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Metabolic syndrome: What is it and how useful is the diagnosis in clinical practice?
Síndrome metabólica: a sua existência e utilidade do diagnóstico na prática clínica
Evangelista Rocha
Serviço de Cardiologia, Hospital Militar Principal, Lisboa, Portugal
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class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Metabolic syndrome: What is it and how useful is the diagnosis in clinical practice?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "637" "paginaFinal" => "639" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Evangelista Rocha" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Evangelista" "apellidos" => "Rocha" "email" => array:1 [ 0 => "evangelistarocha@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Serviço de Cardiologia, Hospital Militar Principal, Lisboa, Portugal" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome metabólica: a sua existência e utilidade do diagnóstico na prática clínica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Concept</span><p id="par0005" class="elsevierStylePara elsevierViewall">The metabolic syndrome (MS) has been recognized for several decades, although under different names and with different definitions, but in recent years controversy has arisen concerning its definition and significance.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The term does not refer to a specific disease, but to a cluster of metabolic risk factors that tend to occur together: central (or abdominal) obesity, elevated triglycerides, low HDL cholesterol, glucose intolerance and hypertension. It is thus not a genuine clinical entity caused by a single factor, but varies in its components between individuals, particularly between different ethnic groups. Although the concept is well established, there are differences in the criteria for a diagnosis of MS published by various organizations, including the World Health Organization (WHO), the European Group for Study of Insulin Resistance (EGIR), the International Diabetes Federation (IDF), the National Cholesterol Education Program Third Adult Treatment Panel (NCEP-ATPIII), the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). Out of this disagreement came a consensus on a worldwide definition of MS, on the initiative of the IDF and the American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI), together with the World Heart Federation, the International Atherosclerosis Society, and the International Association for the Study of Obesity, published in 2009.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The main difference between the IDF and NCEP-ATP III definitions of MS was in the cutoff used for waist circumference,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> but a single overall value is no longer obligatory, and national or regional cutoffs for waist circumference can be used. In this worldwide definition, the criteria for the clinical diagnosis of MS are: elevated waist circumference (population- and country-specific definitions); elevated triglycerides (≥150<span class="elsevierStyleHsp" style=""></span>mg/dl) or under drug treatment with fibrates or nicotinic acid or taking high-dose omega-3 fatty acids; reduced HDL cholesterol (<40<span class="elsevierStyleHsp" style=""></span>mg/dl in males and <50<span class="elsevierStyleHsp" style=""></span>mg/dl in females) or under drug treatment with fibrates or nicotinic acid; elevated blood pressure (systolic<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>130 and/or diastolic<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>85<span class="elsevierStyleHsp" style=""></span>mmHg) or under antihypertensive therapy; and elevated fasting glucose (≥100<span class="elsevierStyleHsp" style=""></span>mg/dl) or under antidiabetic medication. Nevertheless, the definition of MS is not fully harmonized.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prevalence</span><p id="par0010" class="elsevierStylePara elsevierViewall">The prevalence of MS varies according to age, gender, ethnic origin and the definition used,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–10</span></a> the IDF/AHA/NHLBI criteria being more sensitive than those of the NCEP-ATPIII in identifying MS.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> The prevalence is lower in adolescents than in young adults and the elderly; and lower in males.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9,12</span></a> However, it is estimated that 20–30% of adults in most countries could be considered to have MS.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,13</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Risk</span><p id="par0015" class="elsevierStylePara elsevierViewall">It is accepted that individuals with MS are more prone to diabetes and cardiovascular disease.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> A recent meta-analysis shows that in those with MS according to the 2001 NCEP-ATP III criteria and the revised 2004 criteria, the relative risk of cardiovascular events and death is 2 and 1.5, respectively.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However, most studies indicate that the ability of the syndrome to predict cardiovascular events or disease progression is no greater than that based on the sum of its components.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> On the other hand, a meta-analysis published in 2006 showed increased risk after adjustment for traditional cardiovascular risk factors; the association was stronger in women, in individuals at lower risk (<10%) and in studies based on the WHO definition rather than the NCEP-ATP III or other definitions.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In this meta-analysis the risk associated with MS was greater than the sum of its components, but the question of whether MS is a better predictor of risk than traditional risk factors remains the subject of debate.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Causes</span><p id="par0020" class="elsevierStylePara elsevierViewall">The pathogenesis of MS and of each of its components is not fully understood, but central obesity and insulin resistance are the most important variables in its expression. Excessive visceral adiposity triggers the onset of MS, leading to hyperinsulinemia which may not cause raised fasting or postprandial glucose for years, so long as beta cells continue to respond. However, in genetically predisposed individuals these alterations occur as a result of impaired insulin secretion or reduced glucose tolerance. This pathogenic mechanism, insulin resistance (which is difficult to assess in routine clinical practice), and the inflammatory process triggered by obesity, underlie virtually all aspects of MS.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Adipose tissue dysfunction lies behind the risk arising from visceral obesity, which is associated with atherogenic dyslipidemia (raised triglycerides, low HDL cholesterol, and raised ApoB, small dense LDL particles and small HDL particles), endothelial dysfunction and hypertension.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,19</span></a> Metabolic and pathological factors other than obesity also play a part in this complex process: inflammatory factors, adipocytokines (leptin, adiponectin, resistin), cortisol, oxidative stress, vascular factors, heredity and lifestyle.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Not all can be explained by genetics, since the prevalence of MS has risen in recent years but the human genetic profile has not changed. This suggests that the interaction of environmental factors with genetic predisposition leads individuals with MS to accumulate energy in the form of fat. The most likely culprits are excessive consumption of high-energy foods, especially saturated fats, and sedentary lifestyles, all influenced by various factors related to the home, transport, and the workplace.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prevention and treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">The evidence indicates that individuals with MS have high cardiovascular risk. The hypothesis that MS results from insulin resistance points the way to a control strategy; since weight loss frequently reduces insulin resistance, measures that can be adopted to prevent and treat MS include a healthy, low-energy diet together with regular exercise<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and possibly other measures such as bariatric surgery. Besides, there are currently no drugs that can modulate the mechanisms underlying MS as a whole and reduce the metabolic and cardiovascular effects of the associated risk factors. In individuals in whom lifestyle modification has been insufficient and who are considered at high cardiovascular risk, the residual risk may justify using appropriate therapies to control glucose metabolism abnormalities, lipid disorders and hypertension.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To summarize, clinicians should treat individuals with MS as a high-risk group and advise them to adopt a healthy lifestyle, while estimating their overall risk with a view to prescribing the therapies recommended for cardiovascular prevention in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The study by Rossa et al. in this issue of the <span class="elsevierStyleItalic">Journal</span> aimed to determine the prevalence of MS and to identify variables related to its development in a population of hospital workers in Porto Alegre, Brazil. The methodology was that of a cross-sectional study, in which a representative sample of the target population was analyzed, selected on the basis of an estimated MS prevalence of 25%, a figure in agreement with the literature.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,13</span></a> Components of MS and variables related to its clinical consequences (diabetes and cardiovascular disease) were excluded from the multivariate analysis. Since one aim of the study was to identify socioeconomic, demographic and occupational factors related to the development of MS, it was necessary to control for variables that are part of its definition. The figure for MS prevalence determined by the study (13%) was lower than estimated, but this is due to the participants’ relatively young mean age (35 years). It is also not surprising that this figure is lower than in another Brazilian study with a similarly sized sample but of cardiological outpatients (62% in men and 65% in women),<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and lower than in population studies in Portugal – 27% in a population with a mean age of 59<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and 24% in a national survey (mean age 58).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The higher prevalence of MS in those with a lower educational level is noteworthy; this is further evidence of an environmental component in the pathogenesis of MS interacting with genetic factors.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The literature on MS is vast and there is still disagreement concerning both its definition and its prevalence. It should be borne in mind that MS prevalence depends on methodological aspects of sampling and diagnosis, and so comparative studies are often of limited value. At all events, MS is common, and is considered a high-risk obesity state.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> At the same time, as obesity increases in the young, the prevalence of MS is also set to rise. Strategies should therefore be defined to raise awareness in different population groups, from schools to the workplace. It is essential to prevent obesity by adopting healthy eating habits and taking regular exercise to lose weight or to avoid weight gain. If this behavioral component is not effectively modified, the result will be an increasingly medicated society. To avoid this scenario, it will be necessary to involve health professionals, educators, organizations working in health-related areas, political decision-makers and public health authorities, since the metabolic syndrome is beginning to take on the dimensions of a pandemic.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Concept" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Prevalence" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Risk" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Causes" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Prevention and treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Rocha, E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 5 | 15 |
| 2024 October | 41 | 28 | 69 |
| 2024 September | 49 | 20 | 69 |
| 2024 August | 52 | 29 | 81 |
| 2024 July | 35 | 24 | 59 |
| 2024 June | 29 | 17 | 46 |
| 2024 May | 33 | 21 | 54 |
| 2024 April | 23 | 28 | 51 |
| 2024 March | 28 | 20 | 48 |
| 2024 February | 25 | 20 | 45 |
| 2024 January | 23 | 20 | 43 |
| 2023 December | 18 | 22 | 40 |
| 2023 November | 27 | 24 | 51 |
| 2023 October | 17 | 14 | 31 |
| 2023 September | 16 | 23 | 39 |
| 2023 August | 20 | 14 | 34 |
| 2023 July | 21 | 9 | 30 |
| 2023 June | 25 | 17 | 42 |
| 2023 May | 36 | 29 | 65 |
| 2023 April | 18 | 3 | 21 |
| 2023 March | 25 | 24 | 49 |
| 2023 February | 16 | 17 | 33 |
| 2023 January | 12 | 16 | 28 |
| 2022 December | 26 | 24 | 50 |
| 2022 November | 33 | 26 | 59 |
| 2022 October | 30 | 15 | 45 |
| 2022 September | 19 | 38 | 57 |
| 2022 August | 30 | 30 | 60 |
| 2022 July | 25 | 34 | 59 |
| 2022 June | 17 | 31 | 48 |
| 2022 May | 23 | 29 | 52 |
| 2022 April | 28 | 31 | 59 |
| 2022 March | 19 | 33 | 52 |
| 2022 February | 24 | 21 | 45 |
| 2022 January | 34 | 25 | 59 |
| 2021 December | 27 | 29 | 56 |
| 2021 November | 35 | 41 | 76 |
| 2021 October | 34 | 40 | 74 |
| 2021 September | 21 | 17 | 38 |
| 2021 August | 27 | 35 | 62 |
| 2021 July | 23 | 22 | 45 |
| 2021 June | 31 | 12 | 43 |
| 2021 May | 35 | 45 | 80 |
| 2021 April | 28 | 39 | 67 |
| 2021 March | 44 | 15 | 59 |
| 2021 February | 53 | 21 | 74 |
| 2021 January | 26 | 6 | 32 |
| 2020 December | 43 | 10 | 53 |
| 2020 November | 41 | 16 | 57 |
| 2020 October | 20 | 8 | 28 |
| 2020 September | 68 | 12 | 80 |
| 2020 August | 26 | 9 | 35 |
| 2020 July | 51 | 9 | 60 |
| 2020 June | 36 | 4 | 40 |
| 2020 May | 43 | 6 | 49 |
| 2020 April | 50 | 15 | 65 |
| 2020 March | 36 | 4 | 40 |
| 2020 February | 45 | 36 | 81 |
| 2020 January | 22 | 8 | 30 |
| 2019 December | 30 | 3 | 33 |
| 2019 November | 31 | 6 | 37 |
| 2019 October | 24 | 3 | 27 |
| 2019 September | 24 | 26 | 50 |
| 2019 August | 24 | 6 | 30 |
| 2019 July | 30 | 13 | 43 |
| 2019 June | 16 | 7 | 23 |
| 2019 May | 51 | 9 | 60 |
| 2019 April | 17 | 10 | 27 |
| 2019 March | 99 | 9 | 108 |
| 2019 February | 124 | 8 | 132 |
| 2019 January | 45 | 7 | 52 |
| 2018 December | 91 | 9 | 100 |
| 2018 November | 120 | 6 | 126 |
| 2018 October | 229 | 15 | 244 |
| 2018 September | 53 | 12 | 65 |
| 2018 August | 42 | 11 | 53 |
| 2018 July | 39 | 2 | 41 |
| 2018 June | 57 | 6 | 63 |
| 2018 May | 70 | 6 | 76 |
| 2018 April | 90 | 4 | 94 |
| 2018 March | 114 | 9 | 123 |
| 2018 February | 96 | 2 | 98 |
| 2018 January | 68 | 5 | 73 |
| 2017 December | 135 | 10 | 145 |
| 2017 November | 51 | 6 | 57 |
| 2017 October | 28 | 13 | 41 |
| 2017 September | 30 | 11 | 41 |
| 2017 August | 33 | 11 | 44 |
| 2017 July | 26 | 8 | 34 |
| 2017 June | 43 | 6 | 49 |
| 2017 May | 38 | 9 | 47 |
| 2017 April | 31 | 1 | 32 |
| 2017 March | 32 | 3 | 35 |
| 2017 February | 39 | 5 | 44 |
| 2017 January | 22 | 4 | 26 |
| 2016 December | 38 | 13 | 51 |
| 2016 November | 18 | 7 | 25 |
| 2016 October | 39 | 16 | 55 |
| 2016 September | 17 | 6 | 23 |
| 2016 August | 4 | 2 | 6 |
| 2016 July | 12 | 6 | 18 |
| 2016 June | 6 | 12 | 18 |
| 2016 May | 11 | 4 | 15 |
| 2016 April | 36 | 9 | 45 |
| 2016 March | 65 | 24 | 89 |
| 2016 February | 70 | 32 | 102 |
| 2016 January | 41 | 19 | 60 |
| 2015 December | 79 | 22 | 101 |
| 2015 November | 60 | 14 | 74 |
| 2015 October | 58 | 22 | 80 |
| 2015 September | 48 | 13 | 61 |
| 2015 August | 45 | 12 | 57 |
| 2015 July | 32 | 8 | 40 |
| 2015 June | 30 | 6 | 36 |
| 2015 May | 28 | 5 | 33 |
| 2015 April | 38 | 17 | 55 |
| 2015 March | 40 | 18 | 58 |
| 2015 February | 39 | 14 | 53 |
| 2015 January | 43 | 10 | 53 |
| 2014 December | 42 | 7 | 49 |
| 2014 November | 39 | 8 | 47 |
| 2014 October | 62 | 7 | 69 |
| 2014 September | 36 | 10 | 46 |
| 2014 August | 26 | 6 | 32 |
| 2014 July | 40 | 10 | 50 |
| 2014 June | 37 | 7 | 44 |
| 2014 May | 41 | 5 | 46 |
| 2014 April | 36 | 12 | 48 |
| 2014 March | 49 | 27 | 76 |
| 2014 February | 41 | 17 | 58 |
| 2014 January | 66 | 17 | 83 |
| 2013 December | 49 | 20 | 69 |
| 2013 November | 48 | 23 | 71 |
| 2013 October | 40 | 11 | 51 |
| 2013 September | 47 | 13 | 60 |
| 2013 August | 63 | 22 | 85 |
| 2013 July | 55 | 19 | 74 |
| 2013 June | 41 | 14 | 55 |
| 2013 May | 62 | 36 | 98 |
| 2013 April | 78 | 39 | 117 |
| 2013 March | 58 | 24 | 82 |
| 2013 February | 50 | 24 | 74 |
| 2013 January | 54 | 38 | 92 |
| 2012 December | 43 | 21 | 64 |
| 2012 November | 26 | 24 | 50 |
| 2012 October | 39 | 25 | 64 |
Show all
