Metabolic Syndrome in Adults

Background

• Metabolic syndrome is a cluster of commonly co-occurring metabolic risk factors associated with cardiovascular disease and type 2 diabetes mellitus, including:
  • elevated blood pressure
  • atherogenic dyslipidemia
  • insulin resistance
  • central obesity
• It is most common in patients with overweight and obesity, but it can occur in patients with normal weight.
• Risk factors include smoking, physical inactivity, and family history.
• Complications include atherosclerotic cardiovascular disease (ASCVD), diabetes, and chronic kidney disease.

Evaluation

• The definition/diagnostic criteria for metabolic syndrome varies by organization and several sets of diagnostic criteria have been proposed.
• The most common diagnostic criteria for metabolic syndrome is from the International Diabetes Federation (IDF) Task Force on Epidemiology and Prevention and the American Heart Association/National Heart, Lung, and Blood Institute (AHA/NHLBI) and requires 3 of the following 5 criteria:
  • triglycerides ≥ 150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides
  • fasting glucose ≥ 100 mg/dL or drug treatment for elevated glucose
  • reduced high-density lipoprotein cholesterol or drug treatment for reduced high-density lipoprotein cholesterol:
    • in men, < 40 mg/dL (1.0 mmol/L)
    • in women, < 50 mg/dL (1.3 mmol/L)
  • elevated blood pressure demonstrated by any of the following:
    • systolic blood pressure ≥ 130 mm Hg or
    • diastolic blood pressure ≥ 85 mm Hg
    • antihypertensive drug treatment in a patient with a history of hypertension
  • increased waist circumference (as determined by population and country-specific thresholds)

Management

• Treatment of metabolic syndrome includes management of the individual components of the syndrome with the goal of preventing cardiovascular disease and type 2 diabetes.
• Lifestyle modification is the first-line treatment for all patients (Strong recommendation).
  • Treat obesity with a balance of dietary interventions (Strong recommendation), physical activity, and formal behavior modification programs; the goals include:
    • Reduce the patient's body weight by 7%-10% during the first year of treatment, the ultimate goal is a body mass index of < 25 kg/m².
    • Achieve and maintain a waist circumference below the metabolic syndrome definition thresholds.
  • Advise a moderate-intensity physical activity for 30 minutes, preferably 45-60 minutes, ≥ 5 days/week (Strong recommendation).
  • Dietary interventions include:
    • Reduce the intake of total, saturated, and trans fats, cholesterol, simple sugars, and foods with a high glycemic index.
    • Provide an adequate intake of fiber, unsaturated fats, fruits, vegetables, whole grains, and fish.
  • In patients who smoke, smoking cessation is recommended.
• Treatment for individual metabolic risk factors with medication if the patient is not achieving targets with lifestyle changes alone includes:
  • Dyslipidemia treatment goals are a reduction of the elevated low-density lipoprotein (LDL) cholesterol and the elevated non-high-density lipoprotein (HDL) cholesterol, and to a lesser extent, the elevation of reduced HDL cholesterol.
  • Hypertension treatment goal is a target blood pressure of < 140/90 mm Hg, or < 130/80 mm Hg in patients with diabetes or chronic kidney disease (Weak recommendation).
  • For elevated glucose:
    • Lifestyle modification should be used before drug therapy to manage elevated glucose (Strong recommendation).
    • For patients who do not respond to lifestyle modification or have limitations to physical activity, prescribe metformin as first line pharmacologic therapy (Strong recommendation).
    • Other medications that may reduce the progression to diabetes in patients with prediabetes include:
      • alpha-glucosidase inhibitors (acarbose, voglibose)
      • orlistat
      • liraglutide
      • glitazones (pioglitazone, rosiglitazone), but BOXED WARNINGS regarding risk of heart failure may preclude use