Metabolic syndrome

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The Metabolic syndrome (MetS) is a group of risk factors for cardiovascular disease and type 2 diabetes mellitus including:

LogoKeyPointsBox.pngOther simple risk factors predict CVD just as well so its use as a concept is limited[1][2] except perhaps to allow focus on high risk patients[3]

It is generally regarded as being associated with:

  • A proinflammatory state
  • A prothrombotic state

Subgroups of patients may meet the definition of MetS but on follow up not be shown to be strictly at increased risk of cardiovascular disease, a paradox that for example may apply in polycystic ovary syndrome. It is therefore important to realize that we are not dealing with a disease but rather a useful classification associated with epidemiological risk in general populations. The status for example of the apparent metabolic syndrome associated with prolonged high relative intakes of fructose is unclear. This runs the risk of reification and the myths associated with the label metabolic syndrome have been explored[4]. Those that use the label have to recognize that it is not an independent predictor of vascular risk in the elderly[5], precisely the group most at risk of vascular disease.

There are several recent definitions, made from different viewpoints which has epidemiological implications:

  1. International Diabetes Federation (IDF) - 2005
  2. American Heart Association/National Heart Lung and Blood Institute (AHA/NHLBI) - 2004
  3. National Cholesterol Education Program-Adult Treatment Panel-III (NCEP-ATP-III) - 2001[6]

For example cardiovascular disease prevalence is greater for the last two definitions in some populations[7].

The concept has been extended to children and adolescents[8].

Metabolic syndrome definitions in Adults
International Diabetes Federation (2005) NCEP-ATP-III AHA/NHLBI (2004) WHO (1999)
  1. Central obesity
    • Body-mass index (BMI) > 30 kg/m2
    • Or if BMI &le 30 kg/m2waist circumference as ethnic determined
      • Europids
        • Men ≥94cm
        • Women ≥80cm
      • South Asians & Chinese
        • Men ≥90cm
        • Women ≥80cm
      • Japanese
        • Men ≥85cm
        • Women ≥90cm
  2. Plus any two:
    • Raised triglycerides
      • >1·7 mmol/L (150 mg/dL)
      • Specific treatment for this lipid abnormality
    • Reduced HDL-cholesterol
      • <1·03 mmol/L (40 mg/dL) in men
      • <1·29 mmol/L (50 mg/dL) in women
      • Specific treatment for this lipid abnormality
    • Raised blood pressure
      • Systolic ⩾130 mm Hg
      • Diastolic ⩾85 mm Hg
      • Treatment of previously diagnosed hypertension
    • Raised fasting plasma glucose
      • Fasting plasma glucose ⩾5·6 mmol/L (100 mg/dL)
      • Previously diagnosed type 2 diabetes
      • If above 5·6 mmol/L (100 mg/dL) an oral glucose tolerance test is strongly recommended, but is not necessary to define presence of syndrome
      • While one of above is necessary for research, in clinical practice, impaired glucose tolerance is also acceptable
  1. Waist circumference
    • Men ≥ 40 inches (102 cm)
    • Women ≥ 35 inches (88 cm)
  2. Triglycerides &ge 150 mg/dL
  3. HDL cholesterol
    • Men ≤ 40 mg/dL
    • Women &le 50 mg/dL
  4. Blood pressure
    • either &ge 130/85 mm Hg
    • or use of medication for hypertension
  5. Fasting glucose
    • Either ≥ 100 mg/dL (5.6 mmol/L)
    • or use of medication for hyperglycemia
Three of:
  • Central obesity: waist circumference
    • Men > 102 cm or 40 inches
    • Female > 88 cm or 36 inches
  • Dyslipidaemia
    • Triglycerides &ge 1.695 mmol/L (150 mg/dl)
    • HDL-Cholesterol
      • Men < 40 mg/dL
      • Women < 50 mg/dL
  • Blood pressure ≥ 130/85 mmHg
  • Fasting plasma glucose ≥ 6.1 mmol/L (110 mg/dl)
  1. Insulin resistance as evidenced by one of:
    • Type 2 diabetes mellitus
    • Impaired glucose tolerance
    • Impaired fasting glucose
    • Glucose uptake below lowest quartile in population of interest
  2. AND two of:
    • Blood pressure either
      • Antihypertensive medication
      • Systolic ≥ 140 mmHg
      • Diasystolic &ge 90 mmHg
    • Dyslipidaemia either
      • Triglycerides ≥ 1.695 mmol/L
      • HDL cholesterol
        • Men ≤ 0.9 mmol/L
        • Women ≤ 1.0 mmol/L
    • Central obesity with either
      • Waist:hip ratio
        • Men > 0.90
        • Women > 0.85
      • Body mass index (BMI) > 30 kg/m2
    • Microalbuminuria either:
      • Urinary albumin excretion ratio ≥ 20 mg/min
      • Albumin:creatinine ratio ≥ 30 mg/g

References

  1. ↑ Gale EA. Should we dump the metabolic syndrome? Yes. BMJ (Clinical research ed.). 2008 Mar 22; 336(7645):640.(Link to article – subscription may be required.)
  2. ↑ Sattar N, McConnachie A, Shaper AG, Blauw GJ, Buckley BM, de Craen AJ, et al. Can metabolic syndrome usefully predict cardiovascular disease and diabetes? Outcome data from two prospective studies. The Lancet Early Online Publication 2008 (http://www.thelancet.com/journals/lancet/article/PIIS0140673608606029/abstract?iseop=true)
  3. ↑ Alberti KG, Zimmet PZ. Should we dump the metabolic syndrome? No. BMJ (Clinical research ed.). 2008 Mar 22; 336(7645):641.(Link to article – subscription may be required.)
  4. ↑ Gale EA. The myth of the metabolic syndrome. Diabetologia. 2005 Sep; 48(9):1679-83.(Link to article – subscription may be required.)
  5. ↑ Sattar N, McConnachie A, Shaper AG, Blauw GJ, Buckley BM, de Craen AJ, Ford I, Forouhi NG, Freeman DJ, Jukema JW, Lennon L, Macfarlane PW, Murphy MB, Packard CJ, Stott DJ, Westendorp RG, Whincup PH, Shepherd J, Wannamethee SG. Can metabolic syndrome usefully predict cardiovascular disease and diabetes? Outcome data from two prospective studies. Lancet. 2008 Jun 7; 371(9628):1927-35.(Link to article – subscription may be required.)
  6. ↑ Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA : the journal of the American Medical Association. 2001 May 16; 285(19):2486-97.
  7. ↑ Athyros VG, Ganotakis ES, Elisaf MS, Liberopoulos EN, Goudevenos IA, Karagiannis A. Prevalence of vascular disease in metabolic syndrome using three proposed definitions. International journal of cardiology. 2007 Apr 25; 117(2):204-10.(Link to article – subscription may be required.)
  8. ↑ Zimmet P, Alberti G, Kaufman F, Tajima N, Silink M, Arslanian S, Wong G, Bennett P, Shaw J, Caprio S. The metabolic syndrome in children and adolescents. Lancet. 2007 Jun 23; 369(9579):2059-61.(Link to article – subscription may be required.)
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