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PATHOLOGY PERSPECTIVES Treatment for metabolic syndrome is often divided into short-term and long-term goals. Short-term goals include lowering blood glucose and correcting cholesterol levels with medical intervention. Long-term goals include increasing physical activity and losing weight. Reducing body weight by 5–7 percent (10–14 pounds for a 200-pound person) significantly reduces the risk of complications due to insulin resistance. Exercise improves insulin action and decreases blood glucose. Limiting alcohol use and quitting smoking are other important steps. insulin are normal or above normal, but targeted cells fail to receive it. The precise causes of insulin resistance are not fully understood. A genetic component seems clear, but this condition may also be promoted or triggered by eating habits that tax the pancreas and by lack of exercise, which allows blood sugar to elevate. If cells become resistant to insulin, then three bad things happen: insulin accumulates in the bloodstream (hyperinsulinemia); glucose accumulates in the bloodstream (hyperglycemia) and cells have to burn other fuel sources to make • Because a person who is insulin resistant must derive energy from fats and proteins instead of carbohydrates, the potential to gain weight is much greater than for the rest of the population. • Being overweight increases the risk of losing insulin receptors and promoting insulin resistance. • Elevated insulin acts on the pituitary to increase the secretion of luteinizing hormone. • Elevated insulin acts with luteinizing hormone in the ovaries to promote the production of various forms of testosterone. This suppresses the maturation of follicles and interferes with ovulation. Our role with a client caught in this tangle is to be a source of compassion and peace in a world of frustration. THE LINK BETWEEN PCOS AND METABOLIC SYNDROME Curious readers will now be wondering why these two conditions, which don't seem obviously linked, appear together so frequently. The connection between these two problems is a silent but potentially dangerous risk factor: insulin resistance.9 Insulin, you will recall, is a hormone produced by the pancreas that transports blood glucose into hungry cells: especially skeletal muscle and fat cells. Insulin requires receptors on target cells to allow it access; a series of reactions inside the cell allow glucose to be burned in a very clean and efficient way that creates the potential for energy. Insulin resistance is identified when circulating levels of energy—a process that generates a lot of metabolic wastes. In the long run, this sequence is a setup for type 2 diabetes and cardiovascular disease (i.e., metabolic syndrome). But for many women, hyperinsulinemia is also a setup for PCOS. The relationships between hyperinsulinemia and both metabolic syndrome and PCOS are complicated and often circular. A very abbreviated explanation includes the following factors: • Insulin resistance requires that cells burn non-glucose sources of fuel, namely proteins and fats; this produces a variety of metabolic by- products that are potentially toxic. • Elevated insulin also acts on the liver to reduce testosterone-neutralizing enzymes, allowing free testosterone to influence cell functions. • Excessive testosterone makes sebaceous glands more active, leading to acne. • Excessive testosterone promotes secondary male sexual characteristics, especially the loss of head hair (alopecia) and the growth of facial and body hair (hirsutism). • Having a large omentum ("apple shape") may promote excessive testosterone production through insulin resistance and its effects on the ovaries; having excessive testosterone may in turn promote having a large omentum.10 • Elevated insulin acts on the liver to promote the production of triglycerides: these are a form of cholesterol carriers associated with an increased risk of atherosclerosis. The good news in all this tangle is that insulin resistance and its consequences are treatable. Muscular activity increases insulin sensitivity and burns blood sugar. Weight reduction can reverse several processes seen with insulin resistance,11 as well as reducing blood pressure—another factor in metabolic syndrome. And a variety of drugs can increase both the number of insulin receptors and their 114 massage & bodywork january/february 2009