Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Metabolic Syndrome may not be dumped
- M E Nassar, M.D., Ph.D. (22 March 2008)
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Metabolic syndrome and smoking
- Hiroshi Kawane, Hatsukaichi City, Hiroshima, 738-0052, Japan (24 March 2008)
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The metabolic syndrome and the Broad Street pump
- Sern Lim (25 March 2008)
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Should we dump Metabolic Syndrome: Yes
- Anukul GARG (25 March 2008)
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Aetiology and use of metabolic syndrome
- John A. Lee (25 March 2008)
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The metabolic syndrome – revise the processes of care, don’t dump the concept
- Tim A Holt (26 March 2008)
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Practical use of the metabolic syndrome in primary care.
- Clive L Morrison (26 March 2008)
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The metabolic syndrome - a longitudinal perspective
- Bernard M Y Cheung (26 March 2008)
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Do not dump but LEARN to recognize the metabolic syndrome.
- Laszlo Bense (26 March 2008)
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Focus on causality.
- José Pedro L. Nunes (28 March 2008)
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Should the Metabolic Syndrome be replaced by "The blood hyperviscosity syndrome " ?
- Les O. Simpson (29 March 2008)
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Don’t Dump the Metabolic Syndrome – It’s Important in Children and Adolescents!
- Carroll Sean, James P. Hobkirk, Roderick FGJ. King (10 April 2008)
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Cardiovascular risk stratification
- Irugal D M Disssanayake (25 April 2008)
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Rather than dumping the concept it will be useful to separate diseases from symptoms
- Arya K Kumarasena (16 May 2008)
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M E Nassar, M.D., Ph.D., research assistant URMC, Dept of Med.,(G I) Pittsford, NY 14534 USA
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Dear Dr Gale :There is a lot of clinical evidence to maintain the entity, Metabolic Syndrome, viable. First and foremost, it keeps clinicians vigilant for stressing preventive ways for their patients to abort the outcomes of neglected treatment of type 2 diabetes and the cluster of symptoms and signs of the metabolic syndrome. The outcomes are development of the acute coronary syndrome including congestive heart failure and generalized atherosclerosis. Last but not least the progress of type 2 diabetes mellitus, resulting in renal disease. It is equally important to emphasize that the core of the problem may be in the presence of central obesity,increased body mass index over 30 and ineffective hyperinsulinemia etc., and to initiate clinical studies of central obseity treatment to find out from the results of such clinical studies whether type 2 diabetes mellitus can be halted and reversed. Reference my rapid response"Clinical approaches to waist circumference reduction requiring further study (as treatment for insulin resistance in type 2 diabetes mellitus)". BMJ 2005:bmj38429473310.AEv1. Sincerely, ME Nassar, M.D.,Ph.D. Competing interests: None declared |
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Hiroshi Kawane, Professor The Japanese Red Cross Hiroshima College of Nursing, Hatsukaichi City, Hiroshima, 738-0052, Japan
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In Japan there are also pros and cons concerning the metabolic syndrome. According to the Health, Labour and Welfare Ministry, almost a sixth of the population has or risks developing metabolic syndrome. The government launched a campaign calling on the nation to lose weight. The word "metabo," short for metabolic syndrome is becoming familiar among Japanese people and it usually means obesity or fatty belly. From April this year, the new government regulation that requires people over age 40 to be tested for metabolic syndrome starts and 56 million people will be covered. In the compulsory tests, people will have their waists measured. If a man's girth is 85 cm or more, or a woman's is 90 cm or more, they will be placed in a "high-risk" group where, depending on the results of other tests, they will have an "action plan" drawn up by experts to change their eating and exercise habits[1]. Some would also be asked to see a doctor, but the regulation does not make an issue of smoking. The checkup without smoking cessation advice woluld be a big waste of money. Reference [1]Otake T. Metabolic syndrome: Skeptics nix 'comedy' drive to officially fight the flab. The Japan Times. March 16, 2008. (http://search.japantimes.co.jp/cgi-bin/fl20080316x4.html) Competing interests: None declared |
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Sern Lim, Clinical Lecturer University of Birmingham B18 7QH
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A syndrome (from Greek meaning 'running together') rightly indicated by Alberti and Zimmet merely refers to the association of multiple inter- related factors greater than by chance alone. In this regard, the association between obesity, abnormal glucose metabolism, dyslipidaemia and hypertension is well supported by a number of clinical studies [1]. Hence, the existence of such an association (and by extension this syndrome) is not disputed, and indeed was acknowledged in the opening paragraph by Gale. What is disputed, however, is the definition and the clinical value of identifying this syndrome. The current definition of the metabolic syndrome consists of a number of arbitrarily dichotomized variables. That such an artificial diagnosis failed to better prospectively validated cardiovascular risk scoring systems is hardly surprising. The failure of metabolic syndrome, as currently defined to improve cardiovascular risk assessment undoubtedly diminished the enthusiasm amongst many clinical practitioners. Such dispute, however valid should not detract from the consistent and well- supported epidemiological evidence for the clustering of the multiple risk factors. Studying the association between these inter-related risk factors may yield insight into pathophysiological mechanisms and novel therapeutic targets [2]. Medical research and progress are often built on simple clinical observations and epidemiology. John Snow carefully documented the cases of cholera clustering around the Broad Street water pump, which implicated the source of water in the spread of cholera (even in the absence of clear pathophysiological mechanisms) in contradiction to the then-dominant miasma theory. John Snow could not ignore the association between cholera and the Broad Street water pump and raised the question of 'why?'. Perhaps we should be asking the same of the metabolic syndrome. [1] Lim HS, Lip GY. From diabetes to metabolic syndrome: a viewpoint on an evolving concept. Curr Pharm Des 2007; 13: 2580-3 [2] Rader DJ, Daugherty A. Translating molecular discoveries into new therapies for atherosclerosis. Nature 2008; 451: 904-13 Competing interests: None declared |
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Anukul GARG, Speciality Registrar Queen's Medical Centre, NG7 2UH
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The concept of Metabolic Syndrome was evolved to identify the group of risk factors which have higher prediction for Cardiovascular disease when present together than being individually present. But so far the biggest hurdle has been an agreement even with the definition of Metabolic Syndrome among various organisations. In addition there are other risk assessment tools like Framingham Risk scoring which do the same job in more standardised and effective way. We all we probably agree the risk factors more or less remain same in all definitions but all of them have loop holes which need to be filled for example the IDF criteria would simply ignore a lean 65 yr asian smoker with Diabetes, dyslipidemia and high blood pressure which defeats the purpose of identifying people at risk Till date the idea has not added anything more than confusion and that is why I think it should be dumped. Competing interests: None declared |
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John A. Lee, Retired consultant in public health 1 Lugg View Close, Hereford. HR1 1JFA
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Drs. Gale, Alberti, and Zimmet state that the aetiology of the metabolic syndrome is unclear.(1). However, I do believe that there is a single pathophysiological basis for the syndrome (2). In a literature review, I showed that all the coronary heart disease (c.h.d.) risk factors (including those of the metabolic syndrome ) were associated with enhanced activity of the sympathetic nervous system (s.n.s.)and the catecholamines.(3,4)There was also strong evidence that the catecholamines directly caused c.h.d. by a number of mechanisms(4).The risk factors for type 2 diabetes (overweight, sedentary life style etc.)are also c.h.d.risk factors. A key to understanding the metabolic syndrome is that the catecholamines and insulin are antagonistic to each other(2,5). The catecholamines prevent the cellular uptake of insulin(5). The metabolic syndrome,therefore,shows the degree of metabolic or catabolic disturbance resulting from the stimulation of the s.n.s. by a number of different factors. It is accepted that the syndrome enhances the prediction of both c.h.d. and type 2 diabetes (1) and may be therefore useful in both individual and public health prevention by both drug and lifestyle intervention. In particular it could identify those with unascertained risk factors such as psychosocial stress and those wth few risk factors but enhanced s.n.s. activity. It might also reveal those wth risk factors but little metabolic disturbance and, therefore, at low risk. References. 1. Edwin A.M. Gale, George Alberti and P.Z. Zimmet. Head to Head. Should we dump the metabolic syndrome ? BMJ vol.336, 22March, 2008, 640-641. 2.Lee. J.A. Rapid response.Metabolic syndrome and catecholamines. BMJ vol.331/7526/p.1153.(2006). 3. Lee. J.A. Ischaemic Heart Disease and the Autonomic Nervous System. Lancet, Vol.2, October 4, 1980, p747. 4.Lee. J.A. The role of the sympathetic nervous system in ischaemic heart disease. A review of epidemiological features and risk factors, integration with clinical and experimental evidence and hypothesis. Activitas Nervosa Superior (Praha) vol25, no. 2, 110-121 5. David S. Goldstein. Stress, Catecholamines and cardiovascular disease. Oxford University Press (1995) Competing interests: None declared |
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Tim A Holt, Clinical Lecturer Health Sciences Research Institute, University of Warwick, Gibbet Hill Rd, Coventry CV4 7AL
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Edwin Gale makes the point that clinicians rarely record the metabolic syndrome as a diagnosis [1]. A possible reason for this in the UK is that measurement of waist circumference, whilst recommended [2], is not prioritised. The obesity registers of the UK’s Quality and Outcomes Framework are based solely on body mass index (BMI), a missed opportunity to identify those with central obesity [3]. This example highlights a more general problem with the usefulness of the metabolic syndrome concept: the recording of risk factor data in primary care. For prediction of absolute CVD risk, current risk algorithms are bound to outperform definitions of the metabolic syndrome as they take account of age and smoking status. A more important question is whether the inclusion of waist circumference, blood glucose and triglyceride levels (and the interaction between them and the other factors) could improve such algorithms. These three factors are absent in both the Framingham [4] and in the QRISK [5] algorithms, the latter recently developed using routinely collected general practice data. QRISK could not easily have included waist circumference as the data were not sufficiently available, but unlike Framingham it includes BMI. Blood glucose levels are now quite frequently recorded, but typically using report codes that make no distinction between fasting and random values [6]. This problem also affects triglyceride levels, whose values are only useful if measured on fasting samples. The Framingham heart study was designed to identify independent risk factors [7] causally linked to cardiovascular disease. The addition of further factors whose influences are already partially represented creates statistical redundancy and a ‘diminishing returns’ effect [8]. Just as BMI was excluded from the Framingham algorithm, waist circumference might or might not add value as two of the other metabolic syndrome features are already included (blood pressure and high density lipoprotein cholesterol levels). But this assumption needs testing. Improvement in the recording of metabolic syndrome features in appropriately coded form might eventually allow an even better algorithm to be derived from primary care data, but at present we simply don’t have the information to answer this question. The escalating prevalence of obesity, diabetes and cardiovascular risk can only be offset by preventive measures aimed not only at the high absolute risk groups identified by current CVD risk algorithms but also at the younger people whose lifetime risk is raised. Such people are unlikely to produce a high absolute risk score as the risk is longer-term, but the action is required now. It could be argued that all people with obesity deserve intervention, but among them those with the metabolic syndrome are particularly likely to benefit. Use of the IDF definition to identify these younger people overcomes a major problem with both the Framingham and QRISK algorithms that may leave their needs unidentified. One further point: In the case of patients with diagnosed diabetes, co-existence of the metabolic syndrome helps to distinguish those whose diabetes has evolved through a pathway of predominant insulin resistance, from those with a picture of insulin deficiency suggesting the possible need for insulin early in the course of the condition. So my conclusions would be: • Continue to use the IDF metabolic syndrome definition to identify people of all ages likely to benefit from lifestyle measures to reduce cardiovascular and diabetes risk • Continue to use the standard cardiovascular risk algorithms to quantify absolute risk, where this is useful (for instance in rationing prescribing or balancing the risks and benefits of drug therapy) • Consider the policy implications and opportunities of electronically coded recording of risk factor data on future risk algorithm development, particularly related to the issue of fasting/random values References 1. Should we dump the metabolic syndrome?: Yes. Edwin A M Gale. BMJ 2008 336: 640. 2. JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91 Suppl 5: v1- 52. 3. http://www.qof.ic.nhs.uk/ 4. Anderson KM, Odell PM, Wilson PW, Kannel WB: Cardiovascular disease risk profiles. Am Heart J 1991;121(1 Part2):293-8. 5. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M, Brindle P. Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study. BMJ 2007; 335: 136 ; doi:10.1136/bmj.39261.471806.55 6. Holt TA, Stables D, Hippisley-Cox J, O’Hanlon S, Majeed A. Identifying undiagnosed diabetes: cross-sectional survey of 3.6 million patients’ electronic records. Brit J Gen Pract 2008;58:192-196. 7. Kannel WB McGee D, et al. A general cardiovascular risk profile: the Framingham Study. Am J Cardiol 1976;38(1): 46-51. 8. Woodward, M., Brindle P, et al. Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart 2007;93(2):172-6. Tim A Holt tim.holt@warwick.ac.uk Competing interests: None declared |
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Clive L Morrison, General Practitioner Pendyffryn Medical Group, Ffordd Pendyffryn, Prestatyn, Denbighshire, Wales LL19 9DH
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As Gale suggests (1) in those with; diabetes, existing cardiovascular disease (CVD) or risk over 20%, a TC/HDL ratio of 6 or more, intensive treatment with antidiabetics and cardioprotective therapies are already considered to further reduce cardiac mortality (2). It is irrelevant whether they have the metabolic syndrome (MetS). Over 3112 waist measurements have been opportunistically taken in the Prestatyn practice population since 2003 (3). The prevalence in the non- diabetic population is 56.3% (males 58.8%, females 54.2%). The concept of the metabolic syndrome has been used to begin the cardiovascular risk assessment. Simple waist and BP measurement are the first steps in screening to help identify those that may be at higher risk. Diabetes UK have used this approach in its “Measure up campaign” to encourage people to have diabetes screening tests (4), but CVD risk assessment is just as important. Once central obesity has been established, subsequent more invasive procedures such as blood testing for fasting glucose and lipid profile can be considered. Discussing the implications of the five criteria that make up the components of the metabolic syndrome enables health professionals to guide patients in making informed decisions and in gaining their consent to continue screening and to accept the possible need for treatment. After the relevant data has been collected, a Framingham CVD risk is then calculated. However there will be a group who will score just below 20% or have borderline hypertension. The presence of the metabolic syndrome in these patients is often the critical factor that convinces them to commence drug treatment. Difficulties arise in how to manage those below 50 years of age (MetS prevalence 56.2%), in which age does not yet make a significant contribution to the Framingham equation, and even though they have a low CVD risk they also have the metabolic syndrome. Of working age, they are reluctant to engage in the formal lifestyle programmes organised by health and local authorities and the costs in treating their cardiometabolic risks cannot be justified with pharmaceutical interventions. There remains a belief that being overweight attributes a healthy appearance. Many of those overweight will have central obesity but this is viewed as the norm and the waist threshold is perceived so low that it is unachievable or even undesirable. It remains to be seen whether brief interventions on weight loss, physical activity and smoking cessation will have any discernable outcome on the morbidity from the obesity epidemic that is overwhelming primary care. References 1 Gale EAM Should we dump the metabolic syndrome?: Yes BMJ 2008; 336: 640 2 Clinical Knowledge Summaries. Lipids Management http://www.cks.library.nhs.uk/lipids_management/ (last accessed 25 March 2008) 3 Morrison CL. Feasibility of collecting data for the metabolic syndrome criteria in a UK primary care practice. 1st International Congress on Prediabetes and the Metabolic Syndrome. Germany, Berlin 2005, April 13-16, p41 4 Diabetes UK. Measure Up - are you at risk of diabetes? http://www.diabetes.org.uk/Measure_Up_-_are_you_at_risk_of_diabetes/ (last accessed 25 March 2008) 5 University of Leicester and the UK National Screening Committee 2008. Handbook of Vascular Risk Assessment, Risk Reduction and Risk Management; March 2008, University of Leicester Competing interests: None declared |
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Bernard M Y Cheung, Honorary Professor University of Hong Kong
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The problem with the metabolic syndrome is that it is rather new, and therefore many people think of it as a cross-sectional association of risk factors. We have been studying it longitudinally and followed the development from obesity to the metabolic syndrome, and from the metabolic syndrome to hypertension, diabetes and mortality in the Hong Kong Cardiovascular Risk Factor Prevalence Study cohort [1-3]. It is clear that obesity, the metabolic syndrome, hypertension and diabetes form different stages in the cardiovascular continuum. It is unhelpful to think of diabetes as just arising from pre-diabetes or impaired glucose tolerance, as it raises the question of what leads to pre-diabetes. We found that dyslipidaemia characterised by low high-density lipoprotein-cholesterol (HDL) and raised triglycerides precedes pre-diabetes and helps to predict diabetes [1]. In future, serum biomarkers associated with adipose tissues, such as adiponectin or adipocyte fatty acid binding protein [4, 5], may help to refine the concept of the metabolic syndrome and move the discussion forward from epidemiology to the study of biochemical mechanisms.
References
1. Cheung BMY, Wat NMW, Man YB, Tam S, Thomas GN, Leung GM, Cheng CH, Woo J, Janus ED, Lau CP, Lam TH, Lam KSL. Development of diabetes in Chinese with the metabolic syndrome – a six year prospective study. Diabetes Care 2007; 30(6):1430-6.
2. Cheung BMY, Wat NMW, Tam S, Thomas GN, Leung GM, Cheng CH, Woo J, Janus ED, Lau CP, Lam TH, Lam KSL. Components of the Metabolic Syndrome Predictive of its Development: A Six Year Longitudinal Study in Hong Kong Chinese. Clin Endocrinol 2007 Dec 7; [Epub ahead of print].
3. Thomas GN, Schooling CM, McGhee SM, Ho SY, Cheung BM, Wat NM, Janus ED, Lam KS, Lam TH; for the Hong Kong Cardiovascular Risk Factor Prevalence Study Steering Committee. Metabolic syndrome increases all-cause and vascular mortality: the Hong Kong Cardiovascular Risk Factor Study. Clin Endocrinol 2007; 66(5):666-71
4. Xu A, Tso AW, Cheung BM, Wang Y, Wat NMS, Fong CHY, Yeung DCY, Janus ED, Sham PC, Lam KSL. Circulating adipocyte-fatty acid binding protein levels predict the development of the metabolic syndrome: a 5-year prospective study. Circulation 2007; 115(12): 1537-43.
5. Tso A, Xu A, Sham P, Wat N, Wang Y, Fong C, Cheung B, Janus E, Lam K. Serum adipocyte fatty acid-binding protein as a new biomarker for the risk of type 2 diabetes - a 10-year prospective study in Chinese. Diabetes Care 2007; 30(10):2667-72.
Competing interests: None declared |
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Laszlo Bense, independent researcher ANAB Postängsv 232 Norsborg 14552 Sweden
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It is frightening to read the suggestion to dump the metabolic syndrome. Certainly, for those whose knowledge is barely egsisting, regarding this subject it is not worth to know. I have experienced some unfortunate patients who suffered unnecessaryly due to such lack of knowledge. It was remarkable inthe cases of a mother's father, the mother and her son, who all sufered due to the insuficiet knowledge of some doctors to establish the right diagnosis, the metabolic syndrome. The metabolic syndrome seems already be forgotten, therefore I think the we must learn and not dump the metabolic syndrome. Sincerely Laszlo Bense MD PhD Competing interests: None declared |
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José Pedro L. Nunes, Associate professor Faculdade de Medicina da Universidade do Porto, Portugal
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I read with great interest the arguments presented both by E.A.M. Gale and by K.G.M.M. Alberti and P.Z. Zimmet on the metabolic syndrome [1,2]. I fear, however, that I may have contributed to the “existing confusion” [1] by suggesting the existence of a broader syndrome, including not only the standard features of the metabolic syndrome, but also other entities such as sleep apnea, under the name “barisystemic syndrome” [3]. This entity has been suggested as consisting of “the systemic consequences of excessive weight, including hormonal, body habitus, metabolic, hemodynamic and respiratory parameters” [3]. The suggestion has its grounds on what I think are extremely clear data linking weight loss associated to bariatric surgery and a frequent finding of a complete resolution or improvement of diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea. As I have stated previously, “The assumption of excessive weight/obesity as the probable cause for the association of a number of other important cardiovascular risk factors may lead to a general revision of the reasoning concerning this important topic” [3]. Could we turn to causality, recognizing that, at least in many cases, even if these clinical features may be “running together”, the start of the race is likely to have been excessive weight/obesity? References 1. Gale EAM. Should we dump the metabolic syndrome? Yes. BMJ 2008; 336: 640. 2. Alberti KGMM, Zimmet PZ. Should we dump the metabolic syndrome? No. BMJ 2008; 336: 641. 3. Nunes JPL. The risk factor association syndrome as a barisystemic syndrome: a view on obesity and the metabolic syndrome. Med Hypotheses 2007; 68: 541-5. Epub 2006 Oct 9. Competing interests: None declared |
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Les O. Simpson, retired medical research worker Dunedin, New Zealand, 9077
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While the utility, or otherwise of the Metabolic Syndrome has stimulated a number of interesting contributions, no contributor has referred to the significant literature which describes the changes in blood rheology which occur in the various aspects of the Metabolic Syndrome. In fact the conditions which lead to a diagnosis of Metabolic Syndrome are the expected manifestations of increased blood viscosity and poorly deformable red cells. Even though it seems that the medical establishment simply ignores the published information relating to altered blood rheology, the existence of search engines enables those interested to explore the literature. Searches in PubMed for topics such as "cardiovascular disorders and blood viscosity," or hyperlipidemia and blood visocosity," or type 2 diabetes and blood viscocity," etc would produce a wealth of relevant information. The recognition of the role of blood rheology factors, would lead to treatments aimed at the normalisation of blood flow, which in turn would lead to a better quality of life of those diagnosed as suffering from Metabolic Syndrome. Competing interests: None declared |
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Carroll Sean, Reader Carnegie Research Institute, Leeds Metropolitan University, Leeds, LS6 3QS, West Yorkshire, James P. Hobkirk, Roderick FGJ. King
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“I really don’t know what to believe or which side to take. If one keeps on packing and unpacking a suitcase with different contents everything gets muddled, containers burst, and toothpowder and hair lotion impregnate the shirts and socks”. Richard Asher’s musing on fluctuations in medical theory, topical in the 1940’s, have been typified by contemporary problems in defining a metabolic syndrome (MetS) amongst clustered risk factors, its underlying pathophysiology its practical value and even its very existence. In the March 22nd issue of the BMJ, Alberti & Zimmet and Gale continue the argument about ‘Dumping the metabolic syndrome’ in adults.1 These discussions are customary in any evolving concept. We would like to highlight the usefulness of defining MetS in children and adolescents, in whom preventative treatment could be particularly beneficial. Unlike the Framingham or equivalent risk score algorithms in adults, none currently exist in children or adolescents. However, paediatric MetS diagnosis does have long term risk implications.2 Like its adult counterpart, the paediatric MetS has also undergone several definitions in its evolution.3 However, the International Diabetes Federation, as a starting point, have presented a worldwide definition of the MetS for children and adolescents.4 In this context, the ‘handy clinical label’ has the potential to become a useful definition in the fight against the predicted increase in diabetes and cardiovascular disease worldwide. With some necessary modifications in paediatric risk thresholds.5 it will focus our attention on the clustering of metabolic risk factors and their multi-factorial lifestyle treatment in our children and adolescents. References: 1. Gale EA. Should we dump the metabolic syndrome? Yes. Bmj 2008;336(7645):640. 2. Morrison JA, Friedman LA, Wang P, Glueck CJ. Metabolic syndrome in childhood predicts adult metabolic syndrome and type 2 diabetes mellitus 25 to 30 years later. J Pediatr 2008;152(2):201-6. 3. Ford ES, Li C. Defining the metabolic syndrome in children and adolescents: will the real definition please stand up? J Pediatr 2008;152(2):160-4. 4. Zimmet P, Alberti G, Kaufman F, et al. The metabolic syndrome in children and adolescents. Lancet 2007;369(9579):2059-61. 5. Huang TT. Finding thresholds of risk for components of the pediatric metabolic syndrome. J Pediatr 2008;152(2):158-9. Competing interests: None declared |
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Irugal D M Disssanayake, medical officer Hollllywood pvt Hospital,nedlands, WA 6009
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Whatever the name use there should be a yardstick to measure the cardiovascular risk. The term metabolic syndrome is of little practical value for it entails some marginally objective criteria like central obesity. The waist circumference is not a very good term to use as the measurement may be very subjective,for it to be effective ,needs to be integrated as a component in clinical examination. To date i haven't seen any litreture which list out with a check list to exclude metabolic syndrome, not even a life insurance form. So the impact of making the diagnosis of metabolic syndrome has not felt enough,so because of that fact it should not be dumped but need to think about a practical way of giving it the due place. Competing interests: None declared |
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Arya K Kumarasena, Consultant/Director 85 ,Braybrroke ,place colombo2,Sri Lanka
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Fever, cough, body pain etc are symptoms. There are several deceases that can create these symptoms. However it is not uncommon to identify these symptoms themselves as illnesses by some people. As uncontrolled symptom it self can be harmful it may become necessary to treat the symptom in addition to the cause behind it. When a same symptom can appear due to different pathological or/and physiological factors it can cause some confusion. It can take some time to find the multiple causes that created the same symptom. Actually hyperglycemia and hypertension are also symptoms. There are different parthophysiological reasons that can cause these symptoms. However as these symptoms can lead to secondary problems they should also be treated. Even the pathology behind the symptom is not clear identification of the symptom and treatment for symptom is necessary. Certain pathophysiological scenarios can lead to several symptoms. Even the exact reasoning is not available such scenarios can be identified as a syndrome .Treating such syndromes can also be beneficial although the exact picture is not clear. Some time more or less the same combination of symptoms can be caused by different pathophysiological scenarios. Until the picture becomes clear such situations should be managed. Concept of insulin resistance was a very useful concept that was proposed by Professor Reaven. It is a useful tool that can predict some of the future scenarios by analyzing the currently appearing symptoms. However as Professor Gale quite correctly point out scope of insulin resistance appears to be a sub set of the scope of diabetes [1]. I think part of the confusion comes from the definition of diabetes, which has multiple causes[2].Although all the people with insulin resistance are likely to be identified as diabetic patients sub set of patients who will not be identified with insulin resistance should fall in to a different category. Above reference divide the diabetic patients in to two groups. (a) Patients with insulin resistance but not with elevated fasting plasma insulin. They have increased triglycerides and free fatty acids (b) Patients without insulin resistance but with elevated fasting plasma insulin .They have law free fatty acids and high systolic blood pressure. Further research may unveil some more sub caregories. Therefore it is necessary to further analyze and sub divide the concept of “metabolic syndrome” as well as the concept of “diabetes” {“diabetes type 2”). 1. BMJ 2008;336:640 (22 March), doi:10.1136/bmj.39477.500197.AD Head to Head Should we dump the metabolic syndrome?: Yes Edwin A M Gale, professor of diabetes 2. AMERICAN ASSOCIATION OF CLINICAL ENDOCTRINOLOGISTS (AACE) CONSENSUS CONFERENCE ON INSULIN RESISTANCE SYNDROME. ZACHARY T.BLOOMGARDEN, MD. DIABETES CARE, VOLUME26, NUMBER4 (1297-1303), APRIL 2003 Competing interests: None declared |
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