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Letters: Comments and Responses

The Metabolic Syndrome: The Emperor Needs Some Consistent Clothes

Response to Davidson and Alexander

  1. Frank Vinicor, MD and
  2. Barbara Bowman, PHD
  1. From the Centers for Disease Control and Prevention, Division of Diabetes Translation, Atlanta, Georgia
  1. Address correspondence to Frank Vinicor, MD, MPH, Director, Division of Diabetes Translation (K-10), CDC, 4770 Buford Hwy., Atlanta, GA 30341. E-mail: fxv1{at}cdc.gov
Diabetes Care 2004 May; 27(5): 1243-1243. https://doi.org/10.2337/diacare.27.5.1243
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Response to Davidson and Alexander

Drs. Davidson (1) and Alexander (2) suggest that the so-called “metabolic syndrome” has reached sufficient prominence, i.e., it has “come of age,” and that it deserves a new section in Diabetes Care. While enthusiasm about the “metabolic syndrome” among professionals, the media, and the public has developed rapidly and perhaps “come of age,” a more apt description of its scientific status is that “this emperor needs some consistent clothes” (3). Given the following realities of the state of the metabolic syndrome at present, healthy caution is necessary. 1) There is no consensus about the definition of the metabolic syndrome (4). 2) The oft-used National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) recommendations for the diagnosis of the metabolic syndrome, which is assessment of three out of five elements (5), do not reflect an evidence-based process but at best a “consensus among experts” whose recommendations will no doubt change over time (what about C-reactive protein?) (6). 3) Neither “equity” in the prevalence of the metabolic syndrome among racial/ethnic groups (7) nor pathophysiologic parity among the five elements of the ATP III definition of the metabolic syndrome exist (8). 4) The cut points for each of the five elements of the ATP III definition of the metabolic syndrome are presently arbitrary. For example, has the prevalence of the metabolic syndrome now reached “hyperepidemic” proportions with the new and more inclusive definitions (9,10) of impaired fasting glucose and prehypertension? 5) The five elements of the ATP III definition of the metabolic syndrome, including the recommended cut points for these elements, do not reliably indicate the presence of “insulin resistance” (11). 6) In fact, there is no agreement that insulin resistance is the basic abnormality underlying the metabolic syndrome, with emerging evidence (12,13) of the importance of “ectopic fat deposition” preceding insulin resistance. 7) Although a code for the metabolic syndrome has been established (14), coding does not equate with reimbursement (nor, in the mind of the authors, should it… yet). 8) Finally (and most importantly), there is no evidence that interventions to treat the entire metabolic syndrome as defined by NCEP/ATP III (versus appropriate interventions directed to the individual parts, e.g., hyperlipidemia, hypertension, etc.) are efficacious, let alone cost-effective. In summary, given that this is a situation where the basic etiology is unclear, the recommended diagnostic criteria (both the elements and cut points) are not evidence based, and no rigorous scientific evidence exists to indicate that treating the entire panoply of elements in the so-called metabolic syndrome beyond individual risk factor treatment guidelines matters (i.e., what is gained beyond some new nomenclature), the concept of the metabolic syndrome may be “coming of age,” but the practical clinical and public health significance of this interesting entity remains “embryonic” (15,16).

Footnotes

  • DIABETES CARE

References

  1. ↵
    Davidson M: Metabolic syndrome/insulin resistance syndrome/pre-diabetes: new section in Diabetes Care (Editorial). Diabetes Care 26:3179, 2003
    OpenUrlFREE Full Text
  2. ↵
    Alexander C: The coming of age of the metabolic syndrome (Editorial). Diabetes Care 26:3180–3181, 2003
    OpenUrlFREE Full Text
  3. ↵
    Susser M: What is cause and how do we know one? A grammar for pragmatic epidemiology. Am J Epid 133:635–648, 1991
    OpenUrlAbstract/FREE Full Text
  4. ↵
    Ford E, Giles W: A comparison of the prevalence of the metabolic syndrome using two proposed definitions. Diabetes Care 26:575–581, 2003
    OpenUrlAbstract/FREE Full Text
  5. ↵
    Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Executive summary of the third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 285:2486–2497, 2001
    OpenUrlCrossRefPubMedWeb of Science
  6. ↵
    Ridker P, Buring J, Cook N, Rifai N: C-reactive protein, the metabolic syndrome, and risk of incident cardiovascular events: an 8-year follow-up of 14,719 initially healthy American women. Circulation 107:391–397, 2003
    OpenUrlAbstract/FREE Full Text
  7. ↵
    Fernandez J, Allison D: Understanding racial differences in obesity and metabolic syndrome traits. Nutr Rev 61:316–319, 2003
    OpenUrlCrossRefPubMed
  8. ↵
    Hanson R, Imperatore G, Bennett P, and Knowler W: Components of the “metabolic syndrome” and incidence of type 2 diabetes. Diabetes 51:3120–3127, 2002
    OpenUrlAbstract/FREE Full Text
  9. ↵
    Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus (Committee Report). Diabetes Care 26:3160–3167, 2003
    OpenUrlFREE Full Text
  10. ↵
    Chobanian A, Bakris G, Black H, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ, National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National High Blood Pressure Education Program Coordinating Committee: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA 289:2560–2571, 2003
    OpenUrlCrossRefPubMedWeb of Science
  11. ↵
    McLaughlin T, Abbasi F, Cheal K, Chu J, Lamendola C, Reaven G: Use of metabolic markers to identify overweight individuals who are insulin resistant. Ann Intern Med 139:802–809, 2003
    OpenUrlCrossRefPubMedWeb of Science
  12. ↵
    Unger R: Weapons of lean body mass destruction: the role of ectopic lipids in the metabolic syndrome. Endocrinology 144:5159–5165, 2003
    OpenUrlCrossRefPubMedWeb of Science
  13. ↵
    Kahn H, Valdez R: Metabolic risks identified by the combination of enlarged waist and elevated triacyglycerois. Am J Clin Nutr 78:928–934, 2003
    OpenUrlAbstract/FREE Full Text
  14. ↵
    American Association of Clinical Endocrinologists: AACE position statement on the insulin resistance syndrome. Endocr Pract 9:240–252, 2003
    OpenUrl
  15. ↵
    Service J: Idle thoughts from an addled mind: mechanisms of metabolic mischief: meritorious or meretricious? (Editorial). Endocr Pract 9:101–102, 2003
    OpenUrlPubMed
  16. ↵
    Meigs J: The metabolic syndrome: a guidepost or a detour in preventing type 2 diabetes and cardiovascular disease? (Editorial). BMJ 327:61–62, 2003
    OpenUrlFREE Full Text
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Diabetes Care: 27 (5)

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The Metabolic Syndrome: The Emperor Needs Some Consistent Clothes
Frank Vinicor, Barbara Bowman
Diabetes Care May 2004, 27 (5) 1243; DOI: 10.2337/diacare.27.5.1243

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The Metabolic Syndrome: The Emperor Needs Some Consistent Clothes
Frank Vinicor, Barbara Bowman
Diabetes Care May 2004, 27 (5) 1243; DOI: 10.2337/diacare.27.5.1243
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