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The Metabolic Syndrome: a description in evolution
- George I. Varughese, Helen Stone, Jeetesh V. Patel (14 March 2006)
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Metabolic Syndrome
- Richard J Jarrett (18 April 2006)
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The metabolic syndrome vs. main cardiovascular risk factors: Comparing apples and pears
- Pascal Bovet, Fred Paccaud, professor (24 May 2006)
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Early warning for use in primary care to inform patients of risk
- Rupert A Gude (5 June 2006)
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George I. Varughese, Specialist Registrar in Diabetes & Endocrinology University Hospital of North Staffordshire, Stoke-on-Trent ST4 6QG, Helen Stone, Jeetesh V. Patel
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We applaud Sundstrom et al in their efforts to link the metabolic syndrome and its long-term predictive outcome with regard to cardiovascular mortality [1]. The descriptive account of the intricacies involved with different age groups of patients once again demonstrates that we should perhaps regard this ‘syndrome’ with a cluster of cardiovascular risk factors as a ‘description in evolution’, rather than trying to reach a finale in this era of rapidly changing perceptions on the search for a definition for this complex story. If we take into consideration other concurrent risks, such as the impact of ethnicity and the significance of body mass index [2], it makes it all the more problematical and reiterates the joint accord from a statement by the American Diabetes Association and the European Association for the Study of Diabetes that clinicians should concentrate on individual cardiovascular risk factors to tackle these patients [3]. This has particular bearing if one can estimate the future stance and enormous vastness of the situation given the global prevalence of diabetes and projections for 2030 [4], as well as the global challenge of hypertension over the next couple of decades [5]. The ‘sine qua non’ is that aggressive treatment is required taking into account the magnitude of the circumstances and we should act swiftly. 1.Sundstrom J, Riserus U, Byberg L, Zethelius B, Lithell H, Lind L. Clinical value of the metabolic syndrome for long term prediction of total and cardiovascular mortality: prospective, population based cohort study. BMJ 2006 Mar 1; [Epub ahead of print] 2.Snehalatha C, Viswanathan V, Ramachandran A. Cutoff values for normal anthropometric variables in Asian Indian adults. Diabetes Care 2003; 26: 1380–1384. 3.Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome: time for a critical appraisal. Joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2005; 48(9): 1684-1699. 4.Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27(5): 1047-1053. 5.Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365: 217–223. Competing interests: GIV & HS work in Diabetes & Endocrinology and JVP is a Research Scientist in Metabolic Disorders & Cardiovascular Diseases |
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Richard J Jarrett, emeritus professor of clinival epidemiology, University of London 45 Bishopsthorpe Road Londo SE26 4)A
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Sundstrom et al (BMJ 15th April, p 878) claim that in their cohort of 50-year old men, the identification of the metabolic syndrome (as defined) added to the prediction of total and cardiovascular mortality obtained from classical risk factors. However, it is clear from the electronic version of the article that this superiority only emerges after about 15 years of follow-up. As most guidelines for therapeutic intervention are predicated upon ten year risk, the observation does not have pragmatic value. Further, the relatively poor performance of the classical risk factors appears to be due to the unusually low predictive power of total cholesterol in this cohort, which suggests that the result would not be generally applicable. R J Jarrett Competing interests: None declared |
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Pascal Bovet, Senior lecturer University Institute of Social and Preventive Medicine, Bugnon 17, 1005 Lausanne, Switzerland, Fred Paccaud, professor
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Sundström and al. found that a diagnosis of metabolic syndrome better predicts cardiovascular mortality when considered in addition to four «established» risk factors (smoking, diabetes, hypertension and serum cholesterol) (1). Most of the components of the metabolic syndrome (NCEP or WHO criteria), e.g. HDL-cholesterol, microalbuminuria, or impaired glucose metabolism, are however also established independent cardiovascular risk factors or markers (2,3). Hence, the incremental cardiovascular risk attributed to the metabolic syndrome may well reflect the cumulative effect of these components, and not the risk cluster defining the syndrome. In addition, the paper uses cut offs of ≥140/90 mmHg to define hypertension in the “4 risk factors” model and ≥130/85 mmHg as part of the metabolic syndrome in the “4 risk factors + metabolic syndrome” model: inclusion of high normal blood pressure in the latter improves the prediction of cardiovascular mortality (4). Invalid comparisons have often flawed research in this area and assertions on the significance of the metabolic syndrome have been consequently more speculative than adequately demonstrated (5). Moreover, we are concerned by the practical consequences of these results based on invalid premises. According to the paper, one would imply that, conditional to same smoking habits, diabetes status, blood pressure and total cholesterol levels, a doctor should treat more aggressively a patient with low HDL-cholesterol, high triglyceride, and/or impaired glucose metabolism in presence of the metabolic syndrome (which is appropriate) but not in absence of the metabolic syndrome (which is inappropriate). As a matter of fact, the use of other tools (e.g. the hazard ratio for the metabolic syndrome adjusting for all independent effects, including its components) might well reverse the conclusion of the paper. 1) Sundström J, Risérus U, Byberg L, Zethelius B, Lithell B, Lind L. Clinical value of the metabolic syndrome for long term prediction of total and cardiovascular mortality: prospective, population based cohort study. BMJ 2006;332;878-2. 2) 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertension 2003;21:1983-92. 3) Lawes CM, Parag V, Bennett DA, Suh I, Lam TH, Whitlock G, et al: Asia Pacific Cohort Studies Collaboration. Blood glucose and risk of cardiovascular disease in the Asia Pacific region. Diabetes Care 2004;27:2836-42. 4) Vasan RS, Larson MG, Leip EP, Evans JC, O'Donnell CJ, Kannel WB et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001;345:1291-7. 5) Kohli P, Greenland P. Role of the metabolic syndrome in risk assessment for coronary heart disease. JAMA 2006;295:819-21 [Commentary]. Competing interests: None declared |
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Rupert A Gude, General Practitioner Abbey Surgery, Tavistock, Denon, UK PL19 8BU
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Dear Sir, I have almost completed 25 years in General Practice and have watched as my rotund patients developed cardiac disease and strokes. I have intervened to treat their blood pressure or lipids too little , too late. Prof Sundstroms paper reinforces our present practice of encouraging our clinical staff especially our nurses to do a waist circumference and blood pressure followed by appropriate blood tests if indicated. Based on our premise that patients need to be informed of risk and stategies for reducing it, we then counsel patients on life style changes. That the dangers may take 15 or even 20 years to manifest is not a reason to delay and it is surprising that an epidemiologist like Professor Jarrets should comment on the lack of pragmatic value. We are not talking primarily about therapeutics but a means of informing patients that middle age spread is not necessarily a benign condition that makes them cuddly. Yours sincerely
Competing interests: None declared |
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