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In the nearly 2 decades since the term joined the medical vernacular, the cardiovascular risks of "metabolic syndrome" have become widely recognized.
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The cluster of signs and symptoms—including a large waist size, hypertension, insulin resistance, and dyslipidemia—significantly increase the risk of developing diabetes or experiencing a cardiovascular event such as heart attack or stroke.
But beyond definitions, opinions are widely divided about what metabolic syndrome means and the role that the diagnosis should serve in primary care. The debate over the impact and management of metabolic syndrome continued at ENDO 2006, The Endocrine Society's 88th annual meeting, held June 24–27 in Boston.
POINT/COUNTERPOINT
Metabolic syndrome is a reliable predictor that has an important place in clinical practice, says Robert Eckel, MD, of the University of Colorado at Denver and Health Sciences Center, and president of the American Heart Association (AHA).
Requiring no more than a tape measure and a few data points from the medical record, the diagnosis of metabolic syndrome is a red flag that signals the need for intervention, he says.
Taking the other side was John Buse, MD, PhD, director of the Diabetes Care Center at University of North Carolina at Chapel Hill and vice president, medicine and science, of the American Diabetes Association (ADA), who contends that metabolic syndrome is an elusive concept on which even professional organizations disagree.
There are at least five slightly different definitions for metabolic syndrome, including ones from the World Health Organization, the National Cholesterol Education Program Adult Treatment Panel III, the International Diabetes Federation, and the American Association of Clinical Endocrinologists.
Although metabolic syndrome is an "extremely useful pathophysiological concept" that reminds providers of cardiovascular-risk clustering, the value of the designation in primary care is limited, Buse says. As a predictor of cardiovascular events, he notes, the diagnosis is no greater than the sum of its parts.
COMPONENTS
The components of metabolic syndrome, particularly hypertension and dyslipidemia, most often are treated with medications. But the benefits of weight loss should not be overlooked in favor of an attempted quick fix with drug therapy, Eckel says. "The healthful effects of weight loss are still measurable even when weight is regained."
Buse concurs that data indicate a beneficial effect of a high-fiber, low-fat diet even when patients regain weight. "If we can't get people to keep weight off, maybe at least we can help them adopt healthier eating habits," he says.
Richard Heyman, PhD, of San Diego–based Exelixis, represented the drug industry perspective in the debate. "Drugs alone are not enough," he says. "Treatment of metabolic syndrome has to include lifestyle modification."
The observation that treating one component of metabolic syndrome often improves others suggests avenues of research that may prove fruitful. For example, newer types of drugs such as the thiazolidinediones have been shown to improve glucose metabolism while also reducing hyperlipidemia. The observation hints that there may be "nodes" upstream in metabolic processes that could become promising targets for new drug therapies with multiple effects.
"Academic and private-sector research labs are looking for biochemical linkages between components of metabolic syndrome," Eckel says.
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COMING TO TERMS
"The diagnosis of metabolic syndrome is imperfect, but it is user-friendly, economical, and widely accepted," Eckel says. "The same could be said about Cushing's syndrome."
Recently, a number of professional groups have recast the concept of metabolic syndrome and its significance in clinical practice.
In September 2005, the ADA and the European Association for the Study of Diabetes (EASD) issued a joint paper suggesting that metabolic syndrome is an ambiguous entity and should not be a term used in primary care.1
In July, ADA and AHA issued a statement introducing an initiative to encourage a broader approach to health management by adopting the term "cardiometabolic risk" (CMR) to designate the risks of diabetes and cardiovascular events that may result from pre-diabetes, hypertension, dyslipidemia, and obesity.2 The statement's purpose is "to reiterate that the goal of both organizations is to reduce heart disease, stroke, and diabetes," Eckel says.
While ADA is fostering the concept of "cardiometabolic risk" (DOC News, July 2006), AHA continues to use the term metabolic syndrome.
"Whether intended or not, the effect of the [ADA/EASD] paper was that people asked whether ADA and AHA were at war over this," Eckel explains. "That came up so frequently that we decided to change that image.
"Let's not be so concerned about the term," he says. "If
we change the term to cardiometabolic risk, we're still talking about the same
elephant. We may be feeling the leg versus the trunk, but the elephant is a
clustering of risk factors that relate to cardiovascular disease and
diabetes." 
References
2. Eckel RH, Kahn R, Robertson RM, et al.: Preventing cardiovascular
disease and diabetes: A call to action from the American Diabetes Association
and the American Heart Association. Diabetes Care 29: 1697–1699, 2006.
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