Elsevier

Mayo Clinic Proceedings

Volume 83, Issue 8, August 2008, Pages 932-943
Mayo Clinic Proceedings

REVIEW
A Practical “ABCDE” Approach to the Metabolic Syndrome

https://doi.org/10.4065/83.8.932Get rights and content

The metabolic syndrome comprises a cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus that are due to abdominal obesity and insulin resistance. This increasingly important proinflammatory condition remains both underrecognized and undertreated. To aid physicians in their approach to the metabolic syndrome, we assessed and synthesized the literature on cardiovascular risk assessment and early intervention for risk reduction. We performed a comprehensive search of MEDLINE and the Cochrane database for peer-reviewed clinical studies published from January 1, 1988, to December 31, 2007, augmented by consultation with content experts. We used the search terms metabolic syndrome, abdominal obesity, waist circumference, insulin resistance, cardiovascular disease, prediabetes, diabetes, treatment, prevention, aspirin, hypertension, cholesterol, atherogenic dyslipidemia, lifestyle therapy, diet, and exercise. Criteria used for study review were controlled study design, English language, relevance to clinicians, and validity based on experimental design and appropriateness of conclusions. Although growing evidence supports early intervention in patients with the metabolic syndrome, many physicians do not recognize the risk associated with this condition and fail to initiate early treatment. A comprehensive management plan can be assembled through an “ABCDE” approach: “A” for assessment of cardiovascular risk and aspirin therapy, “B” for blood pressure control, “C” for cholesterol management, “D” for diabetes prevention and diet therapy, and “E” for exercise therapy. This ABCDE approach provides a practical and systematic framework for encouraging metabolic syndrome recognition and for implementing a comprehensive, evidence-based management plan for the reduction of cardiovascular risk.

Section snippets

METHODS

We performed a comprehensive search of MEDLINE and the Cochrane database for clinical studies published from January 1, 1988, to December 31, 2007, using combinations of the following terms in their titles or abstracts: metabolic syndrome, abdominal obesity, waist circumference, insulin resistance, cardiovascular disease, prediabetes, diabetes, treatment, prevention, aspirin, hypertension, cholesterol, atherogenic dyslipidemia, lifestyle therapy, diet, and exercise. After screening the titles

MECHANISMS OF INCREASED RISK

The term metabolic syndrome evolved from observations that cardiovascular risk factors cluster in obese, insulin-resistant people; in its current use, it also refers to metabolically obese people of normal weight.18 The concept of the metabolic syndrome is useful because of its emphasis on underlying dysmetabolism and the attention it calls to co-existing cardiovascular risk factors.

Advances in adipocyte biology, subclinical inflammation, and oxidative stress have added to the original

DEFINITION OF THE METABOLIC SYNDROME

Clinical definitions of the metabolic syndrome use commonly measured patient data to identify people who are sufficiently insulin resistant to be at increased cardiovascular risk (Table 2). Although the World Health Organization, National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), and International Diabetes Federation definitions vary slightly, all identify a similar population of insulin-resistant people in need of risk modification. The conclusions of this review

CARDIOVASCULAR RISK PREDICTION

A diagnosis of metabolic syndrome allows early identification of patients with excessive adipose tissue and insulin resistance; as such, it can be considered a tool for the selection of patients who may have an increased lifetime risk of cardiovascular disease. Although the diagnosis should not be confused with a precise risk-scoring instrument, current definitions of the metabolic syndrome may identify a population of patients at greater cardiovascular risk than predicted by traditional risk

ABCDE APPROACH

In 2001, our center proposed an “ABC” approach to the implementation of ACC/American Heart Association (AHA) primary prevention guidelines,45 and we have since adopted an “ABCDE” approach to secondary prevention46 and the treatment of non-ST-segment elevation acute coronary syndromes.47 This review adapts this practical approach to the metabolic syndrome (Table 3).

CONCLUSION

An underrecognized and undertreated condition caused by abdominal obesity and insulin resistance, the metabolic syndrome predisposes people to the development of cardiovascular disease and diabetes. A clinical diagnosis of metabolic syndrome can be used as a tool to identify patients in need of comprehensive cardiovascular risk reduction therapy. A simple ABCDE approach is both easily accessible and comprehensive and can assist physicians by encouraging identification of patients with the

REFERENCES (117)

  • S Devaraj et al.

    Metabolic syndrome: an appraisal of the pro-inflammatory and procoagulant status

    Endocrinol Metab Clin North Am

    (2004)
  • PS Sever et al.

    Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial

    Lancet

    (2003)
  • CM Ballantyne et al.

    Correlation of non-high-density lipoprotein cholesterol with apolipoprotein B: effect of 5 hydroxymethylglutaryl coenzyme A reductase inhibitors on non-high-density lipoprotein cholesterol levels

    Am J Cardiol

    (2001)
  • J Vamecq et al.

    Medical significance of peroxisome proliferator-activated receptors

    Lancet

    (1999)
  • SM Grundy et al.

    Effectiveness and tolerability of simvastatin plus fenofibrate for combined hyperlipidemia (the SAFARI trial)

    Am J Cardiol

    (2005)
  • PL Canner et al.

    Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin

    J Am Coll Cardiol

    (1986)
  • RD Brook et al.

    Effect of short-term weight loss on the metabolic syndrome and conduit vascular endothelial function in overweight adults

    Am J Cardiol

    (2004)
  • FB Hu

    Diet and cardiovascular disease prevention the need for a paradigm shift [editorial]

    J Am Coll Cardiol

    (2007 Jul 3)
  • S Liu et al.

    A prospective study of dietary glycemic load, carbohydrate intake, and risk of coronary heart disease in US women

    Am J Clin Nutr

    (2000)
  • JW Beulens et al.

    High dietary glycemic load and glycemic index increase risk of cardiovascular disease among middle-aged women: a population-based follow-up study

    J Am Coll Cardiol

    (2007 Jul 3)
  • D Giugliano et al.

    The effects of diet on inflammation: emphasis on the metabolic syndrome

    J Am Coll Cardiol

    (2006 Aug 15)
  • C Li et al.

    Increasing trends in waist circumference and abdominal obesity among US adults

    Obesity (Silver Spring)

    (2007)
  • ES Ford et al.

    Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey

    JAMA

    (2002)
  • ES Ford et al.

    Increasing prevalence of the metabolic syndrome among U.S. adults

    Diabetes Care

    (2004)
  • PW Wilson et al.

    Metabolic syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus

    Circulation

    (2005 Nov 15)
  • SM Haffner et al.

    Cardiovascular risk factors in confirmed prediabetic individuals: does the clock for coronary heart disease start ticking before the onset of clinical diabetes?

    JAMA

    (1990)
  • KG Alberti et al.

    Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation

    Diabet Med

    (1998)
  • 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) final report

    Circulation

    (2002)
  • SM Grundy et al.

    Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement [published corrections appear in Circulation. 2005;112 (17):e297 and 2005;112 (17):e298]

    Circulation

    (2005 Oct 25)
  • ES Ford

    Rarer than a blue moon: the use of a diagnostic code for the metabolic syndrome in the U.S

    Diabetes Care

    (2005)
  • R Kahn

    Metabolic syndrome: is it a syndrome? does it matter?

    Circulation

    (2007)
  • SM Grundy

    Does the metabolic syndrome exist?

    Diabetes Care

    (2006)
  • GM Reaven

    The individual components of the metabolic syndrome: is there a raison d'etre?

    J Am Coll Nutr

    (2007)
  • M Blaha et al.

    Clinical use of the metabolic syndrome: why the confusion?

    Clin Diabetes

    (2006)
  • N Ruderman et al.

    The metabolically obese, normal-weight individual revisited

    Diabetes

    (1998)
  • P Dandona et al.

    Metabolic syndrome: a comprehensive perspective based on interactions between obesity, diabetes, and inflammation

    Circulation

    (2005)
  • C Bulcão et al.

    The new adipose tissue and adipocytokines

    Curr Diabetes Rev

    (2006)
  • AP Kong et al.

    The role of adipocytokines and neurohormonal dysregulation in metabolic syndrome

    Curr Diabetes Rev

    (2006)
  • R Yang et al.

    Leptin signaling and obesity: cardiovascular consequences

    Circ Res

    (2007)
  • U Pagotto et al.

    The emerging role of the endocannabinoid system in endocrine regulation of energy balance

    Endocr Rev

    (2006 Feb)
  • P Dandona et al.

    The suppressive effect of dietary restriction and weight loss in the obese on the generation of reactive oxygen species by leukocytes, lipid peroxidation, and protein carbonylation

    J Clin Endocrinol Metab

    (2001)
  • B Isomaa et al.

    Cardiovascular morbidity and mortality associated with the metabolic syndrome

    Diabetes Care

    (2001)
  • HM Lakka et al.

    The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men

    JAMA

    (2002)
  • N Sattar et al.

    Metabolic syndrome with and without C-reactive protein as a predictor of coronary heart disease and diabetes in the West of Scotland Coronary Prevention Study

    Circulation

    (2003 Jul 29)
  • G Hu et al.

    Prevalence of the metabolic syndrome and its relation to all-cause and cardiovascular mortality in non-diabetic European men and women

    Arch Intern Med

    (2004)
  • AM McNeill et al.

    The metabolic syndrome and 11-year risk of incident cardiovascular disease in the Atherosclerosis Risk in Communities study

    Diabetes Care

    (2005)
  • KM Rexrode et al.

    Abdominal adiposity and coronary heart disease in women

    JAMA

    (1998)
  • N Sarwar et al.

    Triglycerides and the risk of coronary heart disease: 10,158 incident cases among 262,525 participants in 29 Western prospective studies

    Circulation

    (2007 Jan 30)
  • JD Otvos et al.

    Measurement issues related to lipoprotein heterogeneity

    Am J Cardiol

    (2002)
  • EB Levitan et al.

    Is nondiabetic hyperglycemia a risk factor for cardiovascular disease? a meta-analysis of prospective studies

    Arch Intern Med

    (2004)
  • Cited by (75)

    • Dyslipidemia

      2023, Hypertension: A Companion to Braunwald's Heart Disease
    • Dyslipidemia

      2018, Hypertension: A Companion to Braunwald's Heart Disease
    View all citing articles on Scopus

    Dr Golden is a member of the Merck Clinical Diabetes Advisory Board.

    See end of article for correct answers to questions.

    View full text