The Metabolic Syndrome in Clinical Practice

Prevalence of metabolic syndrome (MS) in the clinical practice is still debated, due to different diagnostic criteria, target populations and clinical.
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Those listed by Reaven 1 are the following: Each of these principles can be examined briefly. The term the metabolic syndrome is a shorthand notation for a clustering of CVD factors of metabolic origin 3. Perhaps a more precise but more cumbersome term would be metabolic-risk-factor clustering.

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The risk factors included in such a clustering are atherogenic dyslipidemia, elevated blood pressure, elevated plasma glucose, a prothrombotic state, and a proinflammatory state. Atherogenic dyslipidemia further consists of a clustering of elevated triacylglycerols, greater concentrations of small and dense LDL, and low concentrations of HDL. Most patients with atherogenic dyslipidemia also have elevations of apolipoprotein apo B and low concentrations of apo A-I. Evidence of several types indicates that each of the metabolic risk factors either contributes to atherogenesis or predisposes a person to major coronary events.


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Although Kahn et al 2 seemingly do not like to apply the term syndrome applied to risk-factor clustering, Reaven applied the term syndrome to an aggregation of cardiovascular risk factors 4 , 5. Reaven hypothesized that insulin resistance is a major cause of the aggregation that he called syndrome X. In appreciation of this hypothesis and to be more specific, others 6 have used the name insulin resistance syndrome. Presumably, Reaven would not approve of assigning patients a diagnosis of either syndrome X or insulin resistance syndrome; these terms were apparently meant as biological concepts, without clinical utility.

Recently, Grundy et al, in an update of the NCEP report 3 , and the International Diabetes Federation 10 have refined the clinical criteria for making a diagnosis of metabolic syndrome in clinical practice. The WHO group used the widely employed term metabolic syndrome instead of insulin resistance syndrome for risk-factor clustering because of uncertainty as to whether insulin resistance is the only cause of this phenomenon 7. The WHO nonetheless made evidence of insulin resistance a requirement for a diagnosis of metabolic syndrome.

NCEP acknowledged the important role played by insulin resistance but further noted that obesity also contributes to risk-factor clustering. Reaven and Kahn et al part company when it comes to the pathogenesis of metabolic-risk-factor clustering. Reaven 4 , 5 seemingly holds that all of these factors increase insulin resistance; if so, they presumably account for most of the metabolic susceptibility that gives rise to the clustering of risk factors characteristic of the metabolic syndrome.


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    • Kahn et al 2 claim that the causes of clustering are not well understood and likely are many and diverse. Neither Reaven nor Kahn et al, however, emphasized obesity as a major cause of risk-factor aggregation. The NCEP 8 and, particularly, the IDF 10 have taken the position that obesity especially abdominal obesity is a dominant factor behind the multiplication of risk factors.

    According to the NCEP, the onset of obesity elicits a clustering of risk factors in persons who are metabolically susceptible Figure 1 ; 3. Metabolic susceptibility has many contributing factors, including genetic forms of insulin resistance, increased abdominal fat, ethnic and racial influences, physical inactivity, advancing age, endocrine dysfunction, and genetic diversity.

    According to Reaven 4 , 5 , all of these factors increase insulin resistance, which in turn accounts for most of the metabolic susceptibility that gives rise to the clustering of risk factors characteristic of the metabolic syndrome. Proposed pathogenesis of the clustering of cardiovascular disease risk factors of metabolic origin.

    Prevalence of metabolic syndrome in the clinical practice of general medicine in Italy

    It is doubtful that either Kahn et al or Reaven would object to diagnosing patients with type 2 diabetes, even though logic would require that, if a diagnosis of metabolic syndrome is rejected, so should be the use of the term type 2 diabetes in patients with risk-factor clustering.

    The concordance of the 2 conditions is striking A key point is that simultaneous aggregation of risk factors in patients with elevated glucose concentrations is not coincidental but results from a common pathogenesis. Reaven deserves significant credit for focusing attention on a common etiologic basis for both risk-factor clustering and hyperglycemia in patients with type 2 diabetes.

    Furthermore, in addition to assigning a diagnosis of diabetes, these investigators 1 , 2 presumably have no qualms about applying the labels of hypertension, dyslipidemia, or obesity to patients. Therefore, the concern about informing patients that they have a clustering of these risk factors—ie, the metabolic syndrome—is difficult to understand.

    This diagnosis signifying a risk-factor clustering would seem to convey more of a sense of urgency for intervention than would the presence of only a single risk factor. According to Reaven 1 , when any major CVD risk factor is present, the patient should be evaluated for other risk factors. Thus, a physician must be aware of the concept of risk-factor clustering to understand the rationale for this statement. Of course, it could be said that, when any major CVD risk factor is present, the patient should be evaluated for the presence of other conditions, eg, cancer and rheumatoid arthritis.

    When a physician evaluates a patient, all diagnostic possibilities are in play.

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    So why focus on the presence of other risk factors? Obviously, the answer is that metabolic risk factors commonly occur together, and that fact is one of the main arguments for educating physicians about the metabolic syndrome so as to heighten their awareness of the phenomenon of risk-factor clustering. Such an increased awareness will lead to a more comprehensive approach to risk reduction.

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    At the same time, an understanding of the metabolic syndrome will help physicians to recognize that patients with a clustering of measured risk factors usually have several metabolic risk factors that are hidden from view, eg, a prothrombotic state, a proinflammatory state, and multiple lipoprotein abnormalities, including elevations of apo B 3. The simple, recently proposed criteria for clinical recognition of the metabolic syndrome 3 , 10 can be likened to an iceberg. It seems fruitless to dissect surface configuration of an iceberg when most of the danger lies below. On the other hand, for captain of a ship at sea, seeing the tip of the iceberg can be lifesaving.

    The same is true for a finding of the aggregation of metabolic signs such as high triacylglycerol, low HDL, impaired fasting glucose, and mildly elevated blood pressure in a patient with an increased waist circumference. In such a patient, there is much more in the way of metabolic danger than meets the eye. Certainly, the NCEP never intended the syndrome to be a predictor of short-term risk. It has been suggested that the use of the metabolic syndrome can substitute for risk assessment that uses global risk algorithms; but to do so degrades the reliability of global risk assessment for CVD in the near future.

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    Amazon Giveaway allows you to run promotional giveaways in order to create buzz, reward your audience, and attract new followers and customers. A clinical diagnosis of the metabolic syndrome is useful because it affects therapeutic strategy in patients at higher risk. However, there are 2 views about the best therapeutic strategy for patients with the metabolic syndrome. One view holds that each of the metabolic risk factors should be singled out and treated separately. The other view holds that greater emphasis should be given to implementing therapies that will reduce all of the risk factors simultaneously.

    The latter approach emphasizes lifestyle therapies weight reduction and increased exercise , which target all of the risk factors. This approach is also the foundation of other therapies for targeting multiple risk factors together by striking at the underlying causes, as in the development of drugs to promote weight reduction and to reduce insulin resistance. Treating the underlying causes does not rule out the management of individual risk factors, but it will add strength to the control of multiple risk factors.