metabolic syndrome

Abdominal obesity plus two other components: elevated BP, low
HDL, elevated TG, or impaired fasting glucose i.e DM2

Definition
Constellation of metabolic
abnormalities that confer increased
weight, increased risk of
cardiovascular disease(CVD) and
clinically diabetes mellitus.
The major features of metabolic syndrome include
Central obesity
Hypertrilgyceridemia
Low high density lipoprotein (HDL)
Hyperglycemia
hypertension
EPIDEMIOLOGY
• Prevalence increases with age

• Greater industrialization and urbanization- factory
workers
• Increase in waist circumference is found predominantly

in women and men after age 40
• Fasting TG>150 mg/dl and hypertension more likely in

men.
CLINICAL FEATURES
• Usually asymptomatic and a high index of suspicion

is needed for diagnosis
• Examination -
Increased waist circumference Should alert to
search for other
Increased Blood Pressure abnormalities
Lipoatrophy
Acanthosis nigricans/ skin tags, patch
Other associated
conditions
1) Cardiovascular disease
increased risk for new onset CVD, ischemic stroke, PVD
2) Type 2 diabetes mellitus
increased risk by 3-5 folds
3) Hyperuricemia
4) PCOS- prevalence 40-50%
5) commonly associated with obesity, HTN & insulin
resistance (CPAP improves insulin sensitivity)
Metabolic Syndrome
IDF criteria
1. Waist circumference: ≥90 in males ≥80 in females

2. Plus two or more of the following
a) Hypertriglyceridemia: ≥150 TG’s or specific medication
b) Low HDL cholesterol: <40(M) and <50(F) or specific
medication
c) Hypertension: blood pressure ≥130 mm systolic or ≥85 mm
diastolic or specific medication
d) Fasting plasma glucose: ≥100 mg/dl or specific medication
or previously diagnosed T2DM
IDF criteria
Risk Factor Defining Level

Abdominal obesity†
(Waist circumference‡)
Men >90 cm
Women >80 cm
TG 150 mg/dL or Rx for ↑ TG
HDL-C
Men <40 mg/dL
Women <50 mg/dL or Rx for ↓ HDL
Blood pressure 130/85 mm Hg or on HTN Rx
Fasting glucose 100 mg/dL or Rx for ↑ glucose
*Diagnosis is established when 3 of these risk factors are present.
†
Abdominal obesity is more highly correlated with metabolic risk factors than is
BMI. ‡Some men develop metabolic risk factors when circumference is only
marginally increased.
IDF criteria contd…
Pathogenesis …
Pathogenesis contd…
Insulin resistance pp/fasting hyperinsulinemia
Lipolysis by LPL Abundance of FFA’s
Impaired insulin Toxic injury to

mediated glucose Increased insulin
resistance pancreatic islets
uptake
Hyperglycemia Type 2 DM
How to diagnose?
• Generally obese, diabetic, hypertensive

• H/o PCOS in premenopausal women
• Family H/o CVD and DM
• Waist circumference and BP measurement
• Laboratory investigations
Fasting lipid profile and fasting glucose
hs-CRP, fibrinogen, uric acid, urinary microalbumin
LFT for NAFLD
Testosterone, FSH, LH for PCOS
TREATMENT
LIFESTYLE
MODIFICATIONS
• Weight reduction- include a combination of caloric restriction,

increased physical activity, and behavior modification.
DIET---
• ~Diet restriction daily equates to weight reduction of 1kg per week.
• Diets restricted in carbohydrate typically provide a rapid initial

weight loss.
• Adherence to the diet is more important than which diet is chosen.
• A high-quality diet— i.e., enriched in fruits, vegetables, whole

grains, lean poultry, and fish—should be encouraged to provide the
maximum overall health benefit.
What to do..?
PHYSICAL ACTIVITY-
• 60–90 min of daily activity (At least 30 min.) Gradual increases in physical
activity should be encouraged to enhance adherence and avoid injury.
• Some high-risk patients should undergo formal cardiovascular evaluation

before initiating an exercise program.
• Physical activity could be formal exercise such as jogging, swimming, or

tennis or routine activities, such as gardening, walking, and housecleaning.
OBESITY
• Appetite
suppressants-use
fruits
• Absorption inhibitors-
fibre in diet
• Bariatric surgery
TRIGLYCERIDES
• A fasting triglyceride value of <150 mg/dL is recommended. A

weight reduction of >10% is necessary to lower fasting
triglycerides.
• A fibrate (gemfibrozil or fenofibrate) is the drug of choice to

lower fasting triglycerides and typically achieve a 35–50%
reduction.
• Other drugs that lower triglycerides include statins, nicotinic

acid, and high doses of omega-3 fatty acids.
HDL Cholesterol
• For rise in HDL cholesterol, weight reduction is an important

strategy.
• Nicotinic acid is the only currently available drug with

predictable HDL cholesterol-raising properties.
• Statins, fibrates, and bile acid sequestrants have modest

effects (5–10%), and there is no effect on HDL cholesterol with
ezetimibe or omega-3 fatty acids.
LDL Cholesterol
For patients with the metabolic syndrome and diabetes, LDL

cholesterol should be reduced to <100 mg/dL. Fasting
sugar should be below 120 mg/dl and BP should be below
135/85 mm of Hg
BLOOD PRESSURE
• The direct relationship between blood pressure and all-cause

mortality rate has been well established.
• Best choice for the first antihypertensive should usually be an

angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II
receptor blocker.
• In all patients with hypertension, a sodium-restricted diet enriched

in fruits and vegetables and low-fat dairy products should be
advocated.
INSULIN RESISTANCE
• Insulin resistance is the primary Patho-physiologic mechanism for the

metabolic syndrome.
• Several drug classes [biguanides, thiazolidinediones (TZDs)] increase insulin

sensitivity.
• Benefits of both drugs have also been seen in patients with NAFLD and PCOS,
and the drugs have been shown to reduce markers of inflammation and small
dense LDL.
GLYCEMIC CONTROL
• In patients with the metabolic syndrome and Type 2 diabetes,

aggressive glycemic control decreases cardiovascular risk..
• Metformin 500 mg/ 1 gm has also been shown to reduce the

incidence of diabetes, although the effect was less than that seen with
lifestyle intervention.
PROTHROMBOTIC &
PROINFLAMMATORY STATE
• Most patients with metabolic syndrome exhibit a prothrombotic state

characterized by elevations of plasminogen activator inhibitor-1 and
fibrinogen.
• Use of low dose aspirin can be recommended for patients with

metabolic syndrome, who have a high CV risk, those with overt type 2
diabetes mellitus, or atherosclerotic cardiovascular diseases.
• Metabolic syndrome frequently is accompanied by a pro-inflammatory

state, characterized by increased CRP levels. No specific treatment
available.

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Abdominal obesity plus two other components: elevated BP, low

HDL, elevated TG, or impaired fasting glucose i.e DM2

• Prevalence increases with age

• Increase in waist circumference is found predominantly

• Fasting TG>150 mg/dl and hypertension more likely in

• Usually asymptomatic and a high index of suspicion

1. Waist circumference: ≥90 in males ≥80 in females

Risk Factor Defining Level

Insulin resistance pp/fasting hyperinsulinemia

Lipolysis by LPL Abundance of FFA’s

Impaired insulin Toxic injury to

• Generally obese, diabetic, hypertensive

• Weight reduction- include a combination of caloric restriction,

• ~Diet restriction daily equates to weight reduction of 1kg per week.

• Diets restricted in carbohydrate typically provide a rapid initial

• Adherence to the diet is more important than which diet is chosen.

• A high-quality diet— i.e., enriched in fruits, vegetables, whole

• Some high-risk patients should undergo formal cardiovascular evaluation

• Physical activity could be formal exercise such as jogging, swimming, or

• A fasting triglyceride value of <150 mg/dL is recommended. A

• A fibrate (gemfibrozil or fenofibrate) is the drug of choice to

• Other drugs that lower triglycerides include statins, nicotinic

• For rise in HDL cholesterol, weight reduction is an important

• Nicotinic acid is the only currently available drug with

• Statins, fibrates, and bile acid sequestrants have modest

For patients with the metabolic syndrome and diabetes, LDL

• The direct relationship between blood pressure and all-cause

• Best choice for the first antihypertensive should usually be an

• In all patients with hypertension, a sodium-restricted diet enriched

• Insulin resistance is the primary Patho-physiologic mechanism for the

• Several drug classes [biguanides, thiazolidinediones (TZDs)] increase insulin

• In patients with the metabolic syndrome and Type 2 diabetes,

• Metformin 500 mg/ 1 gm has also been shown to reduce the

• Most patients with metabolic syndrome exhibit a prothrombotic state

• Use of low dose aspirin can be recommended for patients with

• Metabolic syndrome frequently is accompanied by a pro-inflammatory

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