Presently, no specific drugs are available to manage the metabolic syndrome.

Lifestyle changes are the best options to prevent the metabolic syndrome or to manage a person diagnosed as having the metabolic syndrome.

Thus, lifestyle changes not only offer the best universal beneficial options for the metabolic syndrome, but they also go a long way in managing and /or reducing the long term consequences of the presence of major risk factors which predispose a person to ASCVD. Although the presence of some of these risk factors may need additional specific drug therapies, lifestyle changes still continue to be central to their treatment.

In order to ensure compliance, the prescribed diet should be individualised. It must be realistic, flexible, and take into consideration the patient's likes and dislikes, to as large an extent as possible, and must suit the patient's life style. It is important to educate the patient about the basic requirements of the diet and judge compliance at regular intervals.

"Acceptable" Body Weight

The aim is to attain acceptable body weight with a special emphasis on attaining the desired waist measurement. Other specific changes would be necessary depending on the presence of associated risk factors such as impaired glycemia or diabetes, hypertension, dyslipidemias etc.

Aim initially at slow reduction of 7% to 10% from baseline weight over one year of management. Even small amounts of weight loss are associated with significant health benefits. Continue weight loss thereafter to extent possible with goal to ultimately achieve desirable weight.

Effective weight loss requires a combination of caloric restriction, physical activity, and motivation; effective lifelong maintenance of weight loss essentially requires a balance between caloric intake and physical activity and the maintenance of sufficient skeletal muscle mass/quality.

After 6 months, the rate of weight loss usually declines and weight plateaus because of a lesser energy expenditure at the lower weight and the lifestyle prescription may need to be revised.

Experience reveals that lost weight usually will be regained unless a weight maintenance program consisting of dietary therapy, physical activity, and behavior therapy is continued indefinitely.

The widespread misconception that carbohydrates (in any form) should not be eaten by people with diabetes should be removed. Carbohydrates in the form of simple sugars need restriction. The carbohydrates should be in the form of complex polysaccharides (starch) and contain adequate amount of digestible fibers.

Carbohydrates should constitute around 60-70% of the total calories which is usually found in traditional diets eaten in various parts of India. Very high carbohydrate intakes and/or high glycaemic index foods can exacerbate the dyslipidemia, including hypertriglyceridemia, of the metabolic syndrome, especially if the overall calory intake is very high.

In addition, there should be ample intakes of fresh fruits and vegetables, and whole grains; fruits and vegetables are recommended to provide fiber, vitamins, minerals and hydration, and to increase satiety through the volume of food ingested, in order to avoid feelings of deprivation and restriction.

Protein intake should be approx. 0.8 gms/kg ideal body weight; this usually comprises around 12-18% of the calorie intake.

The requirements for proteins may be increased in catabolic states, pregnancy, lactation and in some elderly patients. This should be preferably taken from natural sources rather than commercially available protein supplements as far as is possible.

Protein intake may need to be restricted in patients with nephropathy.

Fats should be restricted to around 20-25% of the total calories. If the fat content exceeds 35%, it is difficult to sustain the low intakes of saturated fat required to maintain a low LDL-C. On the other hand, if the total fat content falls below 25%, triglycerides can rise and HDL-C levels can decline; thus, very-low-fat diets may paradoxically exacerbate atherogenic dyslipidemia.

It is recommended that the saturated fat be <7% of total calories; reduce trans fat (< 1% based on WHO recommendations); dietary cholesterol <200 mg/dL; total fat 25% to 35% of total calories. Most dietary fat should be unsaturated; simple sugars should be limited. These goals can be achieved by (1) choosing lean meats and vegetable alternatives; (2) selecting fat-free (skim), 1%-fat, and low-fat dairy products; (3) minimizing intake of partially hydrogenated fats i.e. bakery products to decrease trans fatty acids; (4) avoid repeated reusing of the oil for cooking purposes (frying) purposes as this leads to a significant increase in the trans fatty content of the diet.

Many foods contains fats; this "invisible fat" should be taken into account when estimating the total fat intake. On an average 40% of the fat intake is contributed by the invisible fat in a typical Indian diet.

It is advisable to restrict the total intake of cooking fats to less than 6% of the total energy intake; in simple terms, food should be cooked in the least amount of oil or ghee; if feasible, food should be preferably be grilled, steamed or broiled, microwaved, rather than fried.

The total intake of cholesterol should be restricted to around 300 mg per day. Egg yolks, organ meats, marine invertebrates (including molluscs, crab, shrimps and lobster) have a very high cholesterol content.

The fat intake may need to be further modified if associated dyslipidemia is present.

Recent evidence suggests that attention must be paid to the intake of essential fatty acids (EFAs) such as omega-6 (w6) and omega-3 (w3) fatty acids.

These EFAs must be derived from food as they cannot be synthesised in the body. Not only must they be eaten in adequate amounts, but the relative ratio (w6/w3) is around 5-10:1.

Indian diets usually contain too much of w6 fatty acids and little, if any, of w3 fatty acids. Indian diets usually give a ratio of around 40:1.

The disproportionate ratio is made worse by the use of the so called "safe" cooking oils such as safflower oil and sunflower oil, in which the ratio is around 150:1!

Traditional cooking media like mustard oil, coconut oil and ghee have a poor content of w6 fatty acids allows a more optimal w6/w3 intake, but this has to be balanced with the relatively high saturated fat content.

The other alternative is home scale blending of traditional cooking media with oils rich in w6 to lower the ratios, eg. simple blending of sunflower and mustard oil in 1:1 at home would bring down the ratio to approximately 7 as against 163 for sunflower alone.

Salt restriction is necessary in patients with associated hypertension, cardiac failure and fluid overload. Reduce sodium intake to no more than 100 meq/day (2.4 g of sodium or 6 g of sodium chloride / one teaspoon a day)

These can be eaten by people with diabetes in moderate amounts. Ripe and very sweet fruits are better avoided. Raw and partially ripe fruits and citrus fruits are preferable.

If consumed, alcohol should be used in moderation.

Limit alcohol intake to no more than 1 oz (30 ml) of ethanol (eg, 24 oz [720 ml] of beer, 10 oz [300 ml] of wine, or 2 oz [60 ml] of 100-proof whiskey) per day or 0.5 oz (15 ml) of ethanol per day for women and lighter-weight people.

It should be avoided in all diabetics who are severely obese and on a significantly hypocaloric diet, in those who have high triglyceride levels. All other contraindications to alcohol intake also apply to diabetics.

INTERESTINGLY, OUR TRADITIONAL INDIAN DIETS, WITH SLIGHT MODIFICATION, ARE CLOSE TO WHAT IS NOW CONSIDERED IDEAL DIETS!

PATIENTS DO NOT HAVE TO MAKE ANY "MAJOR CHANGES TO THEIR USUAL DIETARY HABITS, WITH THE EXCEPTION OF AVOIDING SIMPLE SUGARS, CUTTING DOWN ON THE SALT AND ADJUSTING THE FAT INTAKE.

THIS ALLOWS INCREASING COMPLIANCE WITH THE DIET ADVISE!