Metabolic syndrome is characterised by hyper-insulinaemia, low glucose tolerance, dyslipidaemia, hypertension, and obesity. This cluster of factors has been recognised for many years, but the syndrome was not formally labelled until Reaven did so in 1988 and suggested that insulin resistance was its central characteristic.1 Insulin resistance seems to be the main underlying factor leading to the increased risk of mortality from coronary heart disease among people with the syndrome.2 Strategies to combat the forecast epidemic of type 2 diabetes and its vascular complications should focus on preventing and intervening early in metabolic syndrome.

Established macrovascular pathology is common when diabetes is diagnosed,3 implying either delayed diagnosis or an atherogenic prediabetic state. The UK prospective diabetes study showed that, once diabetes is diagnosed glycaemia is only modestly related to cardiovascular disease.4 Insulin resistance may be the common antecedent of metabolic syndrome, type 2 diabetes, and cardiovascular disease. Any strategy aimed at preventing the principal cause of death in …