Metabolic syndrome (syndrome X, insulin resistance syndrome)

Criteria for Metabolic syndrome – It is characterized by a large waist circumference (due to excess abdominal fat), hypertension, abnormal fasting plasma glucose or insulin resistance, and dyslipidemia. Causes, complications, diagnosis, and treatment are similar to those of obesity.

Diagnosis:

  • Waist circumference and BP

  • Fasting plasma glucose and a lipid profile

Screening is important. A family history plus measurement of waist circumference and BP are part of routine care. If patients with a family history of type 2 diabetes mellitus, particularly those ≥ 40 yr, have a waist circumference greater than that recommended for race and sex, fasting plasma glucose and a lipid profile must be determined.

Metabolic syndrome has many different definitions, but it is most often diagnosed when ≥ 3 of the following are present:

  • Excess abdominal fat

  • A high fasting plasma glucose level

  • Hypertension

  • A high triglyceride level

  • A low high-density lipoprotein (HDL) cholesterol level

Criteria Often Used for Diagnosis of Metabolic Syndrome*

Criteria Value
Waist circumference (cm [in]) ≥ 102 (≥40) for men

≥ 88 (≥35) for women

Fasting glucose (mg/dL [mmol/L]) ≥ 100 (≥5.6)
BP (mm Hg) ≥ 130/85
Triglycerides, fasting (mg/dL [mmol/L]) ≥ 150 (≥1.7)
High-density lipoprotein (HDL) cholesterol (mg/dL [mmol/L]) < 40 (<1.04) for men

< 50 (<1.29) for women

*At least 3 of the criteria must be present for the diagnosis.

Causes:

Development of metabolic syndrome depends on distribution as well as amount of fat. Excess fat in the abdomen (called apple shape), particularly when it results in a high waist-to-hip ratio (reflecting a relatively low muscle-to-fat mass ratio), increases risk.

The syndrome is less common among people who have excess subcutaneous fat around the hips (called pear shape) and a low waist-to-hip ratio (reflecting a higher muscle-to-fat mass ratio).

Risk Factors:

Excess abdominal fat leads to excess free fatty acids in the portal vein, increasing fat accumulation in the liver.

Fat also accumulates in muscle cells. Insulin resistance develops, with hyperinsulinemia. Glucose metabolism is impaired, and dyslipidemias and hypertension develop.

Serum uric acid levels are typically elevated, and a prothrombotic state (with increased levels of fibrinogen and plasminogen activator inhibitor I) and an inflammatory state develop.

Patients have an increased risk of obstructive sleep apnea. Other risks include nonalcoholic steatohepatitis, chronic kidney disease, polycystic ovary syndrome (for women), and low plasma testosterone, erectile dysfunction, or both.

Treatment:

  • Healthy diet and exercise
  • Sometimes metformin
  • Management of cardiovascular risk factors

Optimally, the management approach results in weight loss based on a healthy diet and regular physical activity, which includes a combination of aerobic activity and resistance training, reinforced with behavioral therapy.

Metformin, an insulin sensitizer, may be useful. Weight loss of ≈ 7% may be sufficient to reverse the syndrome, but if not, each feature of the syndrome should be managed to achieve recommended targets; available drug treatment is very effective.

Other cardiovascular risk factors (eg, smoking cessation) also need to be managed. Increased physical activity has cardiovascular benefits even if weight is not lost.

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