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Metabolic Syndrome:
Overview and Current Guidelines
Julian Halcox, MD, MA, MRCP
Arshed A. Quyyumi, MD, FRCP
T
he cluster of risk factors for atherosclerosis that
constitute the metabolic syndrome was first rec- TAKE HOME POINTS
ognized in 1983. In 1988, Reaven introduced
the term syndrome X to highlight insulin resis- • Metabolic syndrome is a cluster of risk factors for
tance as a common denominator for the dyslipidemia, cardiovascular disease (CVD) that includes abdom-
elevated blood pressure, and impaired glucose tolerance inal obesity, dyslipidemia, elevated blood pressure,
in the context of abdominal obesity that characterize and impaired glucose tolerance.
this syndrome. Other notable features of the syndrome • CVD is considered the principal clinical end point
include a proinflammatory state, microalbuminuria, and of the metabolic syndrome, while type 2 diabetes
hypercoagulability. Although other terms have been used mellitus is considered another important sequelae.
to describe this cluster of risk factors, metabolic syndrome is • The principal determinant of the syndrome is obe-
now the accepted term. sity, particularly visceral/abdominal obesity.
Up to 50 million people in the United States are • Lifestyle interventions with intensive dietary modi-
believed to have the metabolic syndrome and are thus fications and increased physical activity are first-line
at increased risk of developing atherosclerotic disease. therapy.
Because of this high prevalence and in order to increase • Drug therapies are recommended following lifestyle
awareness of the syndrome among practicing physicians, modification in patients with a CVD risk greater than
several expert bodies (eg, the World Health Organization 20% or in those with another indication for drug
[WHO] and the American Association of Clinical Endo- therapy targeting specific risk factors.
crinologists [AACE]) have published diagnostic criteria
for the metabolic syndrome. The criteria developed in
the National Cholesterol Education Program’s Adult
Treatment Panel III report (ATP III) are the most widely diet, and physical inactivity. Major risk factors for CHD
used in US clinical practice.1 include aging, tobacco use, increased serum concentra-
The purpose of this article, the first in a series on the tion of low-density lipoprotein (LDL) cholesterol, low
metabolic syndrome, is to provide the reader with an serum concentration of high-density lipoprotein (HDL)
understanding of how to recognize patients with and at cholesterol, high blood pressure, and a history of pre-
risk for developing the metabolic syndrome and to re- mature CHD in a first-degree relative (male, < 55 years;
view current strategies for treatment of these individuals. female, < 65 years). Emerging risk factors include hy-
We present a typical case of a patient presenting with the pertriglyceridemia, small, dense LDL particles, insulin
metabolic syndrome to illustrate several key issues in the resistance with glucose intolerance, inflammation, and
management of this condition. a prothrombotic state.
diagnosis of the metabolic syndrome by WHO crite- to 30% over the last 2 decades of the last century.
ria. Presence of 2 other risk factors is also required Just under 40 million US adults are clinically obese
for diagnosis of the metabolic syndrome, includ- (BMI ≥ 30 kg/m2), and over 60% are overweight or
ing taking antihypertensive medication and/or obese (BMI ≥ 25 kg/m2). Although there are mul-
presence of high blood pressure (≥ 140 mm Hg tiple causes for obesity, including genetic, environmen-
systolic or ≥ 90 mm Hg diastolic); plasma triglycer- tal, and psychological causes, the “obesity epidemic”
ides ≥ 150 mg/dL; HDL cholesterol < 35 mg/dL is principally driven by increased consumption of
(< 0.9 mmol/L) in men or < 39 mg/dL (1.0 mmol/L) cheap, calorie-dense food and reduced physical activity.
ratio > 0.9 in men and > 0.85 in women; and/or uri- Accumulation of excessive visceral adipose tissue (in
nary albumin excretion rate ≥ 20 µg/min or albumin- the presence or absence of obesity) is associated with
to-creatinine ratio ≥ 30 mg/g. insulin resistance, hyperinsulinemia, and glucose intol-
erance.7 In addition, excess abdominal obesity is associ-
AACE Criteria ated with a potentially atherogenic lipoprotein profile,
Further clinical criteria for the “insulin resistance which includes (1) hypertriglyceridemia; (2) elevated
syndrome” were proposed by the AACE.6 However, apolipoprotein B levels; (3) an increased proportion of
in this set of criteria a defined number of risk factors small, dense LDL particles; and (4) reduced HDL cho-
is not required, and diagnosis is left to clinical judg- lesterol concentrations. Visceral fat releases nonesteri-
ment. Criteria are similar to those comprising the ATP fied fatty acids that overload muscle and liver with lipids,
III and WHO criteria and include the following: BMI enhancing insulin resistance. Levels of adiponectin are
≥ 25 kg/m2; triglycerides ≥ 150 mg/dL; HDL choles- reduced in obesity and are associated with reduced in
terol < 40 mg/dL (men), < 50 mg/dL (women); blood sulin sensitivity and an adverse risk factor profile.
pressure ≥ 135/≥ 85; 2-hour postglucose challenge
> 140 mg/dL; fasting glucose between 110 and Insulin Resistance
126 mg/dL; family history of type 2 diabetes, hyperten- Insulin resistance typically increases with increasing
sion, or CVD; sedentary lifestyle; advancing age; ethnic body fat composition and is an important predisposing
groups having high risk for type 2 diabetes or CVD; mechanism for development of the metabolic syn-
and polycystic ovary syndrome. drome. Most obese and many overweight individuals
The ATP III criteria are the most easily applied in have reduced insulin sensitivity and evidence of post-
clinical practice as they utilize simple and practical tests prandial hyperinsulinemia. However, a range of resis-
and do not require formal testing of glucose tolerance tance to the effects of insulin is observed within these
or urine collection. Thus, the diagnostic costs are mini- population subgroups.8 Certain ethnic groups, particu-
mized without significant loss of power to predict CVD larly South Asians, have an increased predisposition
risk. A strength of the WHO and ACCE guidelines is to exhibit insulin resistance and develop metabolic
that impaired glucose tolerance is a good predictor of syndrome, even with BMI in the normal range.9 This
the risk of developing type 2 diabetes. variability implies an important genetic contribution
towards insulin resistance and its common metabolic
• How does metabolic syndrome develop? correlates. Indeed, these individuals are typically more
susceptible to the adverse metabolic consequences of
PATHOGENESIS increasing abdominal obesity, making it difficult to dis-
The principal determinant of the metabolic syn- tinguish the relative importance of obesity and insulin
drome is obesity, particularly visceral/abdominal obe- resistance in the development of metabolic syndrome.
sity. Insulin resistance and other metabolic correlates At physiological concentrations, insulin has vasodi-
also mediate certain processes that characterize meta- lator and anti-inflammatory actions that are mediated
bolic syndrome. Increasing age, a sedentary lifestyle, in part through the release of nitric oxide (NO) and
and certain endocrine conditions contribute as well. inhibition of the transcription factor nuclear factor-κB
(NF-κB).10 Additionally, the PI3 kinase pathway medi-
Abdominal Obesity ates the vasodilator and anti-inflammatory effects of
Over recent years there has been a steady and dra- insulin via activation of NO synthase. The MAP kinase
matic rise in the prevalence of obesity in all demo- pathway promotes the mitogenic effects that lead to
graphic groups in the United States. According to the cell growth and proliferation. Insulin resistance is char-
National Health and Nutrition Evaluation Surveys, acterized by impaired activation of the PI3 kinase path-
the age-adjusted prevalence of obesity rose from 15% way, combined with preserved signaling via the MAP
kinase pathway, which shifts the balance in favor of the syndrome, and atherosclerotic cardiovascular events
atherogenic actions of insulin, probably by differential may have a common inflammatory origin (Figure 1).
signal amplification. Insulin resistance in muscle pro-
motes glucose intolerance, which can be worsened by • What are the clinical consequences of the metabolic
increased hepatic gluconeogenesis in insulin-resistant syndrome?
liver as well as by diverting excess free fatty acids to the
liver. In parallel, insulin resistance in adipose tissue is CLINICAL SEQUELAE
associated with decreased uptake and increased release The critical clinical sequelae of the metabolic syn-
of free fatty acids, which are converted in the liver to drome are type 2 diabetes mellitus, hypertension,
triglyceride-rich very-low-density lipoprotein (VLDL) dyslipidemia, and atherosclerotic vascular disease, par-
particles. The resulting hypertriglyceridemia drives the ticularly coronary artery disease.
dyslipidemic triad by promoting the synthesis of small,
easily oxidizable dense LDL and enhanced clearance Diabetes Mellitus
of HDL, which is believed to be highly atherogenic. Most patients who develop type 2 diabetes mellitus
Low HDL may also be a consequence of decreased are obese, predominantly with abdominal obesity, and
ATP-binding cassette transporter 1 expression, which have either relative insulin deficiency or insulin resis-
mediates reverse cholesterol transport in peripheral tance with an insulin secretory defect. Chronic hyper-
cells. glycemia itself can inhibit expression of the insulin
gene and thus impair glucose-stimulated insulin secre-
Inflammation and Adipocytokines tion, which is also inhibited by increased free fatty acid
Adipose tissue is a rich source of cytokines, includ- levels resulting from increased visceral adipose tissue
ing TNF-α and IL-6, adiponectin, and resistin,11 which lipolysis. Clinical manifestation of diabetes in these
are collectively referred to as adipocytokines. Adipocyto individuals may not occur for many years after develop-
kines contribute to insulin resistance via putative endo- ment of glucose intolerance and metabolic syndrome
crine, paracrine, and/or autocrine actions, which may abnormalities. Thus, the development of clinical mac-
also mediate the link between abdominal obesity and rovascular and microvascular disease is promoted
the metabolic syndrome. Relevant functions of TNF-α long before the development of overt diabetes,16 with
include modulation of lipid metabolism; reduction of approximately 50% of type 2 diabetics already having
tyrosine kinase activity in insulin receptors, inhibiting some form of macrovascular or microvascular disease
insulin signaling and sensitivity; downregulation of at the time of diagnosis of diabetes. Individuals with
glucose transporter proteins; promotion of pancreatic diabetes have a greatly increased risk of cardiovascu-
beta-cell dysfunction; and impairment of endothelial lar events, and those events are more likely to be fatal
function. Indeed, circulating and tissue levels of TNF- compared with events in nondiabetics.17 The ATP III
α are typically increased in association with hyper guidelines recognize this increased risk and state that
insulinemia in obesity, with this relationship reversing diabetes is a CHD risk equivalent and that preven-
after weight reduction. Approximately 30% of circulat- tive measures should be as aggressive in patients with
ing IL-6 originates from adipose tissue in healthy indi- diabetes as in those with established clinical atheroscle-
viduals. Waist circumference correlates strongly with rotic disease.
CRP and fibrinogen levels, explaining between 15%
and 42% of the total variability for CRP levels, an asso- Hypertension
ciation that is stronger in women.12 Levels of adiponec- Blood pressure is particularly sensitive to sodium
tin, a protein with potential anti-atherosclerotic proper- intake in obese patients. Insulin also has an anti
ties, are lower in obese and diabetic individuals and natriuretic effect and promotes activation of the sym-
correlate inversely with the degree of insulin resistance, pathetic nervous system. Vascular inflammation and
hyperinsulinemia, and CRP.13–15 impaired endothelium-dependent vasomotor function
Together these cytokines induce an inflammatory may cause vasoconstriction, increased cardiac output,
response in the vessel wall, with circulating levels of and enhanced renal sodium absorption and thus may
CRP and other inflammatory markers serving as po- contribute to the development of hypertension in pa-
tential markers of an adverse cardiovascular prognosis tients with metabolic syndrome.18 Of note, up to 50%
and increased risk of developing type 2 diabetes in pa- of patients with hypertension have evidence of insulin
tients with and without the metabolic syndrome. Thus, resistance and peripheral tissue glucose intolerance,19
the pathophysiology of insulin resistance, metabolic again suggestive of a common etiology.
Metabolic Syndrome
Hyperglycemia/dyslipidemia
Renin-angiotensin
Insulin Resistance/Hyperinsulinemia
Adipocyte system activation
Adipocytokines ↑CRP
Sympathetic activation
inflammation thrombosis Sodium retention
↑Endothelin ↑Cytokines Platelet activation
↑OxLDL TNF-α ↑PAI-1
↑Tissue factor
↑CRP IL-1 ↑Endothelin
↑ICAM-1
↑VCAM-1
Endothelium
Leukocyte
Smooth Muscle recruitment
Constriction
Hyperplasia
Hypertrophy
Migration
Atherosclerosis Hypertension
Figure 1. Pathophysiology of cardiovascular disease in metabolic syndrome. AP-1 = activator protein-1; CRP = C-reactive protein;
ICAM-1 = intercellular adhesion molecule; IL = interleukin; NF = nuclear factor; NO = nitric oxide; OxLDL = oxidized LDL; PAI =
plasminogen activator inhibitor; TNF = tumor necrosis factor; VCAM-1 = vascular cell adhesion molecule.
Dyslipidemia free fatty acids into the portal system, promoting hepatic
The lipid profile associated with metabolic syndrome synthesis of triglycerides and VLDL. Lipoprotein lipase
is characterized by increased apolipoprotein B– in peripheral tissues hydrolyses VLDL to form IDL
containing lipoproteins, plasma triglyceride, and and remnant particles. Triglyceride-rich LDL particles
intermediate-density lipoprotein (IDL) levels as well are also generated and are further modified by lipo
as reduced HDL cholesterol and an increased propor- protein lipase to produce small, dense LDL particles
tion of small, dense, cholesteryl ester–depleted LDL that promote atherogenesis by various mechanisms,
particles with relatively normal or only mildly elevated including increased susceptibility to oxidation, reduced
LDL cholesterol concentration.20 This profile is also hepatic-receptor–mediated clearance, increased
seen in patients with type 2 diabetes mellitus, and scavenger-receptor–mediated uptake, and greater arte-
more commonly in patients without diabetes but with rial wall retention. Furthermore, insulin resistance leads
insulin resistance. Insulin resistant visceral adipocytes to increased hepatic lipase activity, which hydrolyzes and
are more sensitive to the lipolytic effects of glucocor- reduces levels of antiatherogenic HDL cholesterol.
ticoids and catecholamines, which increase release of Other factors associated with metabolic syndrome
Prothrombotic state
Consider aspirin
Figure 2. Management of patients with metabolic syndrome. CHD = coronary heart disease; HDL = high-density lipoprotein; LDL =
low-density lipoprotein.
blood pressure < 125/75 mm Hg; LDL cholesterol con- JNC 7 recommendations. JNC 7 recognizes the particu-
centration < 100 mg/dL; triglyceride level < 150 mg/dL; lar importance of therapeutic lifestyle changes, includ-
and HDL cholesterol concentration > 40 mg/dL in men ing weight loss, physical exercise, implementation of
and > 50 mg/dL in women. Specific drug classes that the low-sodium DASH diet, and limitation of alcohol
are necessary in treating metabolic syndrome include consumption. If blood pressure remains uncontrolled,
statins, ACE inhibitors or angiotensin receptor block pharmacologic therapy should be implemented. Some
ers (ARBs), fibrates, and thiazolidinediones. N-3 fatty recent trials with ACE inhibitors and ARBs have shown
acids may also have an important role. a reduction in the development of type 2 diabetes,
Elevated blood pressure. In the ATP III classifica- making use of these agents more compelling in meta-
tion, a blood pressure level of ≥ 130/≥ 85 mm Hg is in- bolic syndrome.28,29
cluded as one of the criteria for diagnosis of metabolic Insulin resistance and glucose intolerance. Resis-
syndrome. This slightly lower blood pressure threshold tance to the effects of insulin with associated glucose
recognizes the important contribution of even small intolerance and elevated glucose levels is a principal
increases in blood pressure above 120/80 mm Hg to feature of metabolic syndrome. Treatment of insulin
the pathogenesis of arterial disease, particularly in the resistance can improve not only glucose tolerance but
presence of multiple risk factors. The Seventh Report also the associated dyslipidemia and other associated
of the Joint National Committee on Prevention, Detec- metabolic abnormalities. A low-calorie diet that is low
tion, Evaluation, and Treatment of High Blood Pressure in refined carbohydrates and saturated fats together
(JNC 7) also recognized this issue by introducing the with a sensible exercise program should be the main-
concept of “prehypertension” (120–139/80–89 mm Hg). stay of treatment of insulin resistance. Drugs that en-
27 Individuals with prehypertension require more care- hance insulin sensitivity, such as metformin and the
ful blood pressure surveillance and attention to levels thiazolidenediones (eg, rosiglitazone and pioglitazone,
of other risk factors. Patients with metabolic syndrome which are peroxisome proliferator activated receptor γ
who fulfill the diagnostic criteria for hypertension (blood agonists), have the potential to delay the onset of type
pressure ≥ 140/≥ 90 mm Hg, and ≥ 130/≥ 80 mm Hg in 2 diabetes and improve the metabolic profile, and thus
patients with diabetes) should be treated according to reduce the risk of atherosclerosis. In the Finnish Dia-
Every Visit N
Visit 1 6 wk Visit 2 6 wk Visit 3 4–6 mo
Monitor adherence
Begin TLC Evaluate LDL Evaluate LDL
to TLC
response response
If LDL goal not If LDL goal not
achieved, intensify achieved, intensify
LDL-lowering therapy LDL-lowering therapy
Figure 3. Treatment of lipid abnormalities. LDL = low-density lipoprotein; TLC = therapeutic lifestyle changes.
betes Prevention Study, which included 522 participants cholesterol. Therefore, ATP III introduced the concept
with metabolic syndrome, intensive therapeutic lifestyle of non-HDL cholesterol, which incorporates all the po-
changes reduced the risk of type 2 diabetes mellitus by tentially atherogenic lipoprotein subfractions. Non-HDL
58% compared to controls.30 In the Diabetes Prevention cholesterol targets are 30 mg/dL greater than those for
Program, metformin 850 mg twice daily reduced the LDL cholesterol and should be used when triglyceride
progression from impaired glucose tolerance to type 2 levels exceed 200 mg/dL.
diabetes mellitus by 31%, whereas intensive therapeutic In patients who do not achieve LDL cholesterol tar-
lifestyle changes reduced this risk by 58% compared to gets with therapeutic lifestyle changes, statin therapy
placebo.31 Despite promising initial results, insulin sensi- should be initiated. Statin therapy improved survival
tizers have not been shown to reduce the risk of cardio- and reduced cardiac events and strokes in several large,
vascular events, and until results from ongoing studies randomized placebo-controlled clinical trials.32–34 The
persuade us otherwise, these agents cannot at present Collaborative Atorvastatin Diabetes Study and subgroup
be recommended for preventive therapy. analyses in the Heart Protection Study demonstrated
Lipid abnormalities. Lifestyle modification with added benefits in diabetics, even when cholesterol lev-
diet and exercise remains the first-line therapy of lipid els were not significantly elevated.32,33 Statins reduce all
abnormalities in metabolic syndrome (Figure 3). Al- apolipoprotein B–containing lipoproteins and will usu-
though elevated LDL cholesterol is not a defining fea- ally be able to achieve ATP III targets for both LDL and
ture of the abnormal lipid profile in metabolic syn- non-HDL cholesterol in patients with metabolic syn-
drome, this and other apolipoprotein B–containing drome.
lipoproteins are highly atherogenic. Intensity of LDL Fibric acid derivatives improve most components of
lowering should be guided by the cardiovascular risk the atherogenic lipid profile in metabolic syndrome, par-
score: in those at high risk (≥ 20% as determined by ticularly the low HDL level, high triglycerides, and small,
presence of CHD or CHD risk equivalents or Framing dense LDL particles, and their use should be considered
ham risk score), the LDL target is < 100 mg/dL; in patients at high risk (> 20%) or with CHD. High-dose
others with metabolic syndrome should be consid- nicotinic acid can also improve HDL and triglyceride lev-
ered at intermediate risk (10%–20% or 2 or more risk els with similar efficacy to fibrates but can also impair glu-
factors) and treated to a target LDL < 130 mg/dL.1 cose tolerance and increase uric acid levels and therefore
Furthermore, patients with high triglyceride levels should be used with caution in patients with metabolic
(> 200 mg/dL, very common in metabolic syn- syndrome.
drome) also have increased levels of atherogenic Prothrombotic and proinflammatory state. In meta-
remnant particles (eg, VLDL and IDL cholesterol) bolic syndrome, levels of proinflammatory cytokines
that are not addressed by focusing solely on LDL (eg, IL-6 and TNF–α) and acute phase reactants (eg,
CRP and fibrinogen) are typically increased. Plasmino- to ATP III criteria (hypertension, low HDL, and male
gen activator inhibitor-1 levels are also typically elevat- ≥ 45 years old). This is largely explained by his rela-
ed, and tissue plasminogen activator levels are reduced, tively young age, which has a major influence on the
contributing to the characteristic proinflammatory and 10-year risk estimate. Nonetheless, he is at high relative
prothrombotic milieu of metabolic syndrome. The clin- risk for his age-group, and in view of these additional
ical value of measuring these factors is controversial and risk factors would be a potential candidate for lipid-
is an evolving area of interest in preventive cardiovascu- lowering drug therapy to reduce his LDL cholesterol
lar medicine. Although measurement of fibrinogen and level to a target of 130 mg/dL or less. However, he has
other coagulation factors is not currently recommended made some progress with therapeutic lifestyle changes,
in routine practice, the American Heart Association rec- and the physician elects to continue with these mea-
ommends routine aspirin prophylaxis in patients with a sures at this juncture. The physician plans to assess prog-
10-year coronary risk of 10% or more.35,36 ress at 3 and 6 months after the initial consultation, with
consideration of starting pharmacologic therapy with
Case Presentation: Initiation of Therapy a statin and/or angiotensin-converting-enzyme (ACE)
Using the ATP III online risk calculator (available inhibitor if LDL and/or systolic blood pressure remain
at http://hin.nhlbi.nih.gov/atpiii/calculator.asp? elevated. Lifestyle recommendations will continue to
usertype=pub), the physician calculates the patient’s 10- be reinforced during follow-up, and no specific phar-
year cardiovascular risk to be 20%, which can be consid- macologic therapy will be recommended to treat his
ered a CHD risk equivalent. However, the patient does low HDL or insulin resistance in the near future.
not have clinical atherosclerotic disease, and if the risk
is recalculated omitting smoking, his 10-year risk would SUMMARY
be estimated at 6%. The physician therefore advises ag- Metabolic syndrome is a cluster of risk factors for
gressive lifestyle intervention to include diet, exercise, atherosclerosis, including abdominal obesity, elevated
and smoking cessation. The patient receives counsel- blood pressure, dyslipidemia, and glucose intolerance.
ing from a nurse practitioner specializing in preven- Metabolic syndrome increases the risk of type 2 diabetes
tion of vascular disease to improve his understanding and atherosclerotic cardiovascular disease. Development
of his risk status, with a focus on the contribution of of metabolic syndrome is driven predominantly by ab-
and importance of treatment of the multiple risk fac- dominal obesity with increasing age and genetic factors
tors acting synergistically to increase his risk of heart (eg, South Asian and Hispanic ethnicity also contribute).
attack and stroke. He is advised to start a program of Therapeutic lifestyle interventions focusing on dietary
moderate exercise for 10 to 15 minutes 3 times per modification and increased physical activity to maximize
week, with the aim of increasing the duration and fre- weight loss are the mainstay of clinical management of
quency to at least 30 minutes per day at least 5 times per metabolic syndrome. Drug therapy should be consid-
week as his fitness level improves. He is advised to follow ered to achieve therapeutic goals for lipids, particularly
a therapeutic lifestyle changes diet (low in saturated fat low-density lipoprotein cholesterol, and blood pressure
and cholesterol and high in fruit, vegetables, fiber and in patients with metabolic syndrome who do not achieve
complex carbohydrates) as recommended in the ATP targets with lifestyle interventions. Low-dose aspirin
III report. A consult is requested from the local smoking should be considered in patients with a 10-year coronary
cessation service, who prescribe a course of nicotine re- risk of 10% or more. Treatment of insulin resistance with
placement therapy patches, supported by counseling. metformin or thiazolidenediones is not currently recom-
The patient is reviewed after 6 weeks. He has not mended in the absence of type 2 diabetes. HP
smoked for 1 month and is reasonably but not fully
compliant with his diet and exercise regimen. He References
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