 mg/dL) and LDL (mean 89 mg/dL, SD 2.88, reference interval = 48-130 mg/dL). Sixteen patients (20%) did not respond to the physical exercise regimen and retained high cholesterol or triglyceride levels and a BMI and WHR exceeding the normal limits.


The diet and exercise combination presented in this study proved to be an effective treatment for MS, and this or a similar regimen should be recommend by physicians to patients who show signs of MS. For patients who show limited results from exercising on a stationary bicycle (or other exercising methods), drug treatment, such as specific treatment for dyslipid disorder, administration of leptins, leptin genes, or promoter drugs may be necessary, in addition to physical exercise and maintenance of an appropriate diet. Further studies, which should include an appropriate control group, are necessary to confirm these findings, which can be regarded at present as only a hypothesis derived from the signs and symptoms of MS.

Professor Aurelian Udristioiu
Hematology and Oncology Specialists LLC

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This page is a summary of: Abstract: P1204 FROM NORMAL STATUS TO METABOLIC SYNDROME, Atherosclerosis Supplements, June 2009, Elsevier, DOI: 10.1016/s1567-5688(09)70311-3.
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