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Metabolic Syndrome: Dr. Javaid Iqbal



The co-occurrence of metabolic risk factors for both type 2 diabetes and CVD (abdominal obesity, hyperglycemia, dyslipidemia, and hypertension) suggested the existence of a "metabolic syndrome"]. Other names applied to this constellation of findings have included syndrome X, the insulin resistance syndrome, the  deadly quartet, or the obesity dyslipidemia syndrome


, Abdominal obesity, defined as a waist circumference in men ≥102 cm (40 in) and in women ≥88 cm (35 in) with ethnic-specific waist circumference cut-points 

PLUS any two of the following:

I. Triglycerides >150 mg/dL (1.7 mmol/L) or treatment for elevated triglycerides

II. HDL cholesterol <40 mg/dL (1.03 mmol/L) in men or <50 mg/dL (1.29 mmol/L) in women, or treatment for low HDL

III. Systolic blood pressure >130, diastolic blood pressure >85, or treatment for hypertension

IV. Fasting plasma glucose >100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes; 


Increased weight  

 In the Framingham Heart Study cohort, an increase in weight of 2.25 kg or more over 16 years was associated with a 21 to 45 percent increase in the risk for developing the syndrome  

A large waist circumference alone identifies up to 46 percent of individuals who will develop the metabolic syndIn addition to age, race, and weight, 

Soft Drink Consumption

 In the Framingham Heart Study, soft drink consumption was also associated with an increased risk of developing adverse metabolic traits and the metabolic syndrome. 


Use of atypical antipsychotic medications, especially clozapine, significantly increases risk for the metabolic syndrome 

Other factors associated with an increased risk of metabolic syndrome are 

Postmenopausal status, smoking, low household income, high carbohydrate diet, no alcohol consumption, and physical inactivity …

. In addition, poor cardio respiratory fitness is an independent and strong predictor of metabolic syndrome in both men and women 


THERAPY — Treat underlying causes (overweight/obesity and physical inactivity) by intensifying weight management and increasing physical activity.

Lifestyle modification — Prevention or reduction of obesity, particularly abdominal obesity, is the main therapeutic goal in patients with the metabolic 

Weight reduction is optimally achieved with a multimodality approach including diet, exercise, and possible pharmacologic therapy, as with Orlistat 

Diet — Several dietary approaches have been advocated for treatment of the metabolic syndrome. Most patients with the metabolic syndrome are overweight, and weight reduction, which improves insulin sensitivity, is an important outcome goal of any diet. 

The Mediterranean diet may be beneficial 

In a study comparing the Mediterranean diet (high in fruits, vegetables, nuts, whole grains, and olive oil) with a low-fat prudent diet, subjects in the Mediterranean diet group had greater weight loss, lower blood pressure, improved lipid profiles, improved insulin resistance, and lower levels of markers of inflammation and endothelial 

The DASH diet (daily sodium intake limited to 2400 mg, and higher in dairy intake than the Mediterranean diet), compared to a weight reducing diet emphasizing healthy food choices, resulted in greater improvements in triglycerides, diastolic blood pressure, and fasting glucose, even after controlling for weight loss Foods with low glycemic index may improve glycemia and dyslipidemia 

A diet that is low in glycemic index/glycemic load, replacing refined grains with whole grains, fruits and vegetables, and eliminating high-glycemic beverages, may be particularly beneficial for patients with the metabolic syndrome. 


Exercise may be beneficial beyond its effect on weight loss by more selectively removing abdominal fat, at least in women 

Current physical activity guidelines recommend practical, regular, and moderate regimens for exercise. The standard exercise recommendation is a daily minimum of 30 minutes of moderate-intensity (such as brisk walking) physical activity. Increasing the level of physical activity appears to further enhance the beneficial effect.)

Removal of abdominal adipose tissue with liposuction does not improve insulin sensitivity or risk factors for coronary heart disease, suggesting that the negative energy balance induced by diet and exercise are necessary for achieving the metabolic benefits of weight loss 

Prevention of type 2 diabetes — Although not strictly addressing the metabolic syndrome, clinical trials have shown that lifestyle modifications can substantially reduce the risk of development of type 2 diabetes and the levels of risk factors for CVD in patients at increased risk. Prevention of type 2 diabetes is discussed in detail elsewhere..

Diabetes Prevention Program (DPP), 3234 obese subjects with impaired fasting glucose or impaired glucose tolerance were randomly assigned to one of the following groups 

  • Intensive lifestyle changes with the aim of reducing weight by 7 percent through a low-fat diet and exercise for 150 minutes per week
  • Treatment with Metformin (850 mg twice daily) plus information on diet and exercise
  • Placebo plus information on diet and exercise

At an average follow-up of three years, fewer patients in the intensive lifestyle group developed diabetes (14 versus 22 and 29 percent in the Metformin and placebo groups, respectively). The metabolic syndrome (using ATP III criteria) was present in 53 percent of DPP participants at baseline 

In the remaining subjects (n = 1523), both intensive lifestyle intervention and metformin therapy reduced the risk of developing the metabolic syndrome (three-year cumulative incidences of 51, 45, and 34 percent in the placebo, Metformin, and lifestyle groups, respectively).

Cardiovascular risk reduction — Reduction of risk factors for cardiovascular disease includes treatment of hypertension, cessation of smoking, glycemic control in patients with diabetes, and lowering of serum cholesterol according to recommended guidelines 

Antihypertensive therapy — There are conflicting data on whether angiotensin converting enzyme (ACE) inhibitors or Angiotensin II Receptor blockers (ARB) used to treat hypertension in type 2 diabetes may also help to reduce insulin resistance..

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