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14-September-2008 10:43:23 - Metabolic syndrome Dysmetabolic syndrome X Classification and external resources ICD-9 277.7 OMIM 605552 DiseasesDB 31955 MeSH D024821 Metabolic syndrome is a combination of medical disorders that increase the risk of developing cardiovascular disease and diabetes.1 It affects a great number of people, and prevalence increases with age. Some studies estimate the prevalence in the USA to be up to 25% of the population.2 Metabolic syndrome is also known as metabolic syndrome X, syndrome X, insulin resistance syndrome, Reaven's syndrome, and CHAOS Australia. A similar condition in overweight horses is referred to as equine metabolic syndrome; it is unknown if they have the same etiology. Contents 1 Signs and symptoms 2 Diagnosis 2.1 WHO 2.2 EGIR 2.3 NCEP 2.4 American Heart Association/Updated NCEP 3 Etiology 4 Pathophysiology 5 Prevention 6 Therapy 7 History 8 Controversy 9 See also 10 References Signs and symptoms Symptoms and features are: Fasting hyperglycemia - diabetes mellitus type 2 or impaired fasting glucose, impaired glucose tolerance, or insulin resistance; High blood pressure; Central obesity also known as visceral, male-pattern or apple-shaped adiposity, overweight with fat deposits mainly around the waist; Decreased HDL cholesterol; Elevated triglycerides; Associated diseases and signs are: elevated uric acid levels, fatty liver especially in concurrent obesity, progressing to non-alcoholic fatty liver disease, polycystic ovarian syndrome, hemochromatosis iron overload; and acanthosis nigricans a skin condition featuring dark patches. Diagnosis There are currently two major definitions for metabolic syndrome provided by the International Diabetes Federation3 and the revised National Cholesterol Education Program, respectively. The revised NCEP and IDF definitions of metabolic syndrome are very similar and it can be expected that they will identify many of the same individuals as having metabolic syndrome. The two differences are that IDF excludes any subject without increased waist circumference, while in the NCEP definition metabolic syndrome can be diagnosed based on other criteria and the IDF uses geography-specific cut points for waist circumference, while NCEP uses only one set of cut points for waist circumference regardless of geography. These two definitions are much closer to each other than the original NCEP and WHO definitions. WHO The World Health Organization criteria 1999 require presence of diabetes mellitus, impaired glucose tolerance, impaired fasting glucose or insulin resistance, AND two of the following: blood pressure: ≥ 140/90 mmHg dyslipidaemia: triglycerides TG: ≥ 1.695 mmol/L and high-density lipoprotein cholesterol HDL-C ≤ 0.9 mmol/L male, ≤ 1.0 mmol/L female central obesity: waist:hip ratio 0.90 male; 0.85 female, and/or body mass index 30 kg/m2 microalbuminuria: urinary albumin excretion ratio ≥ 20 mg/min or albumin:creatinine ratio ≥ 30 mg/g EGIR The European Group for the Study of Insulin Resistance 1999 requires insulin resistance defined as the top 25% of the fasting insulin values among non-diabetic individuals AND two or more of the following: central obesity: waist circumference ≥ 94 cm male, ≥ 80 cm female dyslipidaemia: TG ≥ 2.0 mmol/L and/or HDL-C 1.0 mmol/L or treated for dyslipidaemia hypertension: blood pressure ≥ 140/90 mmHg or antihypertensive medication fasting plasma glucose ≥ 6.1 mmol/L NCEP The US National Cholesterol Education Program Adult Treatment Panel III 2001 requires at least three of the following:4 central obesity: waist circumference ≥ 102 cm or 40 inches male, ≥ 88 cm or 36 inchesfemale dyslipidaemia: TG ≥ 1.695 mmol/L 150 mg/dl dyslipidaemia: HDL-C 40 mg/dL male, 50 mg/dL female blood pressure ≥ 130/85 mmHg fasting plasma glucose ≥ 6.1 mmol/L 110 mg/dl American Heart Association/Updated NCEP There is confusion as to whether AHA/NHLBI intended to create another set of guidelines or simply update the NCEP ATP III definition. According to Scott Grundy, University of Texas Southwestern Medical School, Dallas, Texas, the intent was just to update the NCEP ATP III definition and not create a new definition.56: Elevated waist circumference: Men - Equal to or greater than 40 inches 102 cm Women - Equal to or greater than 35 inches 88 cm Elevated triglycerides: Equal to or greater than 150 mg/dL Reduced HDL good cholesterol: Men - Less than 40 mg/dL Women - Less than 50 mg/dL Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of medication for hypertension Elevated fasting glucose: Equal to or greater than 100 mg/dL 5.6 mmol/L or use of medication for hyperglycemia Etiology The cause of the metabolic syndrome is unknown. The pathophysiology is extremely complex and has been only partially elucidated. Most patients are older, obese, sedentary, and have a degree of insulin resistance. The most important factors in order are: aging, genetics and lifestyle, i.e., low physical activity and excess caloric intake. There is debate regarding whether obesity or insulin resistance is the cause of the metabolic syndrome or if they are consequences of a more far-reaching metabolic derangement. However, metabolic syndrome is not observed in the absence of insulin resistance, while obesity is not present in many individuals who present with metabolic syndrome. A number of markers of systemic inflammation, including C-reactive protein, are often increased, as are fibrinogen, interleukin 6 IL-6, Tumor necrosis factor-alpha TNFα and others. Some have pointed to oxidative stress due to a variety of causes including increased uric acid levels caused by dietary fructose.789 Pathophysiology Commonly there is development of visceral fat after which the adipocytes fat cells of the visceral fat increase plasma levels of TNFα and alter levels of a number of other substances e.g., adiponectin, resistin, PAI-1. TNFα has been shown not only to cause the production of inflammatory cytokines, but possibly to trigger cell signalling by interaction with a TNFα receptor that may lead to insulin resistancecitation needed. An experiment with rats that were fed a diet one-third of which was sucrose has been proposed as a model for the development of the metabolic syndrome. The sucrose first elevated blood levels of triglycerides, which induced visceral fat and ultimately resulted in insulin resistance 10. The progression from visceral fat to increased TNFα to insulin resistance has some parallels to human development of metabolic syndrome. Prevention Various strategies have been proposed to prevent the development of metabolic syndrome. These include increased physical activity such as walking 30 minutes every day,11 and a healthy, reduced calorie diet.12 There are many studies that support the value of a healthy lifestyle as above. However, one study stated that these measures are effective in only a minority of people.13 The International Obesity Taskforce states that interventions on a sociopolitical level are required to reduce development of the metabolic syndrome in populations.14 A 2007 study of 2,375 male subjects over 20 years suggested that daily intake of a pint of milk or equivalent dairy products more than halved the risk of metabolic syndrome.15 Other studies both support and dispute the authors' findings.16 The most obvious method of prevention is undoubtedly to reduce the amount of carbohydrates, specifically fast digesting starches and sugars.citation needed Therapy The first line treatment is change of lifestyle i.e., caloric restriction and physical activity. However, drug treatment is frequently required. Generally, the individual disorders that comprise the metabolic syndrome are treated separately. Diuretics and ACE inhibitors may be used to treat hypertension. Cholesterol drugs may be used to lower LDL cholesterol and triglyceride levels, if they are elevated, and to raise HDL levels if they are low. Use of drugs that decrease insulin resistance e.g., metformin and thiazolidinediones, is controversial; this treatment is not approved by the FDA in the US. A 2003 study indicated that cardiovascular exercise was therapeutic in approximately 31% of cases. The most probable benefit was to triglyceride levels, with 43% showing improvement; but fasting plasma glucose and insulin resistance of 91% of test subjects did not improve.13 Many other studies have supported the value of increased physical activity and restricted caloric intake exercise and diet to treat metabolic syndrome. History The term metabolic syndrome dates back to at least the late 1950s, but came into common usage in the late 1970s to describe various associations of risk factors with diabetes, that had been noted as early as the 1920s.1718 The Marseilles physician Dr. Jean Vague, in 1947, made the interesting observation that upper body obesity appeared to predispose to diabetes, atherosclerosis, gout, and calculi.19 Avogaro, Crepaldi and co-workers described six moderately obese patients with diabetes, hypercholesterolemia, and marked hypertriglyceridemia all of which improved when the patients were put on a hypocaloric, low carbohydrate diet.20 In 1977, Haller used the term metabolic syndrome for associations of obesity, diabetes mellitus, hyperlipoproteinemia, hyperuricemia and steatosis hepatis when describing the additive effects of risk factors on atherosclerosis.21 The same year, Singer used the term for associations of obesity, gout, diabetes mellitus, and hypertension with hyperlipoprotenemia.22 In 1977 and 1978, Gerald B. Phillips developed the concept that risk factors for myocardial infarction concur to form a constellation of abnormalities i.e., glucose intolerance, hyperinsulinemia, hyperlipidemia hypercholesterolemia and hypertriglyceridemia and hypertension that is associated not only with heart disease, but also with aging, obesity and other clinical states. He suggested there must be an underlying linking factor, the identification of which could lead to the prevention of cardiovascular disease; he hypothesized that this factor was sex hormones.2324 In 1988, in his Banting lecture, Gerald M. Reaven proposed insulin resistance as the underlying factor and named the constellation of abnormalities Syndrome X. Reaven did not include abdominal obesity, which has also been hypothesized as the underlying factor, as part of the condition.25 The terms metabolic syndrome, insulin resistance syndrome, and syndrome X are now used specifically to define a constellation of abnormalities that is associated with increased risk for the development of type 2 diabetes and atherosclerotic vascular disease e.g. heart disease and stroke. Controversy The clinical value of the metabolic syndrome has recently come under fire. It is asserted that different sets of conflicting and incomplete diagnostic criteria are in existence, and that diagnosis of the metabolic syndrome has a negligible association with the risk of heart disease.26 These concerns have led to the American Diabetes Association and the European Association for the Study of Diabetes to issue a joint statement identifying eight major concerns on the clinical utility of the metabolic syndrome.27 It is not contested that cardiovascular risk factors tend to cluster together, but what is contested is the assertion that the metabolic syndrome is anything more than the sum of its constituent parts. See also Hyperinsulinemia Insulin resistance Chronic Somogyi rebound References ^ MedlinePlus: Metabolic Syndrome ^ Ford ES, Giles WH, Dietz WH 2002. Prevalence of metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 2873:356-359. PMID 11790215 ^ The IDF consensus worldwide definition of the metabolic syndrome. PDF ^ Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. 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 2001;285:2486-97. PMID 11368702. ^ Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant D, for the Conference Participants. Definition of metabolic syndrome: report of the National, Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004;109:433-438. ^ American Heart Association's description of Syndrome X ^ Nakagawa T, Hu H, Zharikov S, Tuttle KR, Short RA, Glushakova O, Ouyang X, Feig DI, Block ER, Herrera-Acosta J, Patel JM, Johnson RJ 2006. A causal role for uric acid in fructose-induced metabolic syndrome. Am J Phys Renal Phys 290 3: F625-F631. doi:10.1152/ajprenal.00140.2005. PMID 16234313. ^ Hallfrisch J 1990. Metabolic effects of dietary fructose. FASEB J 4 9: 2652-2660. PMID 2189777. ^ Reiser S, Powell AS, Scholfield DJ, Panda P, Ellwood KC, Canary JJ 1989. Blood lipids, lipoproteins, apoproteins, and uric acid in men fed diets containing fructose or high-amylose cornstarch. Am J Clin Nutr 49 5: 832-839. PMID 2497634. ^ Fukuchi S, Hamaguchi K, Seike M, Himeno K, Sakata T, Yoshimatsu H. 2004. Role of Fatty Acid Composition in the Development of Metabolic Disorders in Sucrose-Induced Obese Rats. Exp Biol Med 229 6: 486-493. PMID 15169967. ^ Lakka TA, Laaksonen DE 2007. Physical activity in prevention and treatment of the metabolic syndrome. Applied physiology, nutrition, and metabolism = Physiologie appliquée, nutrition et métabolisme 32 1: 76-88. doi:10.1139/h06-113. PMID 17332786. ^ Feldeisen SE, Tucker KL 2007. Nutritional strategies in the prevention and treatment of metabolic syndrome. Appl Physiol Nutr Metab 32 1: 46-60. doi:10.1139/h06-101. PMID 17332784. ^ a b Katzmaryk, Peter T; Leon, Arthur S.; Wilmore, Jack H.; Skinner, James S.; Rao, D. C.; Rankinen, Tuomo; Bouchard, Claude October 2003. Targeting the Metabolic Syndrome with Exercise: Evidence from the HERITAGE Family Study.. Med. Sci. Sports Exerc 35 10: 1703-1709. doi:10.1249/01.MSS.0000089337.73244.9B. Retrieved on 2007-06-24. ^ James PT, Rigby N, Leach R 2004. The obesity epidemic, metabolic syndrome and future prevention strategies. Eur J Cardiovasc Prev Rehabil 11 1: 3-8. doi:10.1097/01.hjr.0000114707.27531.48. PMID 15167200. ^ Elwood, PC; Pickering JE, Fehily AM 2007. Milk and dairy consumption, diabetes and the metabolic syndrome: the Caerphilly prospective study. J Epidemiol Community Health 61 8: 695-698. doi:10.1136/jech.2006.053157. PMID 17630368. ^ Snijder MB, van der Heijden AA, van Dam RM, et al 2007. Is higher dairy consumption associated with lower body weight and fewer metabolic disturbances? The Hoorn Study. Am. J. Clin. Nutr. 85 4: 989-95. PMID 17413097. ^ Joslin EP. The prevention of diabetes mellitus. JAMA 1921;76:79-84. ^ Kylin E. Studies of the hypertension-hyperglycemia-hyperuricemia syndrome German. Zentralbl Inn Med 1923;44: 105-27. ^ Vague J. La diffférenciacion sexuelle, facteur déterminant des formes de l'obésité. Presse Med 1947;30:339-40. ^ Avogaro P, Crepaldi G, Enzi G, Tiengo A. Associazione di iperlipidemia, diabete mellito e obesità di medio grado. Acta Diabetol Lat 1967;4:572-590. ^ Haller H. Epidemiology and associated risk factors of hyperlipoproteinemia German. Z Gesamte Inn Med 1977;328:124-8. PMID 883354. ^ Singer P. Diagnosis of primary hyperlipoproteinemias German. Z Gesamte Inn Med 1977;329:129-33. PMID 906591. ^ Phillips GB. Sex hormones, risk factors and cardiovascular disease. Am J Med 1978;65:7-11. PMID 356599. ^ Phillips GB. Relationship between serum sex hormones and glucose, insulin, and lipid abnormalities in men with myocardial infarction. Proc Natl Acad Sci U S A 1977;74:1729-1733. PMID 193114. ^ Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 1988;37:1595-607. PMID 3056758. ^ Richard Kahn 2008. Metabolic syndrome-what is the clinical usefulness?. Lancet 371: 1892-1893. doi:10.1016/S0140-67360860731-X. ^ Kahn R, Buse J, Ferrannini E, Stern M 2005. The metabolic syndrome: time for a critical appraisal. Joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 28: 2289-2304. doi:10.2337/diacare.28.9.2289. PMID 16123508. Retrieved from http://en..org/wiki/Metabolic_syndrome Categories: Diabetes | Endocrinology | Medical conditions related to obesity | SyndromesHidden categories: All articles with statements | Articles with statements since August 2007 | Articles with statements since July 2008 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Deutsch Español í•œêµì–´ Italiano Nederlands 日本語 Polski Português РуÑ?Ñ?кий Suomi Svenska ä¸æ–‡ This page was last modified on 10 September 2008, at 01:42
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